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The choking game, or fainting game [1] [2] is the act of intentionally cutting off oxygen to the brain with the goal of inducing temporary loss of consciousness and euphoria. A related internet challenge, the blackout challenge, encourages the use of the choking game online.
Limited research has been conducted regarding motivations for practicing the fainting game, although thrill seeking has been identified as a risk factor, [3] as has the perception that it is a low-risk activity. [4] Anecdotal reasons stated include:
Reasons for practice are distinct from erotic asphyxiation. Steve Field, chairman of the Royal College of General Practitioners in London, [6] claims that 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. [7]
There are two main mechanisms behind many variations of this practice, both resulting in cerebral hypoxia (oxygen deprivation to the brain). The two mechanisms tend to be confused with each other or treated as one but are quite dissimilar although both have the potential to cause permanent brain damage or death. The two mechanisms are strangulation and self-induced hypocapnia [8] and work as follows:
A ligature such as a belt or rope around the neck, or hands or arm pressure on the neck 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:
The second mechanism requires hyperventilation (forced overbreathing) until symptoms of hypocapnia such as tingling, light-headedness or dizziness are felt, followed by a breath-hold. This alone is enough to cause a blackout, but it is widely believed that the effect is enhanced if lung air pressure is increased by holding the breath "hard" or "bearing down" (tightening the diaphragm as in a forced exhalation while allowing no air to escape or having an assistant apply a bear-hug). [11] These latter actions may augment the effects of hypoxia by approximating the Valsalva maneuver, causing vagal stimulation.
The hyperventilation leads to an excessive elimination of carbon dioxide (CO2) whereas no significant additional amounts of oxygen can be stocked in the body. As only carbon dioxide is responsible for the breathing stimulus,[ citation needed ] after hyperventilation, breath can be held longer until cerebral hypoxia occurs. The blood also becomes abnormally alkaline as a result of the excessive elimination of carbon dioxide; this subsequent rise in blood pH is termed alkalosis. Alkalosis interferes with normal oxygen utilization by the brain. 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.
In the body alkalosis generally induces vasodilation (widening of the blood vessels) but in the brain alone it causes vasoconstriction (narrowing of the blood vessels)[ citation needed ]. 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[ citation needed ]:
Because the brain cannot store reserves of oxygen and, unlike other organs, has an exceedingly low tolerance of oxygen 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 carbon dioxide in the blood through suspension of breathing.
In some versions the bear-hug is replaced by pressure on the neck in which case blackout is a hybrid of strangulation and self-induced hypocapnia.
Unconsciousness may be induced by other methods although these are controversial: pressure over the carotid sinus may induce 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.[ citation needed ]
In both strangulation and 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 if the strangulation stops.
A 2008 Centre for Addiction and Mental Health study found that at least 79,000 students in the Canadian province of Ontario participated in this act. [12] The 2006 Youth Health Risk Behavioral Survey in Williams County, Ohio found that 11% of youths aged 12–18 years and 19% of youths aged 17–18 reported ever having practiced it. [13]
A challenge, named the "Blackout challenge", became widespread on TikTok in 2021, resulting in multiple fatalities of children. [14]
Any activity that deprives the brain of oxygen has the potential to cause moderate to severe brain cell death leading to permanent loss of neurological function ranging from difficulty in concentration or loss of short-term memory capacity through severe, lifelong mental disability to death. [15] Statistics on fatalities and neurological damage are controversial; no definitive, empirical study exists although the indications are that the practice is a significant contributor to death and disability, particularly among male juveniles in most developed countries. Many believe that deaths are significantly underreported because of false attributions to suicide. [16]
One study by the U.S. Centers for Disease Control and Prevention (CDC) found sufficient evidence to indicate that since 1995 at least 82 youths between the age of 6 and 19 have died in the United States as a result of the game (roughly 1% of the deaths attributed to suicide by suffocation in the same age group), see chart. Of these 86.6% were male, and the mean age was 13.3. 95.7% of these deaths occurred while the youth was alone; parents of the decedents were unaware of the game in 92.9% of cases. Deaths were recorded in 31 states and were not clustered by location, season or day of week. [17] Neurological damage is harder to attribute accurately because of the difficulty of linking generalised, acquired neurological disability to a specific past event.
Incidental, or indirect, injuries may arise from falling or uncontrolled movements and crushing by a ligature or an assistant. Such injuries may include concussion, bone fractures, tongue biting and hemorrhaging of the eyes. [18]
The CDC encourages parents, educators and health-care providers to familiarize themselves with the signs of the game. [13] These include discussion of the game, bloodshot eyes, marks on the neck, severe headaches, disorientation after spending time alone, ropes, scarves, and belts tied to bedroom furniture or doorknobs or found knotted on the floor, and unexplained presence of things like dog leashes, choke collars and bungee cords. [19]
The choking game phenomenon was the subject of the 2014 television film The Choking Game , based on the novel Choke by Diana Lopez.
In the season 5 episode of Criminal Minds called "Risky Business," a serial killer uses an online version of the choking game to get teenagers to accidentally commit suicide. [20]
Hypoxia is a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level. Hypoxia may be classified as either generalized, affecting the whole body, or local, affecting a region of the body. Although hypoxia is often a pathological condition, variations in arterial oxygen concentrations can be part of the normal physiology, for example, during strenuous physical exercise.
Asphyxia or asphyxiation is a condition of deficient supply of oxygen to the body which arises from abnormal breathing. Asphyxia causes generalized hypoxia, which affects all the tissues and organs, some more rapidly than others. There are many circumstances that can induce asphyxia, all of which are characterized by the inability of a person to acquire sufficient oxygen through breathing for an extended period of time. Asphyxia can cause coma or death.
Apnea, BrE: apnoea, is the temporary cessation of breathing. During apnea, there is no movement of the muscles of inhalation, and the volume of the lungs initially remains unchanged. Depending on how blocked the airways are, there may or may not be a flow of gas between the lungs and the environment. If there is sufficient flow, gas exchange within the lungs and cellular respiration would not be severely affected. Voluntarily doing this is called holding one's breath. Apnea may first be diagnosed in childhood, and it is recommended to consult an ENT specialist, allergist or sleep physician to discuss symptoms when noticed; malformation and/or malfunctioning of the upper airways may be observed by an orthodontist.
Strangling is compression of the neck that may lead to unconsciousness or death by causing an increasingly hypoxic state in the brain. Fatal strangling typically occurs in cases of violence, accidents, and is one of two main ways that hanging causes death.
Hyperventilation is irregular breathing that occurs when the rate or tidal volume of breathing eliminates more carbon dioxide than the body can produce. This leads to hypocapnia, a reduced concentration of carbon dioxide dissolved in the blood. The body normally attempts to compensate for this homeostatically, but if this fails or is overridden, the blood pH will rise, leading to respiratory alkalosis. The symptoms of respiratory alkalosis include dizziness, tingling in the lips, hands, or feet, headache, weakness, fainting, and seizures. In extreme cases, it may cause carpopedal spasms, a flapping and contraction of the hands and feet.
The diving reflex, also known as the diving response and mammalian diving reflex, is a set of physiological responses to immersion that overrides the basic homeostatic reflexes, and is found in all air-breathing vertebrates studied to date. It optimizes respiration by preferentially distributing oxygen stores to the heart and brain, enabling submersion for an extended time.
Hypercapnia (from the Greek hyper = "above" or "too much" and kapnos = "smoke"), also known as hypercarbia and CO2 retention, is a condition of abnormally elevated carbon dioxide (CO2) levels in the blood. Carbon dioxide is a gaseous product of the body's metabolism and is normally expelled through the lungs. Carbon dioxide may accumulate in any condition that causes hypoventilation, a reduction of alveolar ventilation (the clearance of air from the small sacs of the lung where gas exchange takes place) as well as resulting from inhalation of CO2. Inability of the lungs to clear carbon dioxide, or inhalation of elevated levels of CO2, leads to respiratory acidosis. Eventually the body compensates for the raised acidity by retaining alkali in the kidneys, a process known as "metabolic compensation".
Hyperventilation syndrome (HVS), also known as chronic hyperventilation syndrome (CHVS), dysfunctional breathing hyperventilation syndrome, cryptotetany, spasmophilia, latent tetany, and central neuronal hyper excitability syndrome (NHS), is a respiratory disorder, psychologically or physiologically based, involving breathing too deeply or too rapidly (hyperventilation). HVS may present with chest pain and a tingling sensation in the fingertips and around the mouth (paresthesia), in some cases resulting in the hands 'locking up' or cramping. HVS may accompany a panic attack.
Hypocapnia, also known as hypocarbia, sometimes incorrectly called acapnia, is a state of reduced carbon dioxide in the blood. Hypocapnia usually results from deep or rapid breathing, known as hyperventilation.
Cerebral hypoxia is a form of hypoxia, specifically involving the brain; when the brain is completely deprived of oxygen, it is called cerebral anoxia. There are four categories of cerebral hypoxia; they are, in order of increasing severity: diffuse cerebral hypoxia (DCH), focal cerebral ischemia, cerebral infarction, and global cerebral ischemia. Prolonged hypoxia induces neuronal cell death via apoptosis, resulting in a hypoxic brain injury.
A chokehold, choke, stranglehold or, in Judo, shime-waza is a general term for a grappling hold that critically reduces or prevents either air (choking) or blood (strangling) from passing through the neck of an opponent. The restriction may be of one or both and depends on the hold used and the reaction of the victim. While the time it takes for the choke to render an opponent unconscious varies depending on the type of choke, the average across all has been recorded as 9 seconds.
Hypoxic pulmonary vasoconstriction (HPV), also known as the Euler-Liljestrand mechanism, is a physiological phenomenon in which small pulmonary arteries constrict in the presence of alveolar hypoxia. By redirecting blood flow from poorly-ventilated lung regions to well-ventilated lung regions, HPV is thought to be the primary mechanism underlying ventilation/perfusion matching.
Central neurogenic hyperventilation (CNH) is an abnormal pattern of breathing characterized by deep and rapid breaths at a rate of at least 25 breaths per minute. Increasing irregularity of this respiratory rate generally is a sign that the patient will enter into coma. CNH is unrelated to other forms of hyperventilation, like Kussmaul's respirations. CNH is the human body's response to reduced carbon dioxide levels in the blood. This reduction in carbon dioxide is caused by contraction of cranial arteries from damage caused by lesions in the brain stem. However, the mechanism by which CNH arises as a result from these lesions is still very poorly understood. Current research has yet to provide an effective means of treatment for the rare number of patients who are diagnosed with this condition.
Hypoxemia is an abnormally low level of oxygen in the blood. More specifically, it is oxygen deficiency in arterial blood. Hypoxemia has many causes, and often causes hypoxia as the blood is not supplying enough oxygen to the tissues of the body.
Freediving blackout, breath-hold blackout, or apnea blackout is a class of hypoxic blackout, a loss of consciousness caused by cerebral hypoxia towards the end of a breath-hold dive, when the swimmer does not necessarily experience an urgent need to breathe and has no other obvious medical condition that might have caused it. It can be provoked by hyperventilating just before a dive, or as a consequence of the pressure reduction on ascent, or a combination of these. Victims are often established practitioners of breath-hold diving, are fit, strong swimmers and have not experienced problems before. Blackout may also be referred to as a syncope or fainting.
Brain ischemia is a condition in which there is insufficient bloodflow to the brain to meet metabolic demand. This leads to poor oxygen supply or cerebral hypoxia and thus leads to the death of brain tissue or cerebral infarction/ischemic stroke. It is a sub-type of stroke along with subarachnoid hemorrhage and intracerebral hemorrhage.
A greyout is a transient loss of vision characterized by a perceived dimming of light and color, sometimes accompanied by a loss of peripheral vision. It is a precursor to fainting or a blackout and is caused by hypoxia, often due to a loss of blood pressure.
Latent hypoxia is a condition where the oxygen content of the lungs and arterial blood is sufficient to maintain consciousness at a raised ambient pressure, but not when the pressure is reduced to normal atmospheric pressure. It usually occurs when a diver at depth has a lung gas and blood oxygen concentration that is sufficient to support consciousness at the pressure at that depth, but would be insufficient at surface pressure. This problem is associated with freediving blackout and the presence of hypoxic breathing gas mixtures in underwater breathing apparatus, particularly in diving rebreathers.
A choke-out is a hand-to-hand combat tactic involving the use of a chokehold to cause syncope, or temporary loss of consciousness, at which point the choke is released. Common chokeholds in grappling used to accomplish a choke-out include the rear naked choke, arm triangle, triangle choke, and the guillotine.
Human physiology of underwater diving is the physiological influences of the underwater environment on the human diver, and adaptations to operating underwater, both during breath-hold dives and while breathing at ambient pressure from a suitable breathing gas supply. It, therefore, includes the range of physiological effects generally limited to human ambient pressure divers either freediving or using underwater breathing apparatus. Several factors influence the diver, including immersion, exposure to the water, the limitations of breath-hold endurance, variations in ambient pressure, the effects of breathing gases at raised ambient pressure, effects caused by the use of breathing apparatus, and sensory impairment. All of these may affect diver performance and safety.
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