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.