Choking aside: Another look at self-asphyxial risk-taking behaviour in adolescence

In a previous blog I examined the ‘choking game’ (also known by dozens of names including the ‘fainting game’ and ‘suffocation roulette’). This was a game that I played a couple of times as an adolescent (although we called it ‘Headrush’). This was a game where I would have my breathing temporarily stopped by someone holding onto my chest after a deep expiration and hyperventilation (so that I could not breathe). It induced feelings of light-headedness and dizziness followed by temporary unconsciousness (usually lasting 10 to 15 seconds).

This activity that I engaged in as a teenager is an example of self-asphyxial risk-taking behaviour (SARTB). It also appears that what I did when I was an adolescent was a form of ‘self-induced hypocapnia’ (i.e., a state of reduced carbon dioxide in the blood). It has also been reported that these ‘games’ can be played alone and typically involve self-strangulation, or sometimes with others, and where like my own experiences, the cutting off of the oxygen supply was carried out by somebody else.

Reports of SARTB date back to the early 1950s in the medical literature (for instance, Dr. P. Howard and his colleagues reported a case in a 1951 issue of the British Medical Journal). SARTB has been defined by R.L. Toblin and colleagues in a 2008 issue of the Journal of Safety Research as self-strangulation or strangulation by another person with the hands or a noose to achieve a brief euphoric state caused by cerebral hypoxia. As with autoerotic asphyxiation (i.e., suffocation as a way of enhancing sexual arousal), the aim of SARTB 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).

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). However, a comprehensive systematic review of SARTB was recently published by Busse et al (2015). They attempted to assess the prevalence of engagement in SARTB and associated morbidity and mortality in children and adolescents (and up to early adulthood). Busse and colleagues examined every survey and case study that had been published on SARTB, and more specifically examining the behaviour among those aged 
0–20 years (excluding any study where the motive was autoerotic, suicidal or self-harm). They reported that 36 studies had examined child and adolescent SARTB in 10 different countries (North America and France being the most common, but also reports in the UK).

Risk factors for SARTB were hard to assess because most of the studies examining such risks did not control for other confounding variables. However, five of the studies reported an association between SARTB and a number of other risky behaviours including substance misuse, risky sexual behaviours, poor mental health, poor dietary behaviours, and engagement in risky sports. The review also reported that there did not seem to be any association between SARTB and engagement in physical activity, and experiencing accidents, and/or hospital admissions. It was also noted that a number of other behaviours increased the likelihood of engaging in SARTB including experiences of violence, being more impulsive, having a thrill-seeking personality, and having lower school achievement. However, only six of the 36 studies they reviewed reported the potential for SARTB to be associated with other risky behaviours. No consistent findings were found between SARTB and gender, age and other demographic factors (such as socio-economic status).

Examining the studies as a whole, Busse and colleagues reported that awareness of SARTB ranged from 36% to 91%, and that the median lifetime prevalence of engagement in SARTB was 7.4% (however, these were studies that used convenience sampling, therefore none of the studies were necessarily representative). In the SARTB literature, a total of 99 fatal cases were reported (and of the 24 detailed case reports, most of the deaths occurred when individuals were engaged in SARTB alone and used some type of ligature).

In a different analysis in the Journal of Safety Research, Dr. R.L. Toblin and colleagues used US news media reports to estimate the incidence of deaths from SARTB. Their report identified 82 probable SARTB deaths among youths aged 6-19 years during 1995 and 2007. Of these 82 cases, 71 (86.6%) were male, and the mean age of death was just over 13 years of age. The study also noted that deaths were recorded in 31 US states and were not clustered by location, season or day of week. Busse and colleagues assert the importance of education and prevention and more specifically note:

“As it has been suggested that knowledge and identification of symptoms and signs of engagement in [SARTB] could have possibly enabled early identification and possible prevention of fatal cases, we believe that clinicians, paediatricians, health professionals and teachers should receive education on the symptoms and signs of [SARTB]. The need to educate health professionals has been highlighted as awareness of [SARTB] will enable these individuals to identify symptoms and signs and to act as educators to young people and their parents…We further recommend that more research is carried out together with young people to develop appropriate education material. In line with recommendations from others, we further recommend removing existing videos about [SARTB] from the internet and ensuring that preventative website rather than promotional websites appear first on internet searches” (p.8).

This brief examination of the literature suggests that a significant minority of adolescents have engaged in SARTB and that in extreme cases it may lead to death. Despite being known about for over 60 years, the data concerning SARTB are still limited and relatively little is known about the associated risk factors. However, SARTB certainly appears to be an activity that parents and teachers should be made more aware of even if the prevalence of such activity among children and adolescents is low.

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

Further reading

Aggrawal A. (2009). Forensic and Medico-legal Aspects of Sexual Crimes and Unusual Sexual Practices. Boca Raton: CRC Press.

Busse, H., Harrop, T., Gunnell, D. & Kipping, R. (2015). Prevalence and associated harm of engagement in self-asphyxial behaviours (‘choking game’)
in young people: A systematic review. Archives of Disease in Childhood, doi:10.1136/archdischild-2015-308187.

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.

Griffiths, M.D. (2015). A brief review of self-asphyxial risk-taking behaviour in adolescents. Education and Health, 33, 59-61.

Howard, P., Leathart, G. L., Dornhorst, A.C., & Sharpey-Schafer, E.P. (1951). The mess trick and the fainting lark. British Medical Journal, 2, 382-384.

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.

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.

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.

Die another day: A brief look at ‘addiction to near death’

In previous blogs I have examined both people’s fascination with death and human near death experiences (NDEs). Another aspect to NDEs that I didn’t mention in those articles was the idea of people being “addicted” to NDEs. Arguably, most people’s perceptions of ‘near death addiction’ are probably based on the 1990 US film Flatliners. In that film, a group of five medical students (played by Keifer Sutherland, Kevin Bacon, Julia Roberts, Oliver Platt and William Baldwin) attempt to examine whether there is anything beyond death by carrying out experiments into NDEs. Keifer Sutherland’s character (Nelson) is continually made to experience clinical death (i.e., flatlining with no heartbeat) before being brought back to life by his classmates.

This Hollywood portrayal of possible ‘near death addiction’ bears little resemblance to the academic literature – most of which has been written from a psychodynamic perspective – and relates more to continual self-destructive experiences (usually by adolescents or young adults). The concept of ‘addiction to near death’ (ATND) originates from the writings of Dr. Betty Joseph, a distinguished psychoanalytic clinician often lauded as “the psychoanalysts’ psychoanalyst” and known for her work with highly resistant ‘difficult to treat’ patients. Dr. Joseph first wrote about the ‘addiction to near death’ concept in a 1982 issue of the International Journal of Psychoanalysis. This form of masochistic pathology was a concept that she found useful when working with psychologically dysfunctional adolescents. As Dr. Janet Shaw noted in a more recent 2012 paper on ATND in the Journal of Child Psychotherapy:

“At [the adolescent] stage of development, there is a tendency for adolescents who are troubled to turn to destructive or self-destructive behaviour, suicidal ideation, self-harm, self-starvation and inappropriate sexual behaviour. This is often profoundly shocking and alarming to others, especially if the young person finds the impact on others pleasurable. [Betty] Joseph described a patient addicted to near death as being caught up in a wish to gain pleasure by destroying both himself and the analytic relationship…[She] described masochistic destruction of the self taking place with libidinal satisfaction, despite much concomitant pain. The masochistic position is deeply addictive and this way of using pain for the purposes of pleasure becomes habitual. She summed this up as, ‘the sheer unequalled sexual delight of the grim masochism’ and described the awful pleasure that is achieved in this way”.

However, as Dr. Shaw rightly points out, not all types of destructive and self-destructive behaviour fall into such a category. In her 1982 paper, Dr. Joseph outlined case studies she had treated psychoanalytically from her private practice. Here, she described the masochistic dynamics of her patients, and how hard it was for them to alter these dynamics and get better. She noted that one of the key aspects of the dynamics she described was that her patients derived immense libidinal satisfaction from engaging in destructive near-death behaviours. More specifically, she wrote:

“There is a very malignant type of self-destructiveness, which we see in a small group of our patients, and which is, I think, in the nature of an addiction – an addiction to near-death. It dominates these patients’ lives; for long periods it dominates the way they bring material to the analysis and the type of relationship they establish with the analyst; it dominates their internal relationships, their so-called thinking, and the way they communicate with themselves. It is not a drive towards a Nirvana type of peace or relief from problems, and it has to be sharply differentiated from this. The picture that these patients present is, I am sure, a familiar one – in their external lives these patients get more and more absorbed into hopelessness and involved in activities that seem destined to destroy them physically as well as mentally, for example, considerable over-working, almost no sleep, avoiding eating properly or secretly over-eating if the need is to lose weight”.

In a 2006 issue of Psychanalytic Psychology, Dr. William Gottdeiner also noted that the ATND is such a strong motive that successful treatment of such individuals is unusually difficult. However, Dr. Gottdeiner asserted that one of the severe weaknesses of Joseph’s writings is that she failed to provide in-depth clinical examples of anyone who had engaged in potentially deadly activities. This, Gottdeiner contended, threatened the validity of the ATND construct. Despite such inherent weaknesses, Gottdeiner still believed the ATND construct had strong face validity (i.e., “there are people who seem to repeatedly engage in potentially lethal behavior, making the ATND construct plausible”). Consequently, Gottdeiner tested the construct validity of ATND on females with substance use disorders (SUDs). His argument was that:

“If individuals who are diagnosed with an SUD are successfully treated and they continue to engage in potentially deleterious behavior, then that finding would support the notion that the individual has an addiction to near-death experiences, and that the individual’s substance abuse was a comorbid disorder”.

Gottdeiner’s paper attempted to validate the ATND construct via secondary analysis “of data from a treatment outcome study of individuals who were in residential therapeutic community treatment for SUDs and who received simultaneous safe-sex education during treatment”. His study findings showed that despite safe-sex education and sexual activity in the therapeutic communities being prohibited, that some of the participants still engaged in risky sexual behaviour (irrespective of whether their sexual partners were HIV-positive or not). Gottdeiner argued that these findings tentatively supported the ATND construct. However, Gottdeiner was the first to admit that his study had inherent weaknesses. As he noted:

“The limitations were: data were from retrospective self-reports [and] contained no baseline measures of sexual activity, safe-sex knowledge, condom use, HIV status; it had no male participants, no specific questions about near-death behavior, nor whether alternative safe-sex activities were practice…The limitations of [the] study are considerable, and some might even argue that the connection between the ATND construct and the data presented herein is too much of a stretch to be scientifically useful…Obviously, stronger data would lead to stronger conclusions. Despite the limitations of this study, the findings should motivate clinicians to more seriously consider the existence of an addiction to near-death in their clients”.

More recently, Dr. Janet Shaw examined the ATND construct through the description and evaluation of an in-depth case study account of an adolescent female (‘Susan’). Her paper explored “the way in which pleasure, which is sadistic and masochistic in nature, is associated with cruelty towards the self or others in adolescence”. Dr. Shaw wrote that it felt as if Susan’s main aim was to torment her. As Shaw reported:

“In addition to suicide threats, similar to those she made in the assessment, she made constant reference to systematically starving herself. She was painfully thin, although not actually anorexic and she was poisoning herself by repeatedly taking paracetamol. Susan’s threats to self-harm had a deeply disturbing quality and she clearly enjoyed making them. There was a wish to punish me, as well as herself, through her phantasised attacks…The case material is an example of an adolescent girl with ‘an addiction to near death’ constituting a dominant way of relating to others. Her relentless and manipulative references to self-harm, suicide and dangerous behaviour at various stages of the work were designed to shock and alarm…Susan’s self-destructive behaviour was also continuing in relation to her self- starvation. She said she took laxatives in an attempt to lose more weight. She was becoming dangerously thin and three years into her psychotherapy an appointment with the referring psychiatrist resulted in a diagnosis of anorexia nervosa”.

This quote doesn’t do justice to the very detailed account that Dr. Shaw provided in her lengthy paper. However, her written account is heartfelt and brutally honest. Shaw concludes that the compelling power of addiction overviewed in Susan’s case mustn’t be underestimated. As she notes:

“The narcissistic idealisation of sadistic and masochistic behaviour offers some protection from fear and terror for the patient, but the consequence is to severely limit capacity for thought and imagination, and to restrict awareness. ‘Addition to near death’ forms a small but significant component of the clinical casework of a child and adolescent psychotherapist: it is hoped that Susan’s case material serves to illuminate the phenomenon further and its technical challenges”.

Whether the clinical case of Susan provides any more evidence for validation for Joseph’s ATND construct than the more empirical work of Gottdeiner is debatable. However, this is certainly a fascinating – if somewhat harrowing – area of clinical and academic work that certainly warrants further empirical examination.

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

Further reading

Gottdiener, W.H. (2006). A preliminary test of the Addiction-to-Near-Death construct. Psychoanalytic Psychology, 23, 661-666.

Joseph, B. (1982). Addiction to near death. International Journal of Psychoanalysis, 449-456.

Joseph, B. (1988). Addiction to near death. In Bott Spillius, E. (Ed.) Melanie Klein Today (pp.311-323). London and New York: Routledge.

Ryle, A. (1993). Addiction to the death instinct? A critical review of Joseph’s paper ‘Addiction to near death’. British Journal of Psychotherapy, 10, 88–92.

Shaw, J. (2012). Addiction to near death in adolescence. Journal of Child Psychotherapy, 38, 111-129.

Tunnel vision: A brief look at near death experiences

In 1964, the comic actor Peter Sellers had a series of eight rapid heart attacks after which his heart stopped beating and he was pronounced clinically dead. Thankfully, the doctor successfully brought Sellers back from the brink of death by vigorous heart massage. However, what is not so well known was that Sellers said that while all this was happening, he rose out of his body, and reached for a hand in a bright, loving light. As a result of his experience, Sellers claimed that he had lost his fear of death, had become more introspective, and had found tranquility in yoga. However, he still felt “lost” and would spend many discussions with the Reverend John Hester trying to “reconcile the world of plenty he inhabited with the emptiness of soul that oppressed him”.

Twenty years earlier, in 1944, the world-renowned psychiatrist and analytical therapist Carl Jung also had a near death experience. During a heart attack, Jung claimed to have envisioned the earth from over a 1000 miles in space. He claimed that he could see the Arabian deserts and the Himalayas. Hurtling towards him was a meteorite in the shape of a Hindu temple that was surrounded by a wreath of flashing bright lights. Jung felt the temple held the answers to all life’s most important questions. Before he could enter the temple, a spirit who was to die in his place called him back to earth.

The cases of Peter Sellers and Carl Jung may seem very strange but they are not untypical examples of a near death experience (NDE). NDEs are fairly widespread and the scientific study of them has been a growing research area over the last three decades. It has been claimed that with the increased amount of medical technology such as resuscitation techniques, that the number of people experiencing NDEs is on the increase (also check out my previous blog on Lazarus Syndrome – people that have seemingly come back to life after being pronounced dead).

The medic and philosopher, Raymond Moody, coined the term “near death experience” and says that one of the most asked questions that we as humans ask is “What happens when people die?” Do we simply cease to live or do we go onto something else leaving our mortal remains behind? Without getting into heavy philosophical and theological debates, it is clear that research into NDEs can perhaps help us to understand more about our own mortality and what happens when we die.

There are very few reports on how widespread NDEs are. In 1982, a survey by the pollster George Gallup Jr. reported that 15% of all Americans (23 million people) had experienced a “close brush with death” and that about 8 million had an NDE (about one in twenty people). A 1990 survey by Gallup reinforced his original findings with 12% of people reporting that they had been on the verge of death or had a close call involving an unusual experience.

There has been a lot of research into whether particular types of people are more susceptible to NDEs. Unfortunately, very few consistent findings have been found. It seems that almost anyone can experience NDEs. In fact, it has been reported that factors such as age, social class, race, and marital status have little (if any) influence on NDEs. Other factors that have been found to have little influence on NDEs include religious belief, prior knowledge of NDEs, and whether or not the person has a terminal illness.

However, research appears to suggest that the type of death may influence the type of NDE. For instance, those involved in car accidents and other ‘sudden’ events tend to report more cognitive experiences such as a ‘life review’ where the person’s life flashes before their eyes. One factor that may make a person more likely to experience NDEs is a history of abuse or trauma. The psychologist Kenneth Ring (University of Connecticut) says that these individuals are more likely to dissociate from a painful reality and tune into other realities to feel safe. The Seattle-based pediatrician Melvin Morse has even reported an in-depth study of children showing that they too can experience NDEs in his 1990 book Closer to the Light: Learning from the Near Death Experiences of Children.

The original pioneering academic study of NDEs has been attributed to the American psychiatrist Elizabeth Kubler-Ross who wrote the influential book On Death and Dying in 1969. In her book, she recorded many accounts of NDEs and “out of body travel” from her terminally ill patients and formulated the five classic stages of grieving (denial, anger, bargaining, depression and acceptance). She also reported that her patients often spoke to people who had preceded them in death, and that after death most of their faces became very peaceful.

In 1975, the first book to bring NDEs to mass public attention was Life After Life, a study of 150 cases written by Raymond Moody, and in 1988 wrote the follow-up best seller, The Light Beyond. In 1980, further research by the psychologist Kenneth Ring published in his book Life At Death concluded that NDEs consist of up to five stages. Based on an in-depth study of 102 cases, Ring reported that most people who have NDEs will experience the first stage but that very few reach the final one. His stages included peace (60%), body separation (37%), entering the darkness (23%), seeing the Light 16%), and entering the Light (10%). As with most areas, there are other typologies of NDEs that have been developed. For instance, the psychiatrist Bruce Greyson (University of Virginia) claimed that NDEs consisted of four different types – cognitive, affective, paranormal, and transcendental.

• Cognitive: These experiences involve thought process alterations, such as time shifts, life review and sudden understanding. These tend to occur with unexpected brushes with death rather than anticipated ones such as those with a terminal illness.
• Affective: These experiences involve peace, joy, painlessness, cosmic unity and encounters with a loving being of Light.
• Paranormal: These experiences involve out-of-body travel, precognitive visions, extra-sensory perception, and hyper-acute physical senses.
• Transcendental: These involve travel to an unearthly realm, encounters with a mystical being, visible spirits of deceased or religious figures, and a final point of no return.

It is also clear that not all NDEs are positive. Although most of the case studies reported by Raymond Moody were uplifting, a small proportion of the Gallup poll (about 1%) described their NDEs as “hell” or “tormenting”. As a result of more recent research, Bruce Greyson, and Nancy Bush refined the typology to include those who experienced more negative effects. As a result, it has been reported that there are three fundamentally different types of distressing NDEs: (i) prototypical NDEs with a tunnel and a bright Light, but experienced as terrifying, (ii) NDEs that had a sense of non-existence, eternal void or absurdity, and (iii) NDEs which features classical hellish imagery of tormenting demons and agonizing pain.

Thankfully, most people who have NDEs appear to have positive after-effects as a result of their experience. In his research, Kenneth Ring reports that survivors typically feel a heightened appreciation of life, a sense of personal renewal and a search for purpose, increased confidence, compassion, empathy, tolerance and understanding. At the core of most of these experiences is some kind of spiritual reawakening – although this is not necessarily religious. Life comes to be viewed as a precious gift. Scientific research also indicates that those who have NDEs show significant increases in psychic experiences. In fact, the more a person has, the more psychic experiences they have. Such experiences include precognitive awareness of incoming phone calls, and middle-of-the-night visits by recently deceased loved ones. Recent research suggests that transcendental near-death experiences show some cross-cultural variation that suggests they may be influenced by societal beliefs.

Some scientists are adamant that NDEs can wholly be explained by biological phenomena. For instance, the neurologist Ernst Rodin claims that a lack of oxygen supply to the brain (known as cerebral anoxia) causes delusions and hallucinations, and is a possible cause of NDEs. The London-based psychiatrist Karl Jansen and his colleague the endocrinologist Daniel Carr maintain that the body’s own morphine like substances (endorphins) increase before death and produce the feelings of calm and peacefulness reported by many who undergo NDEs. The neurologist Michael Persinger argues that temporal lobe brain activity and instability above the right ear is responsible for the deep meaningfulness, early memories and out-of-body experiences. The psychologist Susan Blackmore adds to this theory and argues that instability of the temporal lobe is also responsible for paranormal and mystical experiences. She also claims that the “Light at the end of the dark tunnel” experiences are optical illusions created by the effects of anoxia and drugs in which random light spots radiate from the centre of a dark internal visual field (also known as cortical disinhibition). Blackmore also believes that out-of-body experiences are drug-induced illusions as these are common experiences for people who use the drug ketamine recreationally. However, nearly all of these theories are at best only part explanations as none of them can fully explain all NDE accounts.

There are many psychological theories that have been forwarded as an explanation for NDEs. These range from historically based Freudian and Jungian theories through to more contemporary cognitive explanations. An early psychiatric explanation claimed that NDEs were linked with theories of depersonalization that “defend” the nervous system from the mental disorganization during the death crisis. Other psychologists claimed that depersonalization produces an altered passage of time, vivid and accelerated thoughts, a sense of detachment, unreality, automatic movements, and revival of memories. Some psychiatrists such as Ronald Siegal claim that NDEs are simply hallucinations (albeit very ordered ones) whereas some psychoanalysts claim that NDEs are a denial of death – a hallucinatory wish fulfillment defending the ego from its impending annihilation.

Other psychoanalysts claim that ‘birth trauma’ is the root of all neuroses and therefore explain NDEs as a regression to infantile object relations with the dark tunnel as the mother’s birth canal and the bright light as the mother’s radiant face. The famous cosmologist Carl Sagan saw some merit in this idea and proposed that people who have NDEs are reliving their descent down the birth canal. However, this has not been without its critics. On the technical side, it has been argued that infants descending down the birth canal not only have their eyes closed but their brains are too underdeveloped to allow memories of birth. The psychologist Susan Blackmore has also pointed out that that those born by Caesarian section are equally as likely as those born naturally to have NDEs that feature tunnels and out-of-body experiences! A theory by the psychologist Susan Blackwell claims that the human mind creates various mental models of reality based on its experiences, and the most stable one wins out as the favoured version. She claims that NDEs occur when the mind is in crisis and makes up models of reality such as out-of-body experiences, imagining the mind to be floating up above the body.

Whatever the explanation for NDEs, study of them from them is clearly an interesting area for both academics and the public alike. Whether the explanations are biologically, psychologically, or spiritually defined, it will not stop the growth of scientific research in this fascinating area.

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

Further reading

Athappilly, G.K., Greyson, B. & Stevenson, I. (2006). Do Prevailing Societal Models Influence Reports of Near-Death Experiences? A Comparison of Accounts Reported Before and After 1975.Journal of Nervous and Mental Disease, 194, 218-224.

Belanti, J., Perera, M. & Jagadheesan, K. (2008). Phenomenology of near-death experiences: A cross-cultural perspective. Transcultural Psychiatry, 45, 121–133.

Blackmore, S. (1996). Near death experiences. Journal of Royal Society of Medicine, 89, 73-76

Kubler-Ross, E. (1969). On Death And Dying. New York: MacMillan

Moody, R. (1975). Life After Life. New York: Bantam/Mocking bird.

Moody, R. (1988). The Light Beyond. New York: Bantam/Mocking bird.

Morse, M. & Perry, P.J (1991). Closer To The Light: Learning From The Near-Death Experiences Of Children. London: G.K. Hall.

Ring, K. (1980). Life At Death. New York: William Morrow Co.

State of the heart: A brief look at Lazarus Syndrome‬

Back in the late 1990s and early 2000s I used to write regularly for the British magazine Bizarre. One of the articles of mine that they published was on ‘near death experiences’ and it was during my research on that topic that I first came across what has been termed the Lazarus syndrome (sometimes referred to as the Lazarus Phenomenon). The syndrome takes its name after Lazarus (who according to the New Testament was raised from the dead by Jesus), and refers to the spontaneous return of blood circulation after the person has been declared dead. The condition is very rare and there have been less than 30 documented cases in the medical literature over the last 30 years. The term ‘Lazarus Phenomenon’ is relatively recent and was first used by Dr. J. Bray in a paper published in a 1993 issue of the journal Anesthesiology.

Earlier this year, a story appeared in the British press about a Scottish woman who came back from the dead after collapsing while gardening (February 10, 2012). The newspaper reported:

“A woman declared dead after she suffered a massive heart attack astonished doctors and her grieving family when she suddenly came back to life. Relatives of Lorna Baillie were devastated when a team of medics withdrew treatment after spending three hours trying to revive her. The family gathered around her hospital bed to say their goodbyes after doctors told them the 49-year-old grandmother was ‘technically dead’… It was then, 45 minutes later, that Mrs Baillie’s disabled husband John, 58, whispered ‘I love you’ to his wife. And when Mrs Baillie’s eyelids flickered and she appeared to squeeze her eldest daughter Leanne’s hand, the nurse again assured the family that ‘involuntary movements’ were to be expected. Unconvinced, the family demanded the nurse call in a doctor, who found a pulse and rushed Mrs Baillie to intensive care. Mrs Baillie’s miraculous signs of recovery followed, but medics warned that her chances of survival remained slim because her kidneys had failed and she was in a coma. But Mrs Baillie’s condition continued to improve and [was] moved from intensive care to a medical ward. An MRI scan yesterday revealed no obvious brain damage”.

The causes of how seemingly dead people to come back to life are not clearly understood among the medical community. One explanation that has been suggested is that as a consequence of cardiopulmonary resuscitation, there is the buildup of pressure in the chest as a result of cardiopulmonary resuscitation (CPR), and that the relaxing of the pressure (post-CPR) initiates electrical impulses that restart the heartbeat. Other physiological factors that have been suggested include the affected individuals having elevated levels of (i) potassium electrolytes (i.e., hyperkalemia) or (ii) adrenaline (epinephrine). Here are a few ‘typical’ examples reported in the medical literature:

• Case 1: After suffering an abdominal aneurysm, a 66-year-old American man was declared dead after 17 minutes of failed treatment. However, 10 minutes later, one of the doctors felt a pulse, and he made a full recovery with no long-lasting medical problems (Reported in Anesthesia and Analgesia, 2001).
• Case 2: After renal failure secondary to embolism of the superior mesenteric artery, a 93-year old American woman was pronounced dead after 6 minutes of failed resuscitation treatment. Five minutes after being declared dead cardiac activity was observed on the heart monitor, and she made a full recovery (Reported in Anesthesia and Analgesia, 2001).
• Case 3: Following a drug overdose-related heart attack, 27 year-old British man was declared dead after 25 minutes of failed treatment. Shortly after death had been declared, a nurse noticed the heart monitor was again showing heart rhythms so the resuscitation attempt continued and the man made a full recovery with no long-term medical complications (Reported in Emergency Medical Journal, 2001).
• Case 4: A 65-year-old male with congenital deafness and dumbness was found unconscious in his room at a public home. After 35 minutes of resuscitation treatment he was declared death. Approximately 20 minutes later, a police officer found the man moving in the mortuary. He lived for a further four days (Reported in Forensic Science International, 2002)

In 2010, Dr. K. Hornby and colleagues (all at McGill University, Montreal, Canada) published a systematic literature review of auto-resuscitation after cardiac arrests in the journal Critical Care Medicine. They started from the position that there was a lack of consensus as to how long after circulation has topped for death to be determined after cardiac arrest. At present, and because of the Lazarus Syndrome, the medical literature recommends that death should not be certified until 5-10 minutes after failed CPR has taken place. The condition also raises questions and interesting ethical issues as to when post-mortem procedures should occur (e.g., organ harvesting, autopsies, etc.)

The authors located 32 cases (aged 27-94 years of age across 16 different countries) published in the medical literature (from 27 different articles, so most were single case studies). They then systematically collated all data relating to a number of different factors including (i) patient characteristics, (ii) duration of cardio-pulmonary resuscitation, (iii) terminal heart rhythms, (iv) time to unassisted return of spontaneous circulation, (v) monitoring, and (vi) outcomes.

The authors considered the papers to be of “very low quality” (all were case reports or letters to the editor). All of the 32 cases reported auto-resuscitation following failed CPR. The times ranged from just a few seconds up to 33 minutes. They also noted that there was a lot of inconsistency in reporting methods and that only eight of the cases reported continuous electrocardiogram monitoring and exact times. In these eight cases, auto-resuscitation did not occur beyond the 7-minute barrier. They also noted that there were no cases of auto-resuscitation in the absence of CPR. The findings of their review therefore suggest that the provision of CPR may influence the occurrence of auto-resuscitation. Their study concluded that there was insufficient evidence to support or refute the current recommended waiting period of 5-10 minutes to determine death following a heart attack. Similar conclusions were reached by Dr. Vedamurthy Adhiyaman and colleagues, in a 2007 literature review published in the Journal of the Royal Society of Medicine. They looked more widely at auto-resuscitation and located 38 cases published in the medical literature. They also examined the longer-term outcome and reported:

“Seventeen patients (45%) achieved good neurological recovery following ROSC [return of spontaneous circulation]. Three of these patients subsequently died during their hospital stay due to sepsis and pulmonary embolism and 14 (35%) were eventually discharged home with no significant neurological sequelae. Seventeen patients (45%) did not achieve neurological recovery following ROSC and died soon after. The outcome is not known in four patients (10%). There was no significant correlation between the outcome and duration of CPR, time interval for ROSC or the diagnosis”.

The paper most importantly points out that “death is not an event, but a process…a process during which various organs supporting the continuation of life fail”. As their review points out, the ceasing of circulation and respiration is a good example. Obviously, the absence of heartbeat and respiration are the “traditional and the most widely used criteria” to certify that someone has died, but the Lazarus phenomenon demonstrate that on their own they are not a sign of definitive death.

(Footnote: The paper by Adhiyaman and colleagues also notes the many other medical contexts and conditions in which the word ‘Lazarus’ has been used to describe many other unexpected and scientifically unexplained phenomena. For instance: “Lazarus complex describes the psychological sequence in the survivors of cardiac arrest, near-death experiences and unexpected remission in AIDS. Lazarus syndrome is described in paediatric palliative care, when a child is expected to die but unexpectedly goes into remission. Spontaneous movement in brain dead and spinal cord injury patients has been described as Lazarus sign. Survival of species after mass extinction has been called Lazarus effect. The term Lazarus phenomenon was also used for unexpected survival of renal graft patients”).

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

Further reading

Abdullah, R.S. (2001). Restoration of circulation after cessation of positive pressure ventilation in a case of “Lazarus Syndrome”. Anesthesia and Analgesia, 93, 241.

Adhiyaman, V., Adhiyaman, S. & Sundaram, R. (2007). The Lazarus Phenomenon. Journal of the Royal Society of Medicine, 100, 552-557.

Ben-David, B., Stonebraker, V.C., Hershman, R., Frost, C.L. & Williams, H.K. (2001). Survival after failed intraoperative resuscitation: A case of “Lazarus Syndrome”. Anesthesia and Analgesia, 92, 690-692.

Bray, J.G. (1993). The Lazarus phenomenon revisited. Anesthesiology, 78, 991.

Hornby, K., Hornby, L. & Shemie, S.D. (2010). A systematic review of autoresuscitation after cardiac arrest. Critical Care Medicine, 38, 1246–1253.

Maeda, H., Fujita, M.Q., Zhu, B.L., et al (2002). Death following spontaneous recovery from cardio-pulmonary arrest in a hospital mortuary: “Lazarus phenomenon” in a case of alleged medical negligence. Forensic Science International, 127, 82-87.

Walker, A., McClelland, H. & Brenchley, J. (2001). The Lazarus phenomenon following recreational drug use. Emergency Medical Journal, 18, 74–75.