Safe to play a game that passes the seizure test?

I've been using charts like this one to show results of testing for adherence to photosensitive epilepsy guidelines.

Until now I’ve posted charts in this format to show whether a game meets photosensitive epilepsy guidelines…

According to a Reddit post, a game that I’ve said “passed the seizure test” triggered a seizure. Recently the same game—Hearthstone—could have been implicated in a professional gamer’s seizure that happened during a live stream. What’s going on?

I write about games I’ve tested to alert readers to the games that don’t meet internationally recognized image safety guidelines. But I don’t want to create undeserved confidence that a game that passed the seizure test will be safe for anyone with photosensitive epilepsy.

Ian Hamilton, a user interface designer who specializes in and advocates for game accessibility, clarifies the role of testing this way:

“Passing the Harding test doesn’t mean that a game is safe. It means ‘reasonably safe’ because common triggers have been avoided. Something that gets a ‘pass’ can still absolutely cause seizures.”

I regularly write that your experience may differ, that I’m not trained in quality assurance, that I test excerpts of game play, and that health and lifestyle variables affect every individual’s vulnerability to seizures at any given time. Still, the meaning of my findings could be misleading without an understanding of the limitations of the seizure test itself:

  1. the pass/fail guidelines aren’t expected to prevent seizures in all individuals
  2. the test was designed for TV images, not video games

What the Pass/Fail guidelines mean

The guidelines originated in 1994, when the UK’s agency for regulating TV broadcasting (now known as Ofcom) inserted into its code of standards some technical guidelines to accommodate viewers with photosensitive epilepsy. These guidelines, based on studies of photosensitive epilepsy and consultation with Prof. Graham Harding and other photosensitive epilepsy experts, detail flash rates and spatial patterns that typically trigger seizures in people with photosensitive epilepsy. Specifications regarding saturated red images were added later, after the 1997 Pokémon incident in Japan.

Some compromises in the guidelines were made for the sake of practicality. Criteria for acceptable images (commonly referred to as the Harding test) were developed with the understanding that they would realistically protect most individuals with photosensitive epilepsy, but not all. For example, the guidelines permit images that flash at a rate of up to 3 times per second because flash at that frequency affects only 3 percent of photosensitive individuals. UK regulators decided that was “an acceptably small risk.”

I'm taking the word "safety" out of the chart since passing the test doesn't guarantee seizure safety

…but I’m updating all the charts by removing the word “safety” since passing the test doesn’t guarantee seizure safety.

The introduction to the guidelines states that their purpose is “reducing the risk of exposure to potentially harmful stimuli.” It also concedes that even when broadcasting images that comply with the guidelines,

“it is…impossible to eliminate the risk of television causing convulsions in viewers with photosensitive epilepsy.”

Applying TV guidelines to video games

There are no formal guidelines for reducing the seizure risk from video games. A 2005 consensus paper by experts on photosensitive seizures acknowledges that additional work would be required first on the existing guidelines for TV. In the meantime, it is reasonable to use the television guidelines since the impact of screen images on the visual system is the same.

The biggest challenge in applying TV specifications to video games is explained in the consensus paper:

“These principles are easier to apply in the case of fixed media (for example, a prerecorded TV show), which can be analyzed frame-by-frame. Interactive media, such as video games, may afford essentially limitless pathways through the game, depending on user actions. Therefore …in the case of video games, the consensus recommendations apply to typical pathways of play but cannot cover every eventuality of play.”**
Also,when players set their own viewing perspectives and preferences in newer video games, they may create unanticipated seizure risks.

Reducing risk going forward

In sum, a game that fails the Harding test is best avoided by those with photosensitive epilepsy. A game that passes is less likely to act as a trigger. Despite all the qualifiers, I believe there’s value in reminding people that seizures can happen to anybody, that certain video games can trigger them, and that you can lessen the risk by selecting games without lots of flash and patterns. Other strategies to lessen the risk of photosensitive seizures can be found here and here.

Tip of the hat to Ian, who suggested that I avoid the word “safe” when describing games that have passed the test. I also will be revising my prior posts to do some rewording.

Gamer’s seizure on live stream

Here’s a reminder that seizures can happen to anyone. A professional gamer known as Lothar had a seizure recently during his live feed while playing Hearthstone on Twitch. Lothar apparently has no history of seizures and the seizure may or may not have any connection to Hearthstone. In updates about his condition and hospital stay, Lothar didn’t mention photosensitive epilepsy nor has he said he’s been advised to limit his gameplay. 

For the record, Lothar is also a body builder—he’s obviously a guy who has enjoyed good health and takes good care of himself. Lothar has a large and caring following and has been receiving lots of well wishes as he recovers. Why do I mention this incident here? Viewing the incident (you can find it on YouTube) and seeing how it affected so many fans who care about him reinforced for me the seriousness of seizures and the importance of preventing those that are preventable.

** Graham Harding et al. (2005), Photic- and Pattern-induced Seizures: Expert Consensus of the Epilepsy Foundation of America Working Group. Epilepsia, 46: 1423–1425.


The royals in New York, as viewed from the UK

Arrival of the royal couple in New York, as shown on the CBS Evening News.

William and Kate arriving in New York, as seen on the CBS Evening News.

When the Duke and Duchess of Cambridge arrived at their New York hotel this week, it was big news.  Did you catch the squeals of delight from the crowd and the flicker of so many cameras flashing? The arrival scene was featured on a number of American news programs.

 

How it was seen in the UK

This same New York arrival scene was shown in the UK as well—but with an important difference.

This same scene was shown on the UK’s Sky News. Notice anything different?

Rapid-fire flash photography from the swarm of media creates a strobe-like effect on the image, which is known to trigger seizures in some people. In the US this material is broadcast despite the seizure risk.

But for more than 20 years, TV programs and commercials flashing at frequencies that can provoke seizures have been barred from broadcast in the UK. An exception to the regulation is made for breaking news coverage, where potentially seizure-inducing material is allowed to air if accompanied by a warning. These regulations were put in place after a noodle commercial triggered seizures in several British viewers.

Out of curiosity I tested a video clip of that New York sidewalk scene to see if the flash freqency falls into the category of a seizure hazard. I used an application called the Harding Flash and Pattern Analyzer (below) that assesses video sequences for seizure safety. The clip did in fact exceed flash safety limits for people vulnerable to visually induced seizures. Folks in the UK at least got an on-screen warning, which perhaps gives susceptible viewers a chance to avert their eyes.

The flash photography did indeed create a hzard for viewers with photosensitive epilepsy. A clip of the royals arriving in New York failed the seizure safety test.

News video of the royals arriving in New York did indeed fail the seizure safety test, as indicated by the green line above the pass/fail boundary on the graph. Screen is taken from the Harding Flash and Pattern Analyzer.

What happens when American TV programs are shown in the UK?

TV programs and music videos imported to Great Britain from the US (and other countries) need to be tested first, then modified to comply with the British seizure safety mandate. An engineer in a London post-production studio who does this compliance work shared with me that a popular US crime series had nearly 150 violations of seizure safety guidelines in a single episode. Where is the consumer lobby for seizure-safe TV programming in this country? Anybody?


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?


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.


David Lynch music video: 70 safety violations

This warning is shown briefly before the video begins showing an onslaught of flashing images.

This warning is shown briefly before the video begins showing an onslaught of flashing images. This is just a screen shot, not the video itself.

David Lynch’s just-released music video for Nine Inch Nails’ “Came Back Haunted” provides more than 4 minutes of nearly constant seizure-provoking flashes and images. When analyzed for seizure safety, the video fails in 70 instances to adhere to international safety guidelines for flash, including the intermittent use of saturated red images.

Before the barrage of flashes begins, the official release on the Vevo music video website is accompanied by the following message: “WARNING: This video has been identified by Epilepsy Action to potentially trigger seizures for people with photosensitive epilepsy. Viewer discretion is advised.”

Two very big problems with this:

1. There’s a disturbing, no doubt intentional, consequence of highlighting the risk of seizures. Emphasizing that viewers are flirting with danger seems to be a marketing move. Unfortunately, this tactic does attract attention, but it trivializes the actual health risks.

2. Contrary to the claim that the UK Epilepsy Action organization determined that there was a photosensitive seizure risk in the video, Epilepsy Action’s website states that the organization was not consulted about the video. The organization is investigating and plans to continue reporting on it. A news item on the website quite correctly states, “It appears conscientious to show a warning before the video. However, many people with photosensitive epilepsy do not know they have it until something like this triggers their first seizure.” If filmmaker Lynch is conscientious, why not remove the seizure risk in the first place?

Trivializing seizures by using them for marketing

Here’s what happens when the seizure risk is used for marketing purposes. People who know nothing about epilepsy are charmed by the video’s association with seizures and use it to spice up their commentary:

“…before getting into the fact it comes with a STERN WARNING THAT IT HAS BEEN KNOWN TO CAUSE SEIZURES one must take into account it was directed by David Lynch, the man responsible for Twin PeaksEraserhead and Blue Velvet…. I know you’ll all click on the video below to see if I’m just being outlandish and overreactive (what I like to call Glenn-Beck-ish), but remember, you were warned. Also, if you’re rendered comatose (or worse), I call dibs on your watch.”

“Came Back Haunted” packs in a myriad of flashing, distorted clips interspersed with Renzor singing as the camera captures the footage in a near-epileptic state of jitter.”

I found one reasoned commentary. Instead of swallowing the seizures-as-marketing bait, Rachel at bangs.com, to her credit, sees through it:

“…who wants to just hang out and watch a dumb boring music video anyway? I want a bit of DANGER in my viewing experience!”

Safely see for yourself how seizure-inducing it is!

I recorded what happened when I tested “Came Back Haunted” with the program I use to test images for seizure safety, the Harding Flash and Pattern Analyzer. If you view the testing session, you can see what it looks like when a clip is chock full of violations of seizure safety guidelines. When viewing the clip below of the Harding Flash and Pattern Analyzer test session, seizures are very unlikely unless you stare at the upper left-hand corner of the screen at very, very close range. (Smaller images affect a smaller area of the brain’s visual cortex, making it harder to generate the requisite number of neurons misfiring to get a seizure going.)

In this clip the video itself runs at twice its normal speed in the upper left corner of the screen. The rest of the screen shows the analyzer’s findings, in a large line graph and a table that tracks the number of frames that fail the safety test. This is not a borderline case! 

Note: If you’re curious to see the offending video on YouTube in its official form, do keep in mind that since the flashing is downright nasty, the smaller you make the image on your screen, the less danger there is of triggering a seizure.

About Epilepsy Action’s role

Apart from the unauthorized and false statement that Epilepsy Action was consulted, there’s yet another problem with the claim. David Lynch is an American filmmaker, Nine Inch Nails is an American band, and the epilepsy warning refers to a British epilepsy advocacy organization that is vigilant and outspoken in monitoring photosensitive seizure triggers in popular media. Epilepsy Action has drawn the public’s attention to photosensitive seizure-provoking material in visuals broadcast on UK TV, in music videos (Kanye West) and in movies (Twilight: Breaking Dawn).

The American epilepsy advocacy community should be much more proactive and visible to the public, explaining the dangers of seizure-provoking media–including the fact that many people without “regular” epilepsy who have just photosensitive epilepsy are unaware they have the condition. If the epilepsy organizations are concerned about stigma–and they are–they need to advocate against seizure-provoking media and against demeaning portrayals of seizures that stem from photosensitivity. A whole generation of young people is forming opinions about seizures and epilepsy by reading the relentlessly insensitive stuff like David Lynch and Nine Inch Nails making “seizure-inducing magic together.”

Hat tip to John Ledford for making me aware of the video!