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, 4 contained seizure-provoking sequences, and the remaining 3 had sequences that approached the safety limits. 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
  • players will encounter game scenes I didn’t analyze 
  • sitting farther away from the screen and taking frequent breaks can lessen the images’ visual impact

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.


Batman “Arkham” games could make you seize

Batman logoHoly 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.

Batman Arkham Origins

Batman: Arkham Origins (2013)

Batman: Arkham Origins Blackgate for DS3 and PS Vita (2013)

Batman Arkham City

Batman Arkham City (2011)

Batman: Arkham Asylum

Batman: Arkham Asylum (2009)


Some doctors too reassuring about seizure risk

Howcast's video, "What Is Photosensitive Epilepsy (PSE)?"

The Howcast video, “What Is Photosensitive Epilepsy (PSE)?” is apparently designed to be upbeat and reassuring to families worried about video games.

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.”

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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.”

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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.  

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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.”

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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.  

7/19/2014 update: See information on a study showing just 6.2 percent of patients with visually induced seizures tested positive for photosensitivity in the photic stimulation EEG procedure.

——————————————————————————————————————————————————————————————————

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.
  • question reliance on EEG and photic stimulation to diagnose vulnerability to visually induced seizures

It’s a big job. It’s a much bigger undertaking than I can even imagine, but it needs to be done.


David Lynch music video: 70 violations of guidelines for reducing seizures

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!


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).


Video gaming while driving: not a good idea!

This photo in the UK's Daily Record newspaper led to the identification of the driver.

After this photo was published in the UK’s Daily Record newspaper, the “reckless” driver who played a game while driving was identified and charged.

This week a motorist in Scotland was seen—and photographed—playing the video game Real Racing on his iPad while driving on a highway at 65 miles per hour.

In this country some states have laws that prohibit texting or phoning while driving. Most people realize that using any electronic device while driving is a distraction that impairs the driver’s judgment and attention, placing him/her plus any passengers, pedestrians, and nearby drivers at risk. It’s risky and unwise, and illegal in some places, but it’s a widespread practice nonetheless.

Gaming while driving is beyond reckless. Think of it: what if, in addition to the game creating a dangerous distraction, the images trigger a seizure in the driver? Even a brief seizure of a few seconds, especially at 65 mph, could lead to tragedy.

I tested lots of “footage” of Real Racing on the flash and pattern analyzer that determines whether digital image sequences fall within safety guidelines for photosensitive epilepsy. Although this particular game tested within the safety limits for luminosity/flash rate/pattern movement, many other games don’t. Maybe this driver only drives while playing games that pass the seizure safety test…and plays the rest at home.

Scottish police have brought charges against the 20-year-old suspect. “Motoring groups and politicians have condemned his antics,” according to the Daily Record. Read more