Signs it could have been a video game seizure

what Alice sees - colors cropped

My daughter Alice drew this image of what she typically saw while regaining full consciousness after a video game seizure

How can you tell you’ve had a seizure? That your child may have?

It can be easy to recognize a seizure in someone else–if the seizure involves classic convulsions. However, if you have convulsions and nobody is with you to witness the episode, when you regain awareness you probably won’t remember any part of the seizure. You might figure out that something like a seizure happened if you’d been sitting down before and don’t know how you ended up on the floor, or if you experience unexpected bruises or muscle soreness. But since the nature of most seizures is that you aren’t fully aware of your surroundings, you probably won’t know all that happened.

Non-convulsive seizures are tougher to detect in yourself or someone else, since some symptoms can be subtle and many could be attributed to other factors. Before, during and after a seizure people may experience strange sensations that are difficult to describe. Children in particular may have trouble realizing that what they’ve experienced is out of the ordinary and should be reported to a parent.

So a lot of seizures are never identified because they aren’t obvious. The most difficult seizures to identify are complex partial seizures, which elude detection but slow down your thinking, mess with your mood, and scramble your body rhythms for days afterward. And of course, some of the symptoms that follow the event itself, such as irritability, could be attributed to any number of factors.

While it would be good to know for sure if what you or your child experienced was a seizure, very often you can’t know.  I’ve put together a 13 Signs You Might Have Had a Seizure While Playing a Video Game list. Consider the possibility that a seizure occurred if you notice rapid onset of any of these symptoms:

seizure symptoms list

Regarding item #13, consider that sometimes you hear about people with such serious addictions to gaming that they play non-stop for many hours without a break. The common assumption is that if they wet or soiled themselves while playing, they were just too involved in the game to want to stop for a bathroom break. I think it’s much more likely that these incidents occur during the involuntary muscle movement and altered consciousness of a seizure and that the player isn’t aware of either the seizure or the mishap.

Why seizure warnings aren’t very helpful

Given the range of possible symptoms, it’s impossible for game publishers to write a meaningful seizure warning that alerts consumers to all possible symptoms. As an example, Microsoft’s photosensitive epilepsy warning—if you can find it in small print at the bottom of the  Xbox Games Stores screen–says that seizures “may have a variety of symptoms, including lightheadedness, altered vision, eye or face twitching, jerking or shaking of arms or legs, disorientation, confusion, or momentary loss of awareness.”

The link to the Microsoft Games seizure warning is not very easy to see. I've circled it for you.

I’ve circled the link to the Microsoft Games seizure warning — it’s pretty easy to miss

If you even read the warning, that’s a lot to absorb and to keep in mind while playing. Most people aren’t looking for reasons not to go ahead and play.  Nobody really wants to think photosensitive seizures could happen to them or their kids, so it isn’t until something doesn’t seem quite right that you might start trying to figure out an explanation.

What you should watch for are unusual feelings, sensations, or behavior that could indicate a seizure’s start, middle, or aftermath. Until you’ve knowingly experienced a seizure, you probably wouldn’t realize those can indicate a seizure. One clue might be if you notice the same set of symptoms happening  on multiple occasions during a particular game, or in other conditions of flashing light (fireworks or flickering fluorescent bulbs, for example).


Open letter to the BioShock creative team

BioShock Infinite logo largerCongratulations on last month’s successful launch of BioShock Infinite. The reviews are extraordinary. BioShock Infinite is said to set a new standard for what the video game experience can be. Players are moved and enthusiastic about many aspects of the game and speak effusively about their unprecedented degree of involvement with the story and characters. With all the creative energy, care, and respect for players that went into developing BioShock, though, the game–like so many others–exposes players to visuals that can cause seizures.

I examined several BioShock launch trailers and some other “footage” – a total of eight clips of a few minutes each – and assessed them using an application that identifies video sequences that can trigger seizures. Most of the material was fine, but three of the clips contained brief flashing sequences that don’t meet criteria for safe viewing. It doesn’t take more than a brief exposure to trigger seizures in those who are vulnerable.

This BioShock scene uses safe levels of flash

This BioShock scene uses safe levels of flash.

Contrary to what many gamers assume, eliminating seizure triggers doesn’t make a game boring to look at or play. Irrational Software created a visually stunning, highly engaging experience in which most of the scenes don’t pose a seizure risk. Reports of video game-induced seizures began surfacing in 1981 in newspapers and medical journals. A great deal is known about what types of images and sequences can provoke seizures.

Guidelines for seizure-free video sequences were developed in the UK more than 20 years ago. Since 1991 all television programming and commercials there are required to pass a seizure-safety test. Japan put in place a similar measure following the 1997 Pokémon broadcast that led to hundreds of seizures. In 2005 the International Telecommunication Union published recommended universal guidelines for reducing photosensitive seizures from televised material.

While all these efforts were made to reduce the risk to consumers of photosensitive seizures, video game publishers took their own action—providing printed seizure warnings. The warnings began appearing in the early ‘90s, after a few consumers filed personal injury lawsuits. Putting a seizure warning on video games has thus far provided legal cover for your industry, but offers little protection for customers.

Flash in this scene is safe, too.

Flash in this scene is safe, too.

The warnings all state that photosensitive seizures happen to “a very small percentage of people.” Seizures from flashing images are not rare, but people believe they are because that’s what the warnings say! The wording of these warnings is based on researchers’ estimates that were made decades ago, before today’s sophisticated graphics and before more recent studies that suggest that many photosensitive seizures could be going completely unnoticed. Many doctors continue to think these seizures are rare because that’s what they were taught.

If you haven’t heard many reports of seizures happening while playing BioShock, don’t assume the seizures aren’t occurring. They’re just not being identified. A person experiencing seizures is likely to lose awareness and not even realize what’s happening, or notice that a bit of time has passed that they can’t account for. Furthermore, most seizures don’t involve convulsions, and the only sign others might see could be as subtle as a short period of staring.

Whether or not a seizure is noticeable, it’s a serious event with real risks to health. It can impair health, thinking, and behavior for days afterward. Sometimes a seizure results in permanent disability.

This scene failed seizure safety guidelines.

But this screen capture from the Harding Flash and Pattern Analyzer shows that flash in the BioShock sequence shown at upper left failed seizure safety guidelines.

It’s not reasonable to expect parents to continually monitor their kids for possible signs of a seizure, particularly given that video games are played while people face a screen. So let’s turn to older teens and adults in the midst of a game, who might theoretically be more self-aware and responsible for their own well-being. Will they be vigilant for seizure symptoms such as odd sensations or altered consciousness?

Just last month in a New York Times interview your creative director Ken Levine said, “We work really hard to wear down the audience’s ability to even process. If players are immersed enough, they stop treating it as a piece of artifice and just start experiencing it.” Do you see the problem here? In this ideal game experience, how can players be expected to “immediately stop playing and consult a doctor” as the warning advises, if they develop symptoms consistent with a seizure?

With BioShock Infinite now brought to market, people are asking what your company will do next. You could easily raise the bar further for the industry by publicly committing to developing seizure-safe games. I live in the Boston area and would welcome the chance to begin a conversation about this at your headquarters in Quincy.


Lawsuits filed after games caused seizures

courtroomNo  consumer has won a product liability/personal injury case against a game manufacturer whose video game triggered seizures. Cases were either dismissed, settled, or won by the game company.

Despite their limited usefulness to consumers,  seizure warning notices do seem to provide legal protection to game publishers. And juries have a hard time awarding damages to plaintiffs with a pre-existing condition, even if plaintiffs didn’t know of their photosensitive epilepsy prior to the seizure(s) triggered by a video game.

In one case Nintendo actually conceded that its game had in fact triggered seizures, but that didn’t get in the way of the company winning the case. A judge later overturned the jury’s verdict because Nintendo had withheld critical information in contempt of court.

The cases date back to 1991, but the apparent total number of cases–ten–is pretty small.  One has to wonder what percentage of the seizures triggered by exposure to video games are ever identified as visually induced seizures.

One of the few consumers to reach a settlement is John Ledford of Alabama, whose settlement agreement bars John from discussing his own case. John has found another way to raise awareness of video game seizures. He has researched other cases and reached out to epilepsy organizations around the globe to raise their awareness of the continuing seizure hazard from video game images. John’s Facebook page contains most of the history I’ve assembled here:

Year Filed State Plaintiff(s) Game(s)/Platform/Defendant  Outcome 
1991 MI 15-year old Laura Moceri had grand mal seizure while playing. Kid Icarus (Nintendo) Lost
1993 IL Chicago boy suffered occasional seizures during many hours of game play. Nintendo Dismissed
1995 AL John Ledford had his first ever grand mal seizure while playing game at an arcade. The seizure damaged his optic nerve and caused blindness in one eye. King of the Monsters II (SNK Corp.) Settled
1998 LA 13 year-old Joey Roccaforte had clusters of violent seizures Mega Man X (Super Nintendo) Jury ruled for Nintendo; judge later vacated the decision because Nintendo withheld critical information before and during trial.
2001 LA Esther Walker, mother of 30-year old Benjamin Walker, who died from hitting his head on a table and sustaining internal injuries during a game-induced seizure. Nintendo 64 Lost
2001 LA 11 year-old Michael Martin, son of  Eric Martin, mayor of St. Martinsville, LA. Seizures that began happening during games began occurring also during sleep. Super Mario Kart (Nintendo 64) Settled personal injury claim; lost case advocating better warnings.
2001 LA 6 year –old Kynan Hebert, son of Lynette Benoit Nintendo Dismissed
2002 FL 16 year-old Dominic Zummo Star Wars Episode I: Jedi Power Battles (LucasArts Entertainment, SONY) Unknown
2007 NY While watching his brother play a game, 4 year-old boy had a seizure causing permanent injury. Spyro: Enter the Dragonfly (Vivendi, SONY Playstation 2) Last available information: attorney for plaintiff was seeking other plaintiffs for class action suit
2011 CA Navy F-18 pilot John Ryan McLaughlin injured in a grand mal seizure that causes permanent loss of flight status Oblivion: The Elder Scrolls IV (Bethesda Software), Sony Playstation 3. Still pending; no other information available.

What constitutes product liability?

In 1997 the criteria for product manufacturer’s liability for a product that has caused harm were revised by the American Law Institute, an independent body of legal experts that drafts and publishes restatements of common law in order to clarify and simplify it. Its work is used as a resource by state lawmakers, judges, and lawyers. Every state has its own laws concerning burden of proof, the awarding of damages, and the like.

The 1997 restatement of product liability law states, “a product is defective when, at the time of sale or distribution, it contains a manufacturing defect, is defective in design or is defective because of inadequate instructions or warnings.” These conditions are then defined separately:

  • A product “contains a manufacturing defect when the product departs from its intended design even though all possible care was exercised in the preparation and marketing of the product.” 
  • A product “contains a design defect when the foreseeable risks of harm posed by the product could have been reduced or avoided by the adoption of a reasonable alternative design by the seller or other distributor, or a predecessor in the commercial chain of distribution, and the omission of the reasonable alternative design renders the product not reasonably safe.” 
  • A product “is defective because of inadequate instructions or warnings when the foreseeable risks of harm posed by the product could have been reduced or avoided by the provision of reasonable instructions or warnings by the seller or other distributor, or a predecessor in the commercial chain of distribution and the omission of the instructions or warnings renders the product not reasonably safe.”

Some game companies are apparently working to make games that do not provoke seizures, but only Ubisoft has made a public commitment. As far as I can tell, most are merely reworking their warnings.


Nintendo knew about, downplayed seizure risks: BBC report

Nintendo's Mega Man X was among the four games tested by the BBC that did not meet the flashing and pattern safety guidelines used by British TV.

Nintendo’s Mega Man X was one of the four games tested by the BBC for this investigative report that did not meet  British TV seizure safety guidelines.

A BBC report on Nintendo revealed that the company knew more than 20 years ago which of its games were most likely to cause seizures–and downplayed the seizure risk to customers. A former Nintendo customer relations employee interviewed for the story said that many customers called to  complain about experiencing seizures. Because he wanted to advise customers concerned about the seizure risk, he asked the company’s R & D group for a list of the games most likely to cause seizures. 

Developers came up with a list of more than 30 games. Before the list was released to customers, he said, the company’s lawyers pared down the list to 12 – 15 titles. As customer complaints about seizures grew, Nintendo stopped releasing any seizure information about specific games. The Nintendo executive interviewed asserted that the company began making its games safer and started including seizure warnings with game instructions as soon as the problem came to their attention—in 1991.

The story, featured on the BBC’s Outrageous Fortune program in 2004, also includes an interview with photosensitive epilepsy expert Prof. Graham Harding. Using his own flash and pattern analyzer Prof. Harding shows the results of testing some Nintendo games for seizure safety.

To view the ten-minute segment about video game seizures in the report on Nintendo, first go to www.youtube.com/watch?v=0aFhW56c2Vg and fast forward to about 5:15 into the clip. The seizure segment continues at the beginning of this clip.

The documentary was never aired in the US, and I’d long since given up searching for it online. But I recently came upon it thanks to John Ledford, who has been tracking seizure lawsuits filed against the game industry. John became blind in one eye as a result of his first grand mal seizure—which occurred while he was playing a video game in 1994.


Kanye West loves strobe lights

The Harding Flash and Pattern Analyzer shows flash levels in “Lost in the World” fail seizure safety guidelines by a wide margin. At upper left is a screen grab from the new video.

“Kanye West loves strobe lights,” cooed the Huffington Post the other day, reporting the release of the performer’s most recent flash-filled music video. “…the Chicago rapper…seemingly earns an epilepsy warning with every new project. His new video for the not-so-new song ‘Lost in the World’ certainly doesn’t deviate from the pattern.”

Apparently he loves strobe lights so much that–despite being informed, two music video releases ago–that his flashing visuals provoke seizures in some viewers, he is determined to use these effects anyway. Wow, you have to really respect a man who refuses to let the health of the viewing public get in the way of his artistic freedom. The Huff Post article continues in the same admiring tone: “…the rapper is known for his emphasis on quality videos (his half-hour ‘Runaway’ short film was perhaps the biggest statement of the rapper’s visual aesthetic).”

The rapper’s acknowledgement of a potential seizure problem has followed a strange path. In February 2011, accounts of seizures triggered by West’s “All of the Lights” video spurred UK-based Epilepsy Action to request that the video be removed from YouTube. In response, the video was temporarily removed and a warning was placed at the beginning:

This video has been identified by Epilepsy Action to potentially trigger seizures for people with photosensitive epilepsy. Viewer discretion is advised.

A year later the “N—-s in Paris” video was released with this same warning, although Epilepsy Action was never contacted about it.

And now there’s a warning at the beginning of the “Lost in the World” video that doesn’t even explain why the warning is important for viewers. All it says is:

Warning:  Strobe effects are used in this video.

I expect Epilepsy Action will probably make a statement regarding the risks of viewing this latest release, and perhaps take issue with the less-than-explicit warning that was provided. How about some advocacy in the US? It’s time to confront the very preventable public health problem created by strobe effects in entertainment media.


A cynical Kanye West seizure warning

The video repeatedly exceeds seizure safety guidelines. Top left shows a screen grab. Graph shows multiple flash safety violations detected by the Harding Flash & Pattern Analyzer

Do Jay Z and Kanye West deserve kudos for placing a seizure warning at the start of their highly anticipated, flash-filled music video “N**gas in Paris”? Does a warning make it OK to produce videos known to place people at risk for seizures?

“Paris” is by far the most seizure-provoking piece of video I’ve ever tested with the Harding Flash and Pattern Analyzer. After just a few seconds it had already exceeded photosensitive seizure safety guidelines, and multiple violations continued throughout.

Because it contains a seizure warning, which was posted before anyone could complain about the seizure effects, somebody decided these guys have become considerate of those with photosensitive epilepsy. The entertainment press would like you to believe that West, who directed the video, is now sensitive to the issue of seizure-inducing images and may even have saved lives by placing a warning before the new Paris video. What a public relations coup!

“…a simple warning that Jay Z and Kanye West included at the top of their “N**gas in Paris” video may have been the difference between life and death for some of their seizure-prone fans …this according to multiple epilepsy organizations. The concern is obvious … since the video is filled with strobe lights and quick edits,” fawns TMZ.

A story headline at complex.com based on the TMZ piece reads, “CURE & Epilepsy Therapy Project Applaud Kanye West & Jay-Z for Warning in ‘Paris’ Video.” The reporter got statements from both of these highly respected US epilepsy advocacy organizations, praising the artists’ sensitivity to the epilepsy community.

Last year, when the UK’s Epilepsy Action objected to West’s very flashy “All of the Lights,” the video was temporarily removed from the Internet and subsequently reinstated with a seizure warning at the beginnning. The warning credited Epilepsy Action for determining that the video posed a seizure risk. This time around, however, without even consulting Epilepsy Action (!), the same warning was placed at the beginning of the Paris video. According to TMZ this means, “Lesson learned,” and “’Ye and Jay save the day!” Epilepsy Action, however, pointed out that while it may be good to have a warning, it would be far better if the material did not place viewers at risk of possible seizures.

Epilepsy Action notes in a statement that, “despite the concerns raised last year about the All of the Lights video, Kanye West has knowingly made another video which could be harmful to some fans watching it. We would like to see the music industry show much more responsibility by not commissioning videos that contain potentially dangerous imagery.”

The statement continues with a reminder that photosensitive seizures, especially in young people, frequently occur in individuals who don’t even know they are photosensitive. Seizure warnings are therefore totally inadequate because people incorrectly assume that if they’ve never had a visually induced seizure, they aren’t at risk. In the UK, regulations for broadcast television already require that video sequences fall within seizure safety guidelines, and Epilepsy Action is now calling for those regulations to be extended to the Internet.

Hats off once again to Epilepsy Action, and to the awareness and proactive public safety measures taken by UK communications regulators. Is anyone listening in the US and elsewhere???


2011: Inching toward fewer seizures from flashing electronic media

A huge amount of work is needed to protect consumers from the seizures triggered by flicker and flash from screens of everyday electronic media. But in 2011 there were some notable milestones in public awareness and prevention of photosensitive seizures. In no particular order, these are the year’s top five developments:

  1. A scene in the film Twilight Saga: Breaking Dawn triggered seizures in some audience members, most of whom had never experienced seizures before. Publicity about the seizures led to warnings by the UK’s Epilepsy Action and the Epilepsy Foundation of America. The film’s distributors provided a warning that cinemas could opt to provide to audiences. Although seizures triggered by movies shown in theaters aren’t common, this story brought wider attention to the risk of seizures from visual entertainment stimuli.
  2. Multinational game developer and distributor Ubisoft released a developers guide for creating video games that will not provoke visually induced seizures. Presumably it translates international guidelines for visual seizure safety into specific protocols for programmers. However, the guide is available only to member companies of TIGA, theUK’s trade association for video game developers and publishers.
  3. After the UK’s Epilepsy Action notified YouTube that an extended flashing segment in Kanye West’s music video “All of the Lights” could trigger seizures, a seizure warning was placed at the beginning of the video. It would be far better to fix than to keep the problem segments as is, even with a warning. Nobody pays attention to warnings, especially those who so far haven’t had a photosensitive seizure.
  4. Results of the first study to examine the rate of photosensitivity in young people on the autism spectrum were announced. They showed this population is at significantly increased risk of visually induced seizures. In young people 15 and older on the autism spectrum the photosensitivity rate is 25 percent. More studies are urgently needed, but with results as significant as these, more research will certainly be funded. While the study authors were focused more on commonalities in the roots of epilepsy and autism than on environmentally induced seizures in everyday life, the findings provide data that can be put to use immediately. The authors caution that it was too small a study (approximately 200 subjects) to merit placing limits on screen time. Nonetheless, parents of young people with autism spectrum disorders might want to be especially watchful of their children’s exposure to flashing electronic screens and any behaviors associated with screen time.
  5. Lenses that protect against visually induced seizures became readily commercially available. Zeiss F133  (previously known as Z1) cross-polarized, blue lenses can now be obtained from optician Antonio Bernabei, who ships worldwide from Rome. The lenses were developed by Zeiss with Italian photosensitivity researchers who demonstrated their effectiveness in clinical studies. In a study of people vulnerable to visually-induced seizures, while wearing the lenses 76 percent showed no abnormalities on EEG when tested with photic stimulation, and another 18 percent showed reduced EEG activation. Only 6 percent did not benefit at all. Until Bernabei began offering the lenses this past year, consumers and clinicians were unable to locate them without encountering a lot of dead ends.

These developments are more significant for the general public than most people realize because photosensitive seizures are not at all limited to individuals with epilepsy. Nobody knows for sure how many consumers experience visually induced seizures—including the small, unseen seizures that are never identified or reported. Three quarters of the affected people have no known history of seizures, no suspicion that they have this genetic vulnerability to flickering light, and therefore no prevention strategies. Onward to more progress in 2012!


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