HD Online Player (chinese Female Autopsy Video)
Phillipp Schneeberger
Internet gaming disorder (IGD) is an emerging problem. Rarely, media reports about people, who have died during playing video games, but thus far no systematic, scientific study is available about the topic. We investigated such cases, looking for common characteristics, connection between gaming and death, and the possible reasons leading to death.
24 cases were found: one from 1982, the others between 2002 and 2021. Twenty-three of the victims were male, age ranged from 11 to 40 years. More than half of the cases originated from Southeast Asia, and 12 deaths happened in internet cafes. Gamers played action-rich multiplayer games. In 18 cases the gaming session before death was extremely long (around a day or even several days) with minimal rest. The cause of death was pulmonary embolism in 5 cases, cerebral hemorrhage in 2 cases, most of the rest was presumably due to fatal cardiac arrhythmia.
Long sedentary position and dehydration may precipitate thromboembolism, acute blood pressure elevation during gaming may promote cerebral hemorrhage, and several factors (including acute and chronic sleep deprivation, exhaustion, stress) can lead to acute autonomic dysfunction and fatal arrhythmia.
While extensive debates can be found on the internet about the topic, according to our knowledge, it has not been systematically reviewed in the medical or health science literature, nor have we found any studies or case reports. We aimed to investigate the real size of the problem of death linked to playing video games, if these subjects were addicted to gaming as often stigmatized, the connection between gaming and death, and the possible reasons leading to death.
Internet addiction among females usually involves addiction to social media rather than gaming - IGD is seven times higher among male than female adolescents [4]. It seems that deaths were connected to action-rich games (see below), which are less popular among females. Competitiveness in games is more common among males, which may bind them for a long period to the game without pausing.
Using the 2014 Asian data, the prevalence of IGD among adolescents was estimated to be 5%, but since most of them were males, we used 10% for males. The population at risk (adolescent males with IGD) may be around 45 million. This means a roughly 1 death per 2 million gamers over about 15 years course, or 1 per 30 million yearly. Considering only the most avid gamers the incidence is probably higher.
In most cases the name (or the category) of the game the victim had been playing was reported. Detailed description of these categories is provided in the Supplementary material 1. The common feature of these games is that they all need strong, strenuous mental concentration. The gamer may lock out the disturbing outside world, lose track of the passing time, and dimly notice hunger, thirst, tiredness or discomfort, which may lead to the adverse consequences. No one was reported to die while playing a sandbox game (like The Sims, Minecraft) [11], where player use creativity instead of action, or an adventure game [12], which involves exploring and playing along a storyline (sprinkled with action and dexterity elements) in an enjoyably slow pace instead of the aforementioned rush. The games played were definitely or presumably multiplayer games, where the competitive factor or adaptation to the other players enforces the gamer into a faster pace and prevents him from stopping, contrary to single-player mode, where one can do it in his own pace.
In one case (No. 22) stroke in another (No. 24) cerebral haemorrhage was reported as cause of death. Stroke was not further specified. It might have been ischemic stroke, which often causes disability but rarely sudden death, and is very hard to be explained at this age. It more probably could have been haemorrhagic stroke or subarachnoid haemorrhage. Haemorrhagic stroke in young adults can be caused by hypertension, vascular malformation, drug abuse, venous sinus thrombosis, hematologic conditions. According to the bleeding location and size, it may lead to herniation, coma or death. Subarachnoid haemorrhage is due to the rupture of saccular aneurysms in more than half of all cases. 25% of these patients die within 24 h of the event; many die before they reach the hospital. Hypertension or acute elevation in blood pressure, smoking are risk factors for aneurysmal haemorrhage [15].
In 18 cases the gaming session before death was extremely long (around a day or even several days) with minimal rest, which results in acute sleep deprivation, or the victim was repeatedly playing quite long sessions, which suggests chronic sleep deficiency.
Experimental data of such drastic SD in human is not available. In a study, subjects after a night with sleep dept (still 1.7 h sleep on average) showed increase of the QT interval and QT dispersion (still within the normal range), which may make more susceptible to lethal ventricular arrhythmias [18]. A case report demonstrated spontaneous coronary dissection and myocardial infarction after 72 h SD due to overtime work [19].
Several longitudinal human studies demonstrated a U-shaped association between sleep duration and all-cause mortality, optimal amount being around 7 h sleep per day, with increased mortality of both short and long sleepers [20, 21, 22, 23, 24]. Besides direct effect of SD, short sleep may also contribute to development of physiological and social outcomes that may lead to increased mortality; e.g. cardiovascular disease, stroke, dyslipidemia, diabetes, hypertension, obesity, cancer, presence or development of stress, altered inflammatory cytokine levels and impaired immune response [25, 26, 27]. Exact sleep habits of the gamers are not known, but it is presumable that the ones who were indicated as gaming addicts, and were doing regular several-day-long gaming binges or over 10-hour daily gaming sessions, were also taking away time from sleeping in favour of gaming, and are on the short-sleeper arm of the curve. The above results are also based on mainly middle-aged or elder subjects, and applying them on the mostly young gamers is questionable. On the other hand, chronic short-sleeping may have already done subclinical damage in these individuals, making them more susceptible to an acute event.
Outstanding performance attracts audience in gaming, as well, which up today turned into a rapidly growing industry, eSport, with over 1 billion audience [31], and with gamers doing it as a full-time profession. Average eSport player practices around 5.5 h a day and even 10 h a day prior to competitions. 15% reported 3 h or more of sitting and playing without standing to take a break. This sitting for hours staring the monitor with several hundred clicks and keypresses per minute results in chronic overuse (and sometimes career-ending) injuries (eye fatigue, neck or back pain, wrist and hand pain), but one case of deep venous thrombosis was also reported [31]. As far as we know, up until today no case of death among eSport athletes linked to gaming was officially reported. On the other hand, eSport community is far smaller, and exists for a shorter time than the general gamer and IGD population, and the lower numbers may have just not produced a death case.
Death of Chen Rong-Yu (No. 10), was a well investigated, still unexplained case, about which we have more detailed information from an interview with his physician, Dr. Ta-Chen Su in the book Death by video game [32]. Rong-Yu had had a heart attack 3 months before. Extensive examinations (including ECG, echocardiography, 24-hour ECG, coronary angiography, cardiac electrophysiology study) did not show underlying abnormalities. Cardioverter defibrillator implantation was suggested which Rong-Yu refused. Dr. Su provided further hypotheses about his death, elaborated below.
Sleep deprivation is accompanied by a rise in sympathetic tone to maintain arousal and counteract parasympathetic impulses driving the body to a relaxing, regenerative state [34], ultimately resulting in a mentioned imbalance and autonomic disfunction. It can also be a part or trigger of acute or chronic stress reaction.
Gaming itself produce stress, according to cardiologist Robert S. Eliot, (M.D. at the University of Nebraska Medical Center), who used a video game (Pong) to replicate stressful situations in more than 1000 patients. Heart rate increases of 60 beats per minute and blood pressures as high as 220 was often observed within one minute of starting a computer game, without the patients being aware of that [32]. Similarly, increase in heart rate and blood pressure was observed in eSport athletes, as well [35, 36], although such high alteration was not pronounced. Acute elevation of blood pressure can trigger lethal arrhythmia in some cases [37]. Presence of stress during eSport activity can be demonstrated by the elevation of stress hormones [38], just like during physical sports [39].
Even if the game is not especially stressful, extremely long gaming session could be compared to overtime at working, leading to exhaustion. In Japan several hundred cases were reported where people have died while repeatedly working overtime (termed as karoshi: death by overwork) [44, 45].
Quality of source data was sometimes debatable. Information from different sources were highly redundant with hardly any novelty. Sources must have shared or taken information from each other or worked with the same limited communiques. Details were often poor, the exact cause of death was unconfirmed or speculative, autopsy reports were rarely available.
We aimed to review death cases linked to the action of playing video games. In several cases extreme length of sedentary gaming led to deep vein thrombosis and fatal pulmonary embolism. Lethal arrythmia due to acute autonomic dysfunction brought on by stress and sleep deprivation seem to be a frequent cause, as well. It mostly involved adolescent males, who were playing action-rich games. Most of them probably had internet gaming disorder. Incidence of gaming related death itself seems to be relatively low, much lower than sport related death in its risk population, but we should be aware that besides the low direct risk to life, gaming addiction can have adverse criminal and economical consequences, as well, and awareness of the problem should be maintained and prevention should be enforced.
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