death of online gamers, excited delusion, cocaine addiction, internet addiction

1. FORENSIC
INSIGHT ON
CAUSE OF
SUDDEN DEATH
AMONG
ON- LINE GAMERS
MILEN SANTIAGO RAMOS MA, MSc Phd
Clinical Psychology Neuroscience Criminology
PHILIPPINES
4TH
ANNUAL CONFERENCE OF INTERNATIONAL
SOCIETY OF INTERNET ADDICTION
Osaka, Japan October 2015

2. In the fifth edition of the Diagnostic and
Statistical Manual of Mental Disorders
(DSM-5), Internet Gaming Disorder is
identified in Section III as a condition
warranting more clinical research and
experience.
But why did it call so much attention?

3. It is because globally, there have been
deaths caused directly not only by
exhaustion from playing games for
excessive periods of time but also
deaths of gamers related to playing of
video games.
Countries with notable deaths on their
online gamers as China, South Korea,
Taiwan, United Kingdom,United States
Note: countries are arranged alphabetically

4. Objectives
To understand the dynamics of
sudden death among online
gamers

5. THE PHOTOS THAT YOU WILL SEE MAY
OFFEND YOUR SENSIBILITIES

6. CCTV footage shows gamer collapsing in
internet cafe

7. Player found braindead while playing online

8. It has been established in many
research that behavioral
addiction IS VERY like drug
addiction

9. A LITTLE BIT OF HISTORY
In our very first conference it was
noted that there is almost similarity
between drug related and behavioral
addiction. In both cases Delta FosB,
the so called behavioral swtich for
addiction mediate alterations in
dopamine signaling. The model that
was used for drug addiction was
cocaine addiction.

10. Delta fosB and DOPAMINE
"Eric Nestler, at the University of Texas, has shown
how addictions cause permanent changes in
the brains of animals.
A single dose of many addictive drugs will
produce a protein, called delta FosB that
accumulates in the neurons. Each time the drug
is used, more delta FosB accumulates until it
throws a genetic switch, affecting which genes
are turned on or off.

11. Eric Nestler

12. Flipping this switch causes changes that persist
long after the drug is stopped, leading to
irreversible damage to the brain’s dopamine
system and rendering the animal far more
prone to addiction.
Non-drug addictions, such as running and
sucrose drinking, also lead to the
accumulation of deltaFosB and the same
permanent changes in the dopamine system."

13. Dopamine is the primary
neurotransmitter involved in
the REWARD PATHWAY in the brain.
Thus, drugs that increase dopamine
signaling may produce euphoric
effects.

15. DOWN REGULATION OF
DOPAMINE RECEPTORS
INHIBITION OF DOPAMINE
TRANSPORTER

16. Many recreational drugs, such
as cocaine and substituted dopamines, INHIBIT
the DOPAMINE TRANSPORTER (DAT), the protein
responsible for removing dopamine from the
neural synapse.
When DAT activity is blocked, the synapse floods
with dopamine and increases dopaminergic
signaling. When this occurs, particularly in the
nucleus accumbens increased D1 and
decreased D2 receptor signaling mediates the
"rewarding" stimulus of drug intake

17. Methods
Qualitiave Metaanalysis
(metaintegration).

18. Significant number of studies on addiction cases
were culled. Symptoms prior to deaths were
compared on the two types of addiction.
As research on sudden death by online
gamers is not yet as organized into a real
studycases available online were carefully
selected and studied and through behavioral
observation of gamers

19. Limitations
There was no published post
mortem molecular studies done on such
noted deaths

20. During the height of cocaine addiction many
sudden deaths
were witnessed …
the explanation of which is called
excited delusion
It was first identified on institutionalized chronic
psychiatric cases

21. One of the most serious psychiatric sequelae of cocaine
abuse is excited delirium, which may be associated with
hyperthermia and sudden death. Behaviorally, there was
extreme aggression or violence
Excited delirium (ED) syndrome is a serious
medical condition associated with acute onset of
agitated violent behavior that often culminates in a
sudden unexplained death.
A CNS dysfunction of dopamine signaling may underlie
the delirium and fatal autono-mic dysfunction.

22. IS THERE A POSSIBILITY
THAT DEATH OF ONLINE
GAMERS IS ALSO A
MANIFESTATION OF
EXCITED DELIRIUM

23. SCIENTIFIC
evidence

24. EVIDENCE 1

25. Stages of gamer s
death
DENIAL
ANGER
BARGAINING
DEPRESSION
ACCEPTANCE

26. EVIDENCE 2

27. DOPAMINE
DYSREGULATION
SYNDROME (DDS) is a
dysfunction of the
reward system observed in
some individuals taking
dopaminergic
medications for an
extended length of time..
It is characterized by self-
control problems such as
addiction to medication,
gambling, or
sexual behavior

28. IN PARKINSON S DISORDER The most common
symptom is craving for dopaminergic medication.
However other behavioral symptoms can appear
independently of craving or co-occur with it.
Craving is an intense impulse of the subject to obtain
medication even in the absence of symptoms that
indicate its intake. To fulfill this need the person will
self-administer extra doses. When self-administration
is not possible, aggressive outbursts or the use of
strategies such as symptom simulation or bribery to
access additional medication can also appear

29. EVIDENCE 3

30. CONTROVERSIAL DEATHS
ON THE USE OF
STIMULANTS
During the height of cocaine
addiction many sudden deaths were wit-
nessed ………
the explanation of
which is called excited delusion

32. It is a strong suspicion that cocaine addict
died from mishandling of pollice officers and
use of taser

33. EXCITED DELIRIUM

34. It was first identified on institutionalized
chronic psychiatric cases
One of the most serious psychiatric
sequelae of cocaine abuse is excited
delirium, which may be associated with
hyperthermia and sudden death.
Behaviorally, there was extreme
aggression or violence

35. Brain biomarkers for identifying
excited delirium as a cause of sudden
death.
2009 Sep 10;190(1-3):e13-9. doi: 10.1016/j.forsciint.2009.05.012. Epub 2009 Jun 21.
Mash DC, Duque L, Pablo J, Qin Y, Adi N, Hearn WL, Hyma BA, Karch SB, Druid H, Wetli CV.
Department Neurology, Miller School of Medicine, University of Miami, 1501 NW 9th Avenue, Miami, FL 33136, USA.
dmash@med.miami.edu
1) CNS dysfunction of dopamine
signalling
2) presence of heat shock protein (HSP 70)

36. CNS DYSFUNCTION
DOPAMINE SIGNALLING
PRESENCE OF HEAT SHOCK
PROTEIN HSP 70)

37. HEAT SHOCK PROTEIN
important part of the cell's machinery for protein
folding, and
help to protect cells from stress
Hsp70 proteins can act to protect cells from
thermal or oxidative stress
Hsp70 seems to be able to participate in disposal
of damaged or defective proteins
Finally, in addition to improving overall protein
integrity, Hsp 70 directly inhibits apoptosis

38. IS THERE A POSSIBILITY
THAT DEATH AMONG
ONLINE GAMERS IS ALSO A
MANIFESTATION OF
EXCITED DELIRIUM

39. SIMILARITIES BETWEEN
DEATH
OF
COCAINE ADDICTION
AND INTERNET ADDICTION

40. SIMILARITIES IN CASCADES OF EVENTS LEADING TO DEATH
AMONG ON LINE GAMERS AND COCAINE ADDICTIONS
1)TRIGGERED BY DELTA FOSB, THE MOLECULAR SWITCH FOR
ADDICTION
2) CNS DYSFUNCTION IN DOPAMINE SIGNALING IS PRECIPATED
3) ANGER /VIOLENCE AS AN OUTSIDE INFLUENCE AS A
REACTION OF THE GAMER TO THE GAME (I.E REPEATED
FRUSTRATION OF NOT WINNING) AND IN THE CASE OF
THE DRUG ADDICT THE THOUGHT THAT HE WILL BE CAUGHT)
CREATE THE EVENTUALITY
4) HEIGHTENED STRESS LEADS TO DYSAUTONOMIA
5) DEATH

41. The National Institute of Justice (NIJ)-sponsored
grant report
Physiological Model of Excited Delirium uses the
following definition of Excited Delirium:
Excited delirium has been defined as the onset of
a temporary disruption in awareness and
cognition along with aggressive or violent actions.
Some signs associated with excited delirium
include tachycardia (rapid heart rate),
hyperthermia (elevated temperature),
hypotension (low blood pressure), dehydration,
and catecholamine (norepinephrine and
epinephrine) release causing added stress on the
heart."

42. DEATH ON INTERNET
ADDICTION

43. Results
Data showed that deaths of
online gamers proceed in the
same manner as in cocaine addiction.
There is alteration in dopamine acitivity
leading to autonomic dysfunction then
death

44. Conclusion
A CAUSE OF CONCERN
While strong evidence points to same
cause of death for online gamers and
cocaine addicts, a more
systematized scientific post mortem
study of these
cases gearing on the molecular
characterization on dopamine signal-
ling is called for to establish really
the existence of such phenomenon

45. Excited Delirium and its medical status
"Excited delirium is not a clinical entity of its own, but a
constellation of symptoms from a varied and severe
underlying process" (Manojlovic et al., 2005 p.38).
While the American Medical Association does not
recognize ED as a medical diagnosis or psychiatric
condition, the National Association of Medical Examiners
has recognized ED (Stephens, Jentzen, Karch, Wetli, &
Mash, 2004) for more than a decade (Wetli, 2006).

46. One text has been written specifically
on the problem
Excited Delirium Syndrome by Theresa
and Dr. Vincent DiMaio (2005).

47. Thank you
very much
for listening