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 .To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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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