The "choking game" and other strangulation activities in children and adolescents
- Nicole J Ullrich, MD, PhD
Nicole J Ullrich, MD, PhD
- Associate Professor of Neurology
- Harvard Medical School
- Howard P Goodkin, MD, PhD
Howard P Goodkin, MD, PhD
- Professor of Neurology and Pediatrics and Director, Division of Pediatric Neurology
- University of Virginia
- Section Editors
- Amy B Middleman, MD, MPH, MS Ed
Amy B Middleman, MD, MPH, MS Ed
- Section Editor — Adolescent Medicine
- Professor of Pediatrics, Chief of Adolescent Medicine
- University of Oklahoma Health Sciences Center
- Daniel M Lindberg, MD
Daniel M Lindberg, MD
- Section Editor — Pediatric Psychosocial Emergencies
- Associate Professor of Emergency Medicine and Pediatrics
- University of Colorado Kempe Center
- Marc C Patterson, MD, FRACP
Marc C Patterson, MD, FRACP
- Section Editor — Pediatric Neurology
- Professor of Neurology, Pediatrics, and Medical Genetics
- Chair, Division of Child and Adolescent Neurology
- Mayo Clinic College of Medicine
Unintentional injury is the leading cause of death in children, adolescents, and young adults in the United States . Unintentional injury often results from risk-taking behavior such as alcohol or drug use. Self-induced hypoxia (eg, engaging in strangulation activities, such as "the choking game") is another risky behavior among children and adolescents that may have a fatal outcome.
The "choking game" — The "choking game" refers to self-strangulation or strangulation by another person with the hands or a ligature to produce a euphoric state caused by cerebral hypoxia  and is perhaps more accurately described as a "strangulation activity" than as a game [3,4]. Breath holding and/or compression of the abdomen or thorax are involved in some versions of the activity [5-8]. The intent is to release the pressure just before loss of consciousness; failure to do so can result in death, particularly when the activity is performed alone using ligatures [2,5,7,9].
Other names — Other names for strangulation activities include the American dream, air planing, black hole, black-out game, breath play, California choke, California High, choke out, cloud nine, dream game, fainting game, five minutes of heaven, flat lining, funky chicken, gasp game, ghost, knock-out game, natural high, pass-out game, purple dragon, purple hazing, rising sun, rush, the scarf game, sleeper hold, something dreaming game, space cowboy, space monkey, speed dreaming, suffocation roulette, and the tingling game [2,6,9-15].
Autoerotic asphyxia — Autoerotic asphyxia is a similar activity that involves choking oneself during sexual stimulation in order to heighten the sexual pleasure [9,16]. Autoerotic asphyxia may involve elaborate bindings, sophisticated escape mechanisms, sexual images, or cross-dressing [5,17]. Death may occur if loss of consciousness leads to loss of control and inability to reverse or stop the means of strangulation . Participants of autoerotic asphyxia are almost exclusively older adolescent and adult males [5,6,17].
Prevalence — Children and adolescents throughout the world engage in strangulation activities; fatal and nonfatal cases have been reported in the United States, Canada, Australia, Israel, France, England, Ireland, and Saudi Arabia [5,6,18-21]. According to some reports, children have engaged in strangulation activities for generations [5,9,11]; however, the first reference to the "choking game" in the medical literature occurred in 2000 .
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- The "choking game"
- - Other names
- Autoerotic asphyxia
- Predisposing factors
- Cerebral hypoxia and hypoperfusion
- EEG correlates
- CLINICAL FEATURES
- Warning signs
- DIFFERENTIAL DIAGNOSIS
- SUMMARY AND RECOMMENDATIONS