Choker face: A brief look at suffocation roulette

When I was a kid (well about 12 or 13 years old) my friends and I used to occasionally play a game that we called ‘Headrush’ where I would have my breathing temporarily stopped by someone holding onto my chest after a deep expiration and hyperventilation (so that I couldn’t breathe), and it would induce feelings of light-headedness and dizziness followed by temporary unconsciousness (usually lasting 10-15 seconds). I did it twice and on both occasions I felt as though I had lived a whole other life while I was unconsciousness. I’m not condoning the behaviour (as it’s potentially life-threatening) but the experience was pretty mind-blowing (at least that’s my adolescent recollection). The only thing I can relate it to are the accounts I have read by others who have talked about their near death experiences.

I vividly remember the day that I said I would never do it again as my friends and I thought we had caused the death of another boy (a couple of years older than ourselves). My best friend at the time had induced the fainting reaction in our older friend and he was out cold for much longer than the 10-15 seconds we would normally have expected. We thought he was dead. However, after about 25-35 seconds our friend’s hands and feet were making strange movements. I remember his feet ‘clapping’ together constantly for about 20 seconds. After about a minute he came around and said that he had experienced a wonderful feeling that he had lived his life as a seal! Despite the fact that my friend lived to tell the tale, I never participated in the fainting game ever again.

I had not even thought about these adolescent experiences until a few months ago until I came across (quite by chance) a paper written by Dr. Gil Shlamovitz and colleagues on ‘suffocation roulette’ in a 2003 issue of Annals of Emergency Medicine. They reported the case of a 12-year-old boy admitted to hospital because of “recurrent syncopal episodes” (i.e., persistent fainting). The authors reported that the fainting episodes were due to a game they called ‘suffocation roulette’ (a term I had not heard before but was the same game that I described above). After reading this paper, I decided I would have a further look into this phenomenon and it became very clear that the game I played as a young teenager has been played by many others around the world (under dozens of different names that I’ve listed at the end of this blog). It also appears that what we were doing as kids was a form of ‘self-induced hypocapnia’ that refers to a state of reduced carbon dioxide in the blood).

Most academic reports refer to the phenomenon as a type of ‘asphyxial game’ (with ‘the choking game’ or ‘the fainting game’ appearing to be the most commonly reported). Sometimes these ‘games’ are played alone and typically involve self-strangulation, and sometimes with others (where like my own experiences, the cutting off of the oxygen supply was carried out by somebody else. As with autoerotic asphyxiation, the aim of the game is to intentionally cut off the oxygen supply to the brain to experience a feeling of euphoria (the only difference being that in children’s games, it is not done for a sexual reason). A Wikipedia entry on the topic notes:

“According to Dr. Steve Field, chairman of the Royal College of General Practitioners in London, the fainting game is pursued primarily by children and teens ‘to get a high without taking drugs.’ Children ‘aren’t playing this game for sexual gratification.’ It is frequently confused with erotic asphyxiation, which is oxygen deprivation for sexual arousal. Unlike erotic asphyxiation, practice of the fainting game appears to be uncommon in adulthood”.

My own personal experiences of this would support Dr. Field’s assertions. There has been relatively little research into the practice although a fairly recent (2010) paper by Dr. Joseph Drake and colleagues in the journal Academic Pediatrics claims that ‘thrill-seeking’ is risk factor. Another paper published in a 2009 issue of the journal Injury Prevention (led by Dr. A.J. MacNab) said there was a perception among those who engaged in it that inducing fainting was a low-risk activity (something that I can attest to until I thought my friend had accidentally killed someone).

The paper led by MacNab attempted to determine the prevalence of knowledge about and participation in asphyxial games and how best to raise awareness of this risk-taking behaviour and provide preventive education. The study collected data from children and adolescents (aged 9-18 years with an average age of 13.7 years) at eight middle and high schools in Texas (n=6) and Ontario (n=2). They also noted that there had been a recent death from playing the choking game in one of the Texas schools, and that two other fatalities had occurred within the state. Over 2500 questionnaires were completed. They reported that 68% of children had heard about the game, 45% knew somebody who played it, and 6.6% had tried it (and 40% perceived no risk from the activity). The study found that the most respected source of a preventive education message was parents for pre-adolescents (43%) or victim/victim’s family (36%) for older adolescents.

In the 2008 book The Path to Addiction: And Other Troubles We Are Born To Know, Richard McKenzie Neal also says the author reasons that children participate in fainting games include curiosity (as to what the act of fainting might feel like), peer pressure (including a challenge or a dare or a rites of passage into a particular social group), exploration of ways to ‘get high’ and intoxicated at no financial cost. I also read that:

“[In] self-induced hypocapnia blackouts the victim may experience dreaming or hallucinations, though fleetingly, and regains consciousness with short-term memory loss and involuntary movement of their hands or feet. Full recovery is usually made within seconds but these activities cause many permanent brain injuries or death”

This description matches my own personal experiences of playing the fainting game and also seems to match our friend’s account that he thought he was a seal while unconscious. Like autoerotic asphyxiation, the playing of asphyxial games among children and teenagers has occasionally led to fatalities and reported in the clinical and medical literature. For instance, a recent case was reported by Dr. M.K. Egge and colleagues in the journal Pediatric Emergency Care. Their case was a 12-year-old girl who was brought to the paediatric emergency department after her mother found her hanging from her bunk bed. She died five days after being admitted to hospital and it was eventually found that she had played the choking game. Most cases of asphyxial game playing have been reported in the US, UK and Australia, although I did come across papers written in both Spanish and French about the phenomenon.

How prevalent the activity is debatable as most of the academically published studies are case reports (usually when a problem – and in some cases, death – has occurred). One 2006 US (Ohio-based Youth Health Risk Behavioral Survey) study (but not peer reviewed as far as I can tell) reported that approximately one in ten teenagers (11%) aged 12 to 18 years had engaged at least once in fainting games with the figure rising to almost one in five older teenagers (19%) among those aged 17 and 18 years. No-one knows how many teenagers have suffered brain damage or died as a result of such activities. One of the better published studies on fainting/choking games was published by Dr. R.L. Toblin and colleagues in the Journal of Safety Research who reported:

“Because no traditional public health dataset collects data on this practice, the [Centers for Disease Control and Prevention] used news media reports to estimate the incidence of deaths from the choking game. This report describes the results of that analysis, which identified 82 probable choking-game deaths among youths aged 6-19 years during 1995-2007. Seventy-one (86.6%) of the decedents were male, and the mean age was 13.3 years”.

The study also noted that deaths were recorded in 31 states and were not clustered by location, season or day of week. My brief examination of the literature suggests that a significant minority of adolescents have engaged in asphyxial game playing and that in extreme cases it may lead to death. It would certainly appear to be an activity that parents and teachers should be made more aware of.

• According to the online Urban Dictionary, asphyxial games have many different names worldwide including: Airplaning, America Dream Game, Black Boxing, Black Out Game, Breath Play, Breathing the Zoo, Bum Rushing, California Blackout, California Choke, California Dreaming, California Headrush, California High, California Knockout, Catching Some Zs, Choking Game, Cloud Nine, Crank, Dream Game, Dreaming Game, Dying game, Fall Out Game, Flat Liner, Flatline Game, Flatliner Game, Funky Chicken, Getting Passed Out, Grandma’s Boy, Groobling, Halloween, Harvey Wall Banger, High Riser, Hoola Hooping, Hyperventilation Game, Indian Headrush, Knockout Game, Passing Out Game, Pass-out Game, Purple Dragon, Natural High, Neckies, Redline, Rising Sun, Rocket Ride, Sandboxing, Sleeper Hold, Sleepers, Space Monkey, Speed Dreaming, Suffocation Game, Suffocation Roulette, The Game, The Mysto World, Tingling Game, Trip to Heaven

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Barberia-Marcalain, E., Corrons-Perramon, J., Suelves, J.M., Alonso, S.C., Castella-Garcia, J. & Medallo-Muniz, J. (2010). [The choking game: a potentially lethal game]. Anales Pediatrica (Barcelona), 73, 264-267.

Centers for Disease Control and Prevention (2008). Unintentional strangulation deaths from the “choking game” among youths aged 6-19 years: United States, 1995-2007. Morbidity and Mortality Weekly Report, 57, 141-144.

Drake, J.A., Price, J.H., Kolm-Valdivia, N. & Wielinski, M. (2010). Association of adolescent choking game activity with selected risk behaviors. Academic Pediatrics, 10, 410-416.

Egge, M.K., Berkowitz, C.D., Toms, C. & Sathyavagiswaran, L. (2010). The choking game: A cause of unintentional strangulation. Pediatric Emergency Care, 26, 206-208.

MacNab, A.J., Deevska, M., Gagnon, F., Cannon, W.G. & Andrew, T (2009). Asphyxial games or “the choking game”: A potentially fatal risk behavior. Injury Prevention, 14, 45-49.

Neal, R.M. (2008). The Path To Addiction: And Other Troubles We Are Born To Know. Bloomington, Indiana: Author House.

Shlamovitz, G.Z., Assia, A., Ben-Sira, L. & Rachmel, A. (2003). “Suffocation roulette”: A case of recurrent syncope in an adolescent boy. Annals of Emergency Medicine, 41, 223-226.

Toblin, R.L., Paulozzi, L.J., Gilchrist, J. & Russell, P.J. (2008). Unintentional strangulation deaths from the “choking game” among youths aged 6-19 years -United States, 1995-2007. Journal of Safety Research, 39, 445-448.

Urkin, J. & Merrick, J. (2006). The choking game or suffocation roulette in adolescence (editorial). International Journal of Adolescent Medicine and Health, 18, 207-208.