Video games and seizures: A review

This chapter consists of a review of both our own and other published work. The first reports of seizures associated with viewing video games occurred in 1981. Since then an increasing number of incidents have been reported in the literature; these have occurred to both arcade games, games played on a television screen, computer based games and also hand-held games. Most arcade games are played on a cathode ray tube (CRT) monitor usually with a 70Hz refresh rate, whereas hand-held games are played on liquid crystal screens the same as many modern television sets. Although all these devices use a different method of display it has been shown that the critical factor is the material that is presented. A similar problem occurs with television broadcast material but many countries now have guidelines to prevent the broadcast of material which may provoke seizures. Unfortunately there have been few guidelines of this type for the video game industry although some voluntary guidelines now exist. In addition the International Standards Organisation (ISO) is now publishing guidelines which include video games. Our studies have shown that whichever form of domestic CRT TV was being used for a game, either 50 Hz (PAL) or 60 Hz (NTSC), seizures would still occur based on the material which was presented. There is a wide variety of specific games which have induced seizures. Some of the most consistent were Super Mario World, Super Mario Kart, Super Bomberman 2 and Donkey Kong Country. However there are reports of individual seizures with other games such as Elder Scrolls Oblivion. Although video games have been used to test susceptible patients with a history of seizures one of the difficulties in identifying the exact precipitating stimulus is that so many alternative routes exist in the game often calling up differing stimuli. The critical factor from the player's point of view is whether the person is photosensitive or not. Evidence shows that there are three times as many individuals in the population who are photosensitive but have not yet had a seizure than those who have a history of photosensitive epilepsy. It is known that photosensitive epilepsy occurs at a rate of 1 in 4000 of the population. The onset of photosensitive epilepsy is maximal around puberty and the incidence is five times higher amongst 7-19 year olds than in the general population; needless to say this is the group which probably has maximal exposure to video games. Although photosensitive seizures are most common in relation to flashing images we have shown that patients referred with a history of video game seizures are almost always pattern sensitive. Recommendations for avoiding provocative video game material are given.