Disenfranchisement of reflex seizures ending?

The new definition of epilepsy makes it clear that reflex seizures "count" as evidence of epilepsy. In previous definitions, this was not explicity stated.

The new definition of epilepsy makes it clear that reflex seizures “count” as evidence of epilepsy. In previous definitions, this was not explicity stated.

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 new 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. Perhaps the inclusion of reflex seizures in the epilepsy definition will help dispell the idea that reflex seizures are rare.


Removing seizure triggers doesn’t spoil the fun

A short video clip on the website of Vanderquest Limited simultaneously shows a music video both before and after changes were made for photosensitive epilepsy safety. Read on for a link to it.

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?


Can handheld games trigger seizures?

Nintendo's 3DS console

Nintendo’s 3DS console

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:

Professor Layton & Azran Legacies, One Piece Romance Dawn, Mario Golf World Tour, Lego Movie, Yoshi's New Island, Super Smash Brothers, Mario Party Island Tour, CHantae & the Pirate's Curse, Retro City Rampage, Professor Layton vs Phoenix Wright, Kirby Triple Deluxe, Chi Bi-Robo Photo Finder, Bravely Default, Conception II

14 Big 3DS Games of 2014, published January 30, 2014 on IGN.com

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.


Images in race car games can provoke seizures

racing games driver's view (580x305)

Rapidly changing scenery can include image sequences that trigger seizures.

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.

During a rapid airborne rollover in Dirt 2, the road appears at the top of the screen. This sequence of flipping images violated  seizure safety guidelines.

During a rapid airborne rollover in Dirt 2, shown in this screen grab, the road appears at the top of the screen. This sequence violated seizure safety guidelines.

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:

Driver - San Francisco, Split Second, Grid 2, Forza Horizon, Wipeout 2048, F1 2011, Dirt 2

The fast action of racing games means higher seizure risks.

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.


Task force may look into video game seizures [updated]**

The Massachusetts State House in Boston, where a bill was filed to investigate video game seizures as a public health issue.

The Massachusetts State House in Boston, where a bill was filed to investigate video game seizures as a public health issue.

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.


Safe, unsafe video games enter the classroom

The flash level in this Minecraft scene could provoke a seizure.

Flashing in this Minecraft sequence exceeds safety guidelines for photosensitive epilepsy and could provoke a seizure.

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.

Fallout 3

Portal 2

Armadillo Run

Heavy Rain

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.


Grand Theft Auto V looks seizure-safe

Grand Theft Auto V passed the seizure safety assessment test.

Grand Theft Auto V passed the seizure safety assessment test. This scene got close to the safety limit but stayed within it.

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.

Even a scene like this in GTA IV passed the safety test (in the caution zone).

Scenes like this in Grand Theft Auto IV (2008) also passed the safety test because they did not employ quick sequences of alternating light and dark images.

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.

GTA III (2001) contained flickering scenes such as this one that failed the seizure safety guidelines because of rapidly alternating lighting levels.

GTA III (2001) contained flickering scenes such as this one that failed the seizure safety guidelines. Rapidly alternating light, from dark (screen above) to bright (screen below) and back, create a strobe-like effect.

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.

A well lit screen alternating with the darker version above can trigger seizures if the flicker occurs 3 times per second or more.

This brightly lit screen alternating with the darker version can trigger seizures if the flicker occurs 3 times per second or more.

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.


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