1. Parsh, Sophia A. SN
  2. Parsh, Bridget EdD, RN, CNS

Article Content

A mother brought her adolescent son to the clinic where I work, concerned that he had attempted suicide based on ligature marks on his neck. In the clinic, the patient confided to the nurse that the ligature marks were due to self-asphyxiation but that he'd had no suicidal intent. What can you tell me about this behavior?-L.P., N.Y.


Sophia A. Parsh, SN, and Bridget Parsh, EdD, RN, CNS, reply: First identified in 1934, self-asphyxial behavior (SAB), also called self-asphyxial risk-taking behavior, is defined as self-strangulation often achieved with hands, a noose, placement of a bag covering the head, or hyperventilation to achieve a brief euphoric state caused by cerebral hypoxia.1,2 Although cerebral hypoxia creates a sense of giddiness, it can also cause many adverse reactions and injuries, including loss of neurons, muscle spasms, numbness of the extremities, dizziness, seizures, injuries from falling, and even death.2,3 In one report, the CDC identified 82 probable SAB deaths from 1995 to 2007 among youths ages 6 to 19. Most (86.6%) were male, and the mean age was 13.3 years.4


SAB is known by many other terms, including the choking game (see Colloquial terms for SAB). In a cross-sectional weighted survey of 5,348 eighth-graders, 22% had heard of someone participating in the "choking game" and 6.6% had participated themselves, yet most did not realize its potentially life-threatening consequences.5 Researchers found that the lifetime prevalence of choking game participation was 6.1% for these eighth-graders, with no differences between males and females. Among those who had participated in the activity, 64% had done so more than once and almost 27% had done so more than five times.5 Many adolescents who partake in SAB have the illusion of safety because they can achieve euphoria without using drugs or alcohol.6


A person can engage in SAB with or without the intent to achieve or enhance sexual arousal.4 SAB may be the first step toward autoerotic asphyxiation or asphyxiophilia, the enhancement of sexual arousal by oxygen depletion in the brain.7,8 Asphyxiophilia is considered a form of SAB and is most likely to be practiced by adult and older adolescent males.9

Table Colloquial ter... - Click to enlarge in new windowTable Colloquial terms for SAB

Risk factors

Young age, male gender, and lack of awareness of the danger of SAB are risk factors for SAB.6,10 Cases of SAB can be clustered in certain areas, indicating a shared knowledge among youth through personal communication or social media.11,12 Adolescents exposed to images or descriptions of self-injury on social media sites may be at increased risk for self-harm.13


Signs and symptoms that may accompany SAB include ligature marks on the neck, impulsive behavior, abusive language, and mood swings possibly related to cerebral hypoxia (see Watch for warning signs of SAB).14 Those practicing SAB may also have a history of dangerous autoerotic behavior and/or engagement in solo sexual activity, including searching websites for pornography or methods of asphyxiation.14


Distinguish SAB from attempted suicide

Although strangulation from SAB and suicide attempts often present similarly, those engaging in SAB usually have no recent stressor and no suicidal ideations or indications.14 These patients typically take safety precautions, such as keeping their feet on the floor to prevent accidental hanging or tying a knot loosely so it is easy to release.5 Even so, some patients die from SAB.


Most parents of children who die from SAB were unaware of the behavior before their child's death.4 Awareness among healthcare providers and even forensic pathologists is also low because participants usually don't seek medical help for injuries.15 Many deaths from SAB are inaccurately classified as suicidal or accidental deaths.7 To counter this lack of awareness, nurses must be alert for signs of SAB.


Nursing considerations

Patients who engage in self-strangulation should be screened for depression and suicidality. A psychiatric consult is indicated for children and adolescents who survive near-hanging, as well as for those who may be using SAB to self-medicate. In addition, a neuropsychiatric evaluation may be indicated to assess for neurologic complications.9


Vigilant assessment and therapeutic communication helps keep patients safe and impacts prevention and recurrence.15 Due to embarrassment, many patients will not admit to SAB and may even prefer to tell their parents that they attempted suicide instead.14


Along with identifying signs and symptoms of SAB, nurses can initiate nonjudgmental conversations with the patient, initially without family present to ensure patient safety and obtain accurate assessment data. Educate patients about the dangers of self-strangulation and/or asphyxiation, emphasizing that it is not a game and that it can lead to serious injury or death.9 When talking with patients, nurses should examine their own attitudes and avoid showing shock, disgust, or anxiety. Knowledge and nonjudgmental attitudes on the part of healthcare professionals can help reduce the stigma of SAB and improve identification of patients at risk.16


In addition, educate parents about SAB and encourage them to engage in open, nonjudgmental communication so the child is comfortable sharing information about concerns and activities.12 Advise parents to follow their child on social media to identify dangerous practices and trends their child may be exposed to, and to talk with their child about the serious consequences of dangerous activities such as SAB.12,17


Developing therapeutic relationships, promoting open communication between patients and families, and educating parents to be vigilant for signs and symptoms of SAB can be the difference between life and death for young patients engaging in this risky behavior.


Watch for warning signs of SAB4,5,9,14

Signs that a child or adolescent may be engaging in SAB include:


* discussion of or curiosity about the "choking game" or other terms for SAB


* red eyes, pinpoint bruising around eyes, or petechiae on face, eyelids, or conjunctiva


* bruises, marks, or strange impressions on the neck


* wearing high-necked garments despite warm weather


* severe headaches and/or vision impairments


* disorientation after spending time alone


* ropes, scarves, and belts tied to bedroom furniture or doorknobs or found knotted on the floor; padded or short ropes; neckties in odd knots


* unexplained presence of dog leashes, choke collars, or bungee cords


* wear marks on bedposts or closet rods


* history of internet searches for topics relating to self-strangulation or choking


* mood swings or episodes of uncharacteristic hostility.




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World Health Organization. Mental Health. Suicide data.