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

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.