Fainting game

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The fainting game or choking game, also known by a variety of other nicknames (see end of article), is not technically a game but an activity whereby a state of unconsciousness or near unconsciousness is produced by restricting the supply of oxygenated blood to the brain. This activity can be practiced in groups where participants "assist" one another in achieving the state of collapse, or, more dangerously, can be performed alone on oneself. Though there are adults who also engage in this activity, young people especially seem to be attracted to "choking games" , and juveniles especially so. There has been some speculation among experts that adolescents are attracted to "choking games" perhaps owing to the erotic nature of the body's response to oxygen deprivation. There have been many reports of death from the game, but it is expected that this is underreported due to being mistaken as suicides. A host of variations have been responsible for a large number of deaths and permanent neurological disabilities. The majority of these deaths and injuries have been amongst the juvenile males who engage in this fad. Given that this activity has been known to cause many deaths and permanent disabilities it is perhaps surprising that it appears to be so widespread. No empirical study is known to have been done on the reasons for its attraction but anecdotally stated reasons include: Peer pressure, it is done as a dare, a right of passage or a social group finds it amusing to watch each other losing consciousness or behaving erratically. Curiosity in an altered state of consciousness, the experience of a brownout , an imagined approximation to a near death experience or more recently, copycatting elements of the film Flatliners A belief, not clearly substantiated, that it can induce a brief sense of euphoria. A belief, also not clearly substantiated, that it may enhance erotic feelings. The prospect of intoxication, albeit brief, at no financial cost. An underlying lack of education concerning the physiological mechanisms involved and the real dangers this presents.

1 Practice and methods
2 Mechanisms behind the activity
3 Other names
4 Sources
5 See also
6 External links

Practice and methods

Almost all forms of the game begin with some form of hyperventilation, which can be done sitting or lying down, but it is very common to start squatting or bent over, and quickly standing up before the next part, which increases the effect. Generally, while standing up the participant also takes a large breath, which is more important in the second variation below. After that, the two most common variations are explained below. While there are differences, no way of doing the game is safe, and all may have unintended health affects as discussed in the next section. The methods covered in this article are commonly used, but only a small subset of the methods that exist.

The "choking" variation

This practice calls for pressure to be put on the carotid artery in some way, which is technically strangulation. Versions of this method may or may not call for hyperventilation or the quick standing up.[1] Common methods for this are:

Using one's own thumbs pressed on arteries to restrict blood flow. [2]
Using the wrists (or thumbs) of an assistant to cause strangulation. This method can be used by pressing up the participant against a wall. [3]
Use of a choke hold, which by itself in enough to cause blackout, but preceded with hyperventilation can be used to create the desired effect. This may be referred to as choking out and some variations may not be considered a version of the choking game. [4]
Applying a ligature around one's neck.

This variation can be even more dangerous if the action that causes blackout is not controlled by the participant. It is not always necessary for the participant to hold their breath, and those administering it rely on observation of a blackout to know when to release pressure. If pressure is continued to be applied after blackout, the risk of permanent damage or death increases drastically. The use of thumbs on the neck can be self-induced and usually stops automatically on blackout. Where an assistant applies hand pressure, and in all cases where a ligature is used, stopping at the right moment before permanent damage occurs becomes a judgment call on the part of the operator or just good luck. Sometimes a hand is raised into the air by the participant so that it will be more obvious when blackout has occurred and those administering it will know to release pressure - but any case where an active action is required to stop the strangulation state is an extremely dangerous situation. Self-strangulation through the use of a ligature is the most common cause of death or brain damage although many schoolchildren have accidentally killed or caused permanent brain damage to their friends by all methods. It is believed that many deaths attributed to suicide by adolescents are actually solo self-asphyxiations and death was an unintended outcome. ^[1]

The breath hold variation

Another common way in which the game is preformed is to create pressure in the lungs, essentially strongly holding one's breath. Common methods for this are:

Putting your thumb in your mouth and blowing. [5]
Putting pressure on the chest while the breath is held. This can be done by:
- Putting pressure on the chest and pinning the participant up to a wall. This method is very common and the chinese knockout, wall-hit, and many other names name often refers to it. Pressure to the chest can be done with hands or a friend's head. [6]
- A bear hug from behind [7]

Tradition may dictate that the participant hold their arms in a crossed pattern while this is done.

Catching the participant

Any variation that involves the participant standing up presents a risk of simple impact injury after blackout, because the one's body will probably go fully limp. If an assistant is helping by putting pressure on the chest or a doing a bear hug, that person and other assistants may help by spotting the fall. Tradition with other variations may require a wall of spotters or clearing the environment of hard objects.

Mechanisms behind the activity

Both variations mentioned above result in unconsciousness by depriving the brain of oxygen but the ways by which the deprivation is achieved are very different. The two tend to get confused or treated as one. Both have the potential to cause permanent brain damage or death. The two mechanisms are strangulation and self-induced hypocapnia and work as follows:

The vulnerable carotid artery, (large, red tube), and the vagus nerve running parallel on its left

Strangulation

Thumbs or wrists pressed on the neck or the ligature compresses the internal carotid artery. Apart from the direct restriction of blood to the brain there are two other significant responses produced by pressing on the neck:

Pressing on the carotid arteries also presses on baroreceptors. These bodies then cause vasodilation (dilation (widening) of the blood vessels) in the brain leading to insufficient blood to perfuse the brain with oxygen and maintain consciousness.
A message is also sent via the vagus nerve to the main pacemaker of the heart to decrease the rate and volume of the heartbeat, typically by up to a third. [8] In some cases there is evidence that this may escalate into asystole, a form of cardiac arrest that is difficult to treat. There is a dissenting view on the full extent how and when a person reaches a stage of permanent injury, but it is agreed that pressure on the vagus nerve causes changes to pulse rate and blood pressure and is dangerous in cases of carotid sinus hypersensitivity.

Holding the strangulation after blackout has occurred will certainly worsen any of these effects.

Self-induced hypocapnia

The second common method necessarily requires hyperventilation for a minute, or until symptoms of hypocapnia such as tingling, light-headedness or dizziness are felt, followed by a breath-hold. The effect is greatly enhanced if lung air pressure is increased by holding the breath "hard", that is forcing exhalation while allowing no air to escape. This alone is enough to cause a blackout, as demonstrated by the thumb in mouth and blow method, but the most common practices require external pressure applied.

The fact that hyperventilation causes rapid cerebral hypoxia is paradoxical because the body should be well stocked with oxygen after over-breathing. The mechanism here is that the blood is made abnormally alkaline as a result of the excessive elimination of CO₂; this subsequent rise in blood pH is termed alkalosis. The symptoms of alkalosis are: neuromuscular irritability, muscular spasms, tingling and numbness of the extremities and around the mouth, and a dizziness, or giddiness, often interpreted as a sense of euphoria. This brief euphoria is what practitioners of the fainting game seek. Unfortunately alkalosis has other far-reaching and dangerous effects on the neuromuscular system and, among other things, interferes with normal oxygen utilization by the brain. In the body alkalosis generally induces vasodilatation (widening of the blood vessels) but in the brain alone it causes vasoconstriction(narrowing of the blood vessels). This vasoconstriction appears to be made even worse by a sudden increase in blood pressure caused by squeezing or holding the breath ‘hard’. The alkalosis induced euphoria can be followed rapidly by hypoxia-induced unconsciousness. The sequence of events leading to unconsciousness from hyperventilation is as follows:

Decrease in partial pressure of alveolar CO₂.
Decrease in partial pressure of arterial CO₂.
Increase in blood pH, (respiratory alkalosis).
Vasoconstriction of blood vessels supplying brain.
Pooling of the blood present in the brain at the time.
Brain rapidly uses up O₂ available in the pooled blood.
O₂ concentration in the brain drops.
Unconsciousness from hypoxia of cerebral tissue.

Because the brain can not store reserves of O₂ and, unlike other organs, has an exceedingly low tolerance of O₂ deprivation, it is highly vulnerable if vasoconstriction is not reversed. Normally, if the brain is hypoxic, autonomous systems in the body divert blood to the brain at the expense of other organs; because the brain is vasoconstricted this mechanism is not available. Vasoconstriction is only reversed by the build-up of CO₂ in the blood through suspension of breathing. If this build-up does not happen quickly enough, or if the vasodilation mechanism itself is slow to respond, irreversible brain damage or death becomes a possibility. This mechanism is too complex to be dealt with adequately within this article; for a good treatment of the paradoxical relationship between hyperventilation and hypoxia see USAF Respiratory Physiology.

In some versions where the bear hug is replaced by pressure on the neck blackout is a hybrid of strangulation and self-induced hypocapnia.

Other mechanisms

Unconsciousness may be induced by other methods: Pressure over the carotid sinus may induce a syncope (fainting) without any other action at all but this is difficult to reproduce and is not the basis of the game. For those susceptible to carotid sinus syncope, of which most people would be unaware until it occurred, this can be an exceedingly dangerous game. In both strangulation and self-induced hypocapnia blackouts the victim may experience dreaming or hallucinations, though fleetingly, and regains consciousness with involuntary movement of their hands or feet much to the amusement of the onlookers. Full recovery is usually made within seconds but these activities cause many deaths and permanent brain injuries every year, particularly when played alone or with a ligature. Permanent brain damage may be subtle and not immediately obvious to either the participants or it's observers.

Other names

The practice goes by many other names in different parts of the world or simultaneously in a single location. The names are usually one of several types: ones that assign drug-like qualities to the game, ones that describe the effects, ones that emphasize the risks involved, and others that come from pop-culture references. Common names in the United Kingdom, Australia and North America include:

Airplaning, America Dream Game, Black Out Game, Breath Play, Breathing the Zoo, Bum Rushing, California Blackout, California Choke, California Dreaming, California Headrush, California High, California Knockout, Choking Out, 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, Halloween, High Riser, Hoola Hooping, Hyperventilation Game, Indian Headrush, Knockout Game, Passing Out Game, Pass-out Game, Purple Dragon, Natural High, Redline, Rising Sun, Rocket Ride, Sandboxing, Sleeper Hold, Space Monkey, Speed Dreaming, Suffocation Game, Suffocation Roulette, Teen Choking Game, Tingling Game, Trip to Heaven, Wall-Hit

Sources

^ Dr. AJ McNab; Self strangulation by hanging from cloth towel dispensers in Canadian schools http://injuryprevention.bmj.com/cgi/content/full/7/3/231