Non-suicidal self-strangulation among adolescents in Saudi Arabia: Case series of the choking game

Abstract

Adolescence is known to be a time of exploration and initiation of risky behaviors. Much attention has been given to risk behaviors such as smoking, violence, and sexual promiscuity; other serious behaviors such as self-strangulation or the choking game, which is carried out by adolescents in response to peer pressures or to gain a transient sense of euphoria, have received little attention, with the available literature coming from the developed world. This is the first report of cases of non-suicidal self-strangulation from the Arab World. In this case series, we report 5 cases of non-suicidal self-strangulation that presented to the Emergency Department of a tertiary care hospital in Riyadh, Saudi Arabia during 2010-2012. All of the 5 cases were young male adolescents aged 10-13 years. This activity resulted in the death of 2 boys; one boy sustained hypoxic ischemic insult to the brain with clinical deficits; and the remaining 2 were fortunate to be discharged home in healthy condition. None of the cases had underlying mental health problems, and multidisciplinary involvement ruled out suicide and homicide activities. Non-suicidal self-strangulation is a fatal behavior that adolescents engage in. Increased efforts are needed to address this serious and preventable public health issue. Awareness and education of adolescents and their parents is crucial. Awareness of healthcare providers is also necessary in order to avoid misdiagnosis of such cases.

Adolescent Mental Health and the Choking Game

“…In fact, various negative short-and long-term health outcomes from engagement in the CG have been reported, including chronic headaches, changes in behavior, confusion, short-term memory loss, recurrent episodes of syncope, seizures, retinal hemorrhage, visual impairments, neurologic damages, and death. 1,5,[10][11][12][13][14][15] Given the newness of this area of research, the data concerning the CG are still limited, and relatively little is known about the clinical characteristics and the underlying motivations of adolescents involved in this potentially lethal behavior. Hence, continued scientific investigation is necessary to advance research in this field.…”

“Brincadeira do desmaio”: uma nova moda mortal entre crianças e adolescentes. Características psicofisiológicas, comportamentais e epidemiologia dos ‘jogos de asfixia’

“…However, authors 11,16,21,25,31,32 have stressed that most children/adolescents who take risks by engaging in asphyxial behaviors do not have the intention of dying. They are unaware that they are being auto-aggressive, but instead they are behaving like curious children and young people who are eager to experience new physical sensations 16,18 and who need to feel secure about their own sense of existence 13,33,34 .…”

Clinical Consequences of Self‐Induced Hypocapnia

“…It is thought that many of the deaths result from engagement in this activity while alone. 2 The internet is a dangerous source of information about such games. Multidisciplinary work with psychologists and educators and participation in community prevention programs is required.…”

“…Individual practice is associated with increased risk of mortality. 2 This patient was of particular interest because the mechanism used (holding the breath and getting punched in the chest) is not very common. Most cases reported in the literature describe bilateral neck compression as the principal mechanism to achieve self-induced hypocapnia.…”

“…Most cases reported in the literature describe bilateral neck compression as the principal mechanism to achieve self-induced hypocapnia. 2 This entity can lead to cerebral vasoconstriction, increased cytokines 3 production and hypoxia. Syncope, seizures and cognitive deficits have been reported as immediate side effects.…”