A new definition of epilepsy published this week affirms that photosensitive and other reflex seizures qualify as “real” epilepsy. This clarification may eventually help increase awareness of seizures from video games and other electronic media.
Although reflex seizures have long been included in official classification schemes of epileptic seizures, they don’t fit cleanly into established categories of seizure types and epilepsy syndromes. In neurology training they are typically mentioned only briefly. And typically they are taken too lightly by doctors using the prevailing diagnostic criteria for epilepsy: at least two unprovoked seizures at least 24 hours apart.
Because reflex seizures, by definition, are provoked by specific triggers, there’s confusion and most doctors have been reluctant to diagnose epilepsy in people whose epileptic seizures require an environmental provocation. The authors of the new definition paper acknowledge this:
“Under limits of the current definition, [a] patient might have photosensitive epilepsy, yet not be considered to have epilepsy because the seizures are provoked by lights…People with reflex epilepsies previously have been disenfranchised by the requirement that seizures be unprovoked. The inclusion of reflex epilepsy syndromes in a practical clinical definition of epilepsy now brings these individuals into the epilepsy community.”
Diagnostic criteria under the new definition now include at least two unprovoked or reflex seizures at least 24 hours apart. The new definition also allows an epilepsy diagnosis after a single seizure–either unprovoked or reflex–if there is a high probability of recurrence.
I’ve written previously about the inconsistency inherent in using the criterion of “unprovoked” to diagnose epilepsy in people whose seizures happen only in response to sensory triggers such as flashing light. This thinking (along with the assumption that photosensitive epilepsy is very rare) has led to marginalization of reflex seizures in the research community and among clinicians as well. Marginalization means doctors have been underdiagnosing reflex epilepsy, researchers seeking funding pursue other topics to study, and the public and public policy makers are largely unaware of the public health issue of photosensitive seizures.
The practical clinical definition was developed by a 19-member multinational task force of the International League Against Epilepsy (ILAE), incorporating input from hundreds of other clinicians, researchers, patients, and other interested parties. I’m more than pleased that the ILAE is choosing to make it clear that reflex epilepsy deserves the same respect as other forms of the disease (the same definition paper characterizes epilepsy as a disease rather than a disorder). It’s fortunate that the chair of the ILAE task force that produced the new definition is Robert Fisher, MD, PhD of Stanford, lead author of the 2005 consensus paper describing seizures from visual stimulation as “a serious public health problem.” No doubt Dr. Fisher’s appreciation of the magnitude of the problem was instrumental in ensuring that the task force addressed it.
Not all epileptologists agree with all aspects of the new epilepsy definition–and Epilepsia has given them a voice as well, publishing half a dozen commentaries, all of which are available free online. I contributed a piece as well, providing a patient/family perspective.
Of course, it remains to be seen how long it will take for neurologists to shift their attitudes and diagnostic practices regarding reflex epilepsy–and whether that shift helps draw attention to the problem of seizures provoked by electronic media.
Gaming fans who object to the concept of seizure-safe games have some major misconceptions about how their favorite games would look after seizure-inducing visuals are removed.
I’ve seen people in online forums threaten to stop their game subscription if the game’s images are made safe. These folks are assuming that making safety modifications to the graphics will mean “neutering” the game experience in a way that ruins their enjoyment. In fact, very minor changes to images, which can be pretty hard to detect, are often all that’s needed.
Thanks to extensive research that defined the characteristics of images that induce seizures, it’s possible to make small changes that interrupt any such seizure-generating sequences. For example, after changes are made to some video frames, the flash interval–more than 3 flashes per second–which can lead to a seizure in people with photosensitive epilepsy, no longer induces seizures.
Want some proof?
NOTE: For those with visual sensitivity, before you click on the upcoming link to side-by-side videos, know that you should be able to view the page safely because the problem images aren’t very large. If you’d prefer not to risk it, you might want to step back farther from your screen or cover the left side of your screen, because that’s where the problem images are.
Now click to see the side-by-side images of a music video running in its original form (with safety violations) and after modifications were made to comply with seizure safety guidelines (in the UK, they’re requirements, not guidelines). The changes are very subtle! Can you find them? As you’ll see in the modified version, even visual sequences that contain some flashes and quick cuts can therefore pass the safety test. Basically, portions of some flashing sequences (9 instances) have been altered or removed, which does little to change the overall viewing experience. Edits to the video that allowed it to be broadcast were done within a single day by London-based post-production firm Vanderquest Limited.
Readers familiar with the Harding Flash and Pattern Analyzer that I routinely use to test video material for seizure safety will recognize the HFPA results shown beneath both versions of the music video. Although the original, uncorrected official version could not be broadcast in the UK due to regulations barring seizure-inducing material from being shown there, it lives on on YouTube.
Imagine these types of edits to the user interface of a video game. Exactly how do they ruin the gaming experience?! Or artistic expression?
Think the screen of a handheld game is too small to provoke seizures?
It isn’t. Games on the 2.9 inch screen of Nintendo’s Game Boy Advance SP provoked quite a few seizures in my daughter when she owned one ten years ago.
Nintendo’s current handheld is the popular 3DS console, which has a 3.5 inch screen. I recently tested some 3DS games to ascertain their seizure safety.
The rule of thumb (as it were) is that, for flashing and patterns to trigger seizures, the provoking image must take up at least one fourth of an individual’s visual field. It’s not unusual for kids to hold their portable games at close enough range for that small a screen to fill that much of their total view. Incidentally, although concerns were raised when the 3DS was introduced three years ago, there isn’t any conclusive evidence that 3D effects increase the risk of seizures in people who are photosensitive.
The IGN.com website recently identified the 14 most anticipated 3DS games for 2014 release. Here’s how they fared when tested for compliance with guidelines for preventing visually induced seizures; 6 of the 14 failed, and an additional 5 came close. Tests were done using the Harding Flash and Pattern Analyzer.
Here is how these highly anticipated 3DS games performed as far as meeting image safety guidelines for preventing photosensitive seizures:
Yes, there are seizure warnings on all game packages, but the warnings are pretty worthless for consumers. A year ago I posted about Nintendo being fully aware of, but publicly downplaying, the risk of seizures from its games.
Parents concerned about their kids playing shooter and adventure games that feature a lot of violence may feel more comfortable with the racing game genre. But these games aren’t necessarily harmless–because they contain lots of images with the potential to trigger seizures in those with photosensitive epilepsy.
Problem image sequences in racing games involve lights and patterns in a variety of scenes, such as:
- close-ups of rotating wheels/tires
- revolving scenery as seen by driver when cars do airborne flips
- collision impact shock, lighting change, and vibrations
- fast-moving patterns of quickly changing views of bridges, tunnels, and landscape features
I tested clips from 7 recommended racing games listed on a site that reviews video games, movies, music, and other media, and advises parents on their content. The potential of particular games (or any other media) to provoke seizures is absent in product reviews on this site and others.
Of the 7 games, 5 contained seizure-provoking sequences. The very fast-paced action and inevitable crashes provide many opportunities for visual overstimulation, although some of the games with equally exciting visuals did not actually fail the seizure safety test.
My results were arrived at using the Harding Flash and Pattern Analyzer, a tool for determining compliance of video images with guidelines for prevention of visually induced seizures. Your results may vary:
- settings on your monitor affecting brightness, contrast, and other visual effects can raise or reduce the demands on the visual cortex
- factors such as fatigue, illness, alcohol, etc. temporarily lower an individual’s seizure threshold
- sitting farther away from the screen and taking frequent breaks can lessen the images’ visual impact
Although players will encounter scenes in the game that I didn’t analyze, making adjustments such as those above can significantly reduce an individual’s risk of visually provoked seizures.
Here are the results from the Harding Flash and Pattern Analyzer:
Methodology: I ran multiple video clips through the analyzer, including official announcement trailers and gameplay clips uploaded by users. If the initial test for a game didn’t show safety violations, I continued testing up to an additional 6 – 8 clips for each game before moving on (or until a failure occurs, if that came first).
I’ve previously tested multi-player, role-playing games (MMORPGs) and first-person shooters. Overall, based on my samplings of these genres and racing games, MMORPGs are least likely to trigger seizures.
Massachusetts State Rep. Ruth Balser has filed a bill calling for a working group to examine video game seizures as a public health issue in Massachusetts. The bill has been assigned to the Joint Committee on Public Health, where Rep. Balser is a member. I had met with her a couple of years ago to share my concerns about video game seizures as an underrecognized public health problem, particularly in young people.
To date, state legislatures have considered proposals to limit access by minors to “mature” and violent game content, and one legislator in New York State has proposed that signs be posted warning of possible seizures wherever video games are sold or rented. There have been no proposals like this one in Massachusetts, where the issue of concern is the public health problem of the seizures precipitated by video games. It’s my hope that this can be investigated and discussed in a straightforward way without all the emotion that gets people so polarized whenever the game industry and its supporters are asked to respond to concerns.
The goal of this initiative is not to spoil anybody’s leisure time activities, or put game developers out of business, or take away anybody’s right to play games. It’s to reduce the risk of seizures while consumers play video games. The issue needs public discussion, and a thoughtful report prepared in the interest of public health is a good way to start.
I’m learning about the process of enacting legislation in this state. The bill was formally introduced to the Joint Committee on Public Health in September: I provided articles on photosensitive epilepsy and letters of support for the bill, and made a very brief oral statement.
The next step for the bill involves the Committee’s Director of Research, who will review the background information and support letters I provided. He will then recommend to the Committee’s House and Senate Chairs whether the bill should receive consideration by the full committee. In December, before he makes that recommendation, I will meet with him to discuss the issues and answer any questions. Stay tuned–in the coming weeks I’ll report on the progress of Mass. House bill H1892.
**3/31/14 update: There won’t be any further progress on the bill during the current legislative session (that ends at the end of the year). I’ve learned that this effort requires a lot more work than an individual can contribute…it was a valuable experience, and the door is open to file a revised version of the bill in future legislative sessions.
Playing video games during school used to be against the rules, but not anymore. In fact, more students play them in school now, and not necessarily because they’re bored. Popular video games are being brought by teachers into the classroom as teaching tools.
While parents can monitor which games their kids play at home, when an entire class is working on projects in Minecraft—as part of the history curriculum–parents may not know or have any say in the matter. If parents have concerns about the teacher’s choice of games, they’re typically thinking about age appropriateness of content or the amount of violence depicted. The likelihood of particular games triggering seizures is unlikely to be on anyone’s mind. Shouldn’t the games our kids are exposed to during school pass tests for seizure safety?
Some years ago I observed my daughter in math class using an educational application to practice “math facts.” She had nothing to do after she’d finished the in-class assignment, so she was sitting in front of a program that ran a flashy screen sequence to reward students for getting a certain number of answers correct. We had already requested that she not be exposed to computer screens during school. I began to wonder what other video games were being used in school and whether they might possibly provoke seizures.
Since then computer use in schools and elsewhere has grown tremendously. Teachers are increasingly incorporating more complex games into the curriculum to engage students and provide more creative, immersive, open-ended learning experiences. Using World of Warcraft, Minecraft, Civilization, and other games teachers are providing instruction in such diverse skills as problem-solving, collaboration, resource management, narrative style, and inference, and in subjects such as government, history, and language arts. This trend is expected to grow as more teachers enter the workforce who grew up playing these immersive games.
Which of these games are safe?
Recognizing the opportunity for a huge new market and a promising approach to raising student engagement and performance, video game companies and teachers are now collaborating on developing school-friendly versions of popular games. The education consultancy TeachThought recommends six video games as platforms teachers can use to enrich instruction in any content area at any grade level:
The Elder Scrolls IV: Skyrim
Civilization V – one minor safety violation in about a dozen gameplay clips and trailers.
Using the Harding Flash and Pattern Analyzer, I tested these six for compliance with internationally developed guidelines for image safety for individuals with photosensitive epilepsy, . Only one game—Armadillo Run— had real potential to trigger seizures. Surprisingly, it’s also the only game in this group that has no fiery explosions, villains, or monsters that typically generate the problem flashes in video games. Instead it’s a puzzle game showing simulated action of shapes and patterns, with a clean and appealing illustration style. Without actually testing a game for seizure safety, you can’t make assumptions about what’s safe and what isn’t.
When I previously tested World of Warcraft and other MMORPGs, and again in more extensive recent tests, I didn’t find a seizure problem. Minecraft, however, contains images that can trigger seizures in individuals with photosensitive epilepsy.
With so many games to choose from, there’s no telling which will be incorporated into classroom instruction and homework. And teachers (as well as students, parents, and doctors) don’t know which games are seizure safe. (Most game companies probably don’t know, either.) When choosing video games as teaching tools, teachers are likely to be swayed by other factors: their level of familiarity with the game, recommendations of colleagues, the relevance of story lines to the curriculum, and the degree of age appropriateness for their students.
How to get people to pay attention to the image safety issue? More on that in my next post.
Say what you like about the just-released Grand Theft Auto V, but it’s not likely that the game will trigger seizures. You’d think an action-adventure game like this would be full of bright screen flashes that pose a seizure risk. I tested a lot of trailers and game play clips and didn’t find any scenes with unsafe-for-seizures visuals. Your results could vary, of course.
But I’ve got a hunch the folks at developer Rockstar Games are making the effort to make the game safe. In a few instances the flash level got close to the safety limit, but didn’t go past it, which makes me think the developers know where the official limit is (3 or more flashes per second) and have decided to respect it. While it’s possible that someone could, under the right circumstances, experience a seizure even when the flash level is near but below the danger zone, the chances of that happening aren’t high.
Unlike many immersive games with missions and quests, GTA isn’t set in an exotic fantasy world, where art directors might claim the need for artistic freedom (to use whatever visual effects they deem necessary). It’s not full of bright, flashing explosions. The appeal of the game is in the very down-to-earth characters, story lines, and realistic settings–not the quality of the visual experience.
Grand Theft Auto has evolved quite a bit since its beginnings as an arcade shooting game in 1997. The visual style of earlier versions, from 2001 GTA III and prior, is noticeably more jarring: jumpier, more flash, and indeed, a GTA III trailer failed the safety test.
Guidelines for seizure-free video sequences were developed more than 20 years ago in the UK in response to seizures provoked by TV. In 2005 the International Telecommunication Union, an agency of the United Nations, published recommended guidelines for reducing photosensitive seizures from television. These guidelines for safe flash rates and pattern movement could be applied to any screen-based media. I tested downloaded trailers for compliance with the safety guidelines using an application designed for this, the Harding Flash and Pattern Analyzer.
In its first three days after its launch last week, the game grossed a billion dollars in sales, setting a record for any kind of entertainment release. So much for the argument that making games safe will spoil all the appeal and fun.
Actually, maybe revealing that the game won’t cause seizures is not good PR for the company. Somehow a safe game doesn’t seem in keeping with GTA’s guys-will-be-guys attitude. Maybe Rockstar would prefer that customers don’t realize the game seems to lack seizure-provoking images. The average GTA player may not want to feel that the game has been “softened” in any way. In GTA culture, playing a seizure-safe game is probably for wimps.
Holy flashes, Batman! The Caped Crusader apparently doesn’t look out for people vulnerable to photosensitive seizures. The next game in the hugely popular Batman game franchise fails to meet photosensitive epilepsy image safety guidelines.
Batman: Arkham Origins will be released October 25 containing image sequences that could give you a seizure. If you are concerned about the risk of seizures, steer clear–or make sure to wear your blue Bat-lenses to block out seizure-provoking scenes. I tested official release trailers for the game and for Arkham Origins: Blackgate, a version just for handhelds, and found episodes of excessive flash in both violations. Of course, your results may vary, because with games it’s impossible to anticipate all potential screen sequences.
The previously released Batman: Arkham video games can trigger flash-induced seizures, too. , With the same image sequence analysis tool I tested earlier Batman: Arkham games, Arkham Origins and Arkham Asylum, to see whether they fail as well. Indeed, they do. All three are portrayed not in old-fashioned comic book style, but in the style of today’s typical online adventure games.
Shown below are screen captures from the analysis tool as it assesses each of these titles. For those unfamiliar with the format of these test results, click on the screen to see it full-size. The upper left corner shows the specific video frame being analyzed. Underneath is a table showing the safety violations involving flash rate, red flash, and patterns. The bulk of the screen is a graph reflecting how video sequences from the game trailers measure up against international guidelines for preventing photosensitive seizures. Each second of video is composed of a sequence of 29 individual frames, and across the bottom of the screen the frames are shown in sequence in the video.
You know how you’re not supposed to trust all the medical information on the Internet? Very true, and sometimes it’s actually the medical professionals who are placing material online that is oversimplified to the point of being misleading.
Trying to explain photosensitive epilepsy in a video of a minute and a half is pretty tough, and a Howcast clip that attempts to do that is just full of statements that make me very uncomfortable. It’s one of a series of videos on different aspects of epilepsy, but the presenters, despite their epilepsy expertise, aren’t necessarily experts in the specialty of photosensitivity. Photosensitive seizures are considered so out of the mainstream of epilepsy that few epilepsy specialists know a great deal about them.
The video in question, uploaded a year ago, features a pediatric epilepsy nurse and the Director of Pediatric Epilepsy at highly respected hospitals in New York City. My own qualifications for assessing the content of their video are found here. I’m quite certain that I’ve read more of the research on photosensitive epilepsy and seizures triggered by video games than anyone on the planet who isn’t a photosensitive epilepsy specialist. There are very, very few photosensitivity experts in the US.
This video downplays the overall prevalence/likelihood of photosensitive seizures, and it doesn’t address photosensitivity in people with no other seizures. And it overstates the conclusiveness of EEG for identifying seizure activity. Epilepsy clinicians and advocacy groups tend to want to reassure young patients and their families that in the vast majority of cases, video games and other flash-filled leisure pursuits don’t pose a seizure risk. While it’s good to encourage patients to live lives that are as normal as possible, the oversimplified message promotes the view that photosensitive epilepsy is quite rare and that doctors can know for sure, based on EEG testing, whether an individual should worry about video games as a seizure risk.
If you want to watch the video, please come back here to read my responses to what’s in it! Here’s a transcript with my comments in blue.
————————————————————————————————————————————————————————————————————-Nurse: “You know, whenever anybody comes into the office, they always ask us first thing whether epilepsy can be triggered by strobe lights, and people often think back to when the first Pokemon movies came out and all those children in Japan seized during the movies. So photosensitive epilepsy is something people worry about all the time.”
Two issues here:
1) Epilepsy is a condition that makes people vulnerable to seizures. It’s the seizures that are triggered; the epilepsy condition already exists. Why take issue with such a seemingly minor point? Being less than careful in how she worded things allowed a doctor in a WebMD video to incorrectly reassure viewers that video games cannot cause seizures!
2) The problem is much bigger than the population of epilepsy patients who come in to be evaluated by neurologists–people with no seizure history may develop photosensitive epilepsy (for example, the Navy pilot who can’t ever fly again after having a grand mal seizure while playing Oblivion: The Elder Scrolls IV). The general public, though–which presumably is the audience for this video–doesn’t worry enough about it. The epilepsy community should be doing more outreach to the general public to let them know they could be at risk.
Doctor: “On all the video games there’s those warnings that say, you know, you shouldn’t play this game in case you have epilepsy. But only one specific type of epilepsy has photosensitivity to it, and that’s a generalized epilepsy, that’s when the whole brain turns on all at once–”
This is what neurologists believed in the past. But numerous studies in the last 20+ years show this is not the case. A 1994 paper that included a review of other studies concluded that about 30 percent of photosensitive seizures are partial seizures—which do not involve the whole brain. The doctor’s statement could lead viewers to think that only people with generalized (typically grand mal) seizures need to worry about photosensitivity.
Nurse:…”lights up all at once, there’s a big burst of electricity through the whole brain. It’s one of the reflex epilepsies, so kids for the most part with epilepsy can play video games and can go under strobe lights unless they very specifically seize when they’re under strobe lights, and when we do the EEGs, we do the tests of their brain waves, we actually flash lights at them to see if it does create a seizure.”
The intermittent photic stimulation procedure used during EEG measures the brain’s reaction to a strobe light. The effect of a strobe light on the brain is not equal to the effect of playing a fast-moving, flashing video game. Some people who don’t respond to the strobe light can have seizures in response to video games or other visual stimuli. Studies of video game seizures frequently include individuals who experience seizures from games but do not test positive for photosensitivity. Photosensitive epilepsy in the research literature describes epileptic discharges on EEG in response to a strobe light in a laboratory. Some studies discuss non-photosensitive video game seizures: people who have the seizures even though a strobe light doesn’t produce signs of epilepsy on an EEG.
Doctor: “So by doing the EEG and flashing the lights in the child’s eyes, and having the EEG run at the same time, we can conclusively tell families whether the children can play video games or not play video games, and that will make a child very happy, hopefully finding out that it’s perfectly safe to play the video games and that they don’t have photosensitive epilepsy.”
EEG doesn’t conclusively rule out any type of seizure! It can confirm seizures but cannot rule them out since the technology does not detect all seizure activity. Some people who have seizures have normal EEGs. Oddly enough, in another video, What’s the Difference between Seizures and Epilepsy?” featuring the same clinicians in the same Howcast series, they contradict their statements in the first video, conceding that some seizures are too located too deep inside the brain to be detectable by EEG on the scalp.
Nurse: “As well as the teenagers and the young adults who will call or text and say, “Can I go–we’re going to a party and I know there’s going to be strobe lights. Is that OK?” So at least we have an answer for them after we’ve done the initial EEG.“
Photosensitive epilepsy is a genetic trait that is dormant until it becomes activated by a combination of factors. The most common time for the disorder to emerge is in adolescence. Thus a child who shows no signs of photosensitivity (again, based on testing with strobe lights, not video games) may later experience photosensitive seizures.
We need epilepsy clinicians and advocacy organizations to:
- be more concerned about the many visual stimuli in our environment that can trigger seizures
- think more broadly about who may be at risk–including members of the public who have no other seizures
- convey their concern about hazardous visual stimuli to the public, the digital entertainment industry, and lawmakers
- push for public policy changes that will rein in the stimuli and reduce the occurrence of visually triggered seizures.
It’s a big job. It’s a much bigger undertaking than I can even imagine, but it needs to be done.
A study released today in the journal Pediatrics confirms what a lot of parents have already figured out: kids with autism spectrum disorders (ASD) and kids with ADHD spend much more time playing video games than typically developing peers and “may be at particularly high risk for significant problems related to video game play, including excessive and problematic video game use.” Only boys participated in the study merely because both disorders are diagnosed more frequently in boys–there is no reason to expect the results would be any different if girls were included.
The study notes that in the general population, long-term. excessive video game use can have a variety of detrimental effects. “Although longitudinal research [collecting data on a group of subjects over an extended time] is needed to examine the outcomes of problematic video game use in these special populations…the current findings indicate a need for heightened awareness and assessment of problematic video game use in clinical care settings for children with ASD and ADHD.” Of course, many kids start playing video games before they are diagnosed with ASD or ADHD, so maybe the heightened awareness and assessment should extend to all kids?
Well, this is a first step, to compare, as this study did, behavioral characteristics and game usage of neurotypical kids against kids with ASD and ADHD. The problem with these studies is that all they can point to is associations between behaviors and game use in the three cohorts. No causality. There’s an association between attention problems and problematic video game use, which means the attention problems could already exist or could be the result of game use (or both, probably). The study calls for longitudinal studies (following the participants over a long period of time) “to examine the long-term effects of screen-based media use in children with ASD.”
Without waiting for the results of a longitudinal study, researchers could find out pretty quickly how the brain responds to video games in kids with ASD and ADHD and in neurotypical peers. Hook up all three groups to an EEG while they play, note the differences in the way their brains react. Track brain activity when they aren’t playing, and compare it to their activity in front of a game. This provides the opportunity to show causality. Despite the drawbacks of EEG, it’s the most practical tool for this type of study.
I’m willing to bet that the rate of seizures (especially the kind you can’t see) detected during playing is higher in the ASD and ADHD kids. The seizures and seizure-like abnormalities in brain waves have an immediate effect on cognitive function (including attention/focus)and behavior. Inability to focus is a very common post-seizure symptom, and it can last for a day or two after a seizure. A child who plays video games often and who has this sort of neurological response to video games may therefore exhibit inability to pay attention and other behavioral difficulties all the time.
I’m still eager to have researchers take up the pilot study I proposed a few years ago that looks at the EEGs of ASD kids and neurotypical kids, both at rest and while playing video games. In the meantime, whether or not the studies are telling us something totally new, if they encourage parents to think more carefully about their children’s gaming habits and question possible links to behavior issues, that’s a good thing.