I used to be a competitive runner and I have a degree in exercise physiology. I coached track for over 15 years, including the UCLA and USA Olympic women's teams. When my running career was ended in 1994 by a drunk driver, my body went into severe chemical withdrawals as my running mileage went from 130 per week to zero. I became arthritic almost overnight and sometimes needed help crossing the street. This also led to a psychological depression, something I had never experienced before.

While I spent some years rebuilding myself physically, I ended up spending a lot of time playing computer games. The advent of online gaming, and especially competitive MMO's, allowed me to compete again without the use of my legs. I believe my endurance training, especially my neurological and endocrine adaptations, gave me an edge. Playing for long hours gave me a high that was not unlike the high I would get running ultra marathons.

I began playing longer and longer hours, and by the time I co-wrote the first paper on virtual good sales with Ashley Dunn of the Los Angeles Times in 2000 I was "...playing 12 hours a day..." which was a conservative estimate. It was my new profession and I was really enjoying it. Given my background, I was under no illusions about just how punishing this was on my body.

When World of Warcraft was released in 2004, I was well trained for the big day. I had been an alpha tester and knew exactly what to do. I was one of the first 100 players world-wide to L60, I did not use the "bare handed rogue" cheat that was in the game the first week, and I started several days late because I switched servers when I realized my start server was hopelessly congested. To achieve this goal playing solo, I played 22 hours a day for 8 days straight. The second player to hit 60 on my server arrived there more than two weeks later.

Playing 22 hours straight for just one day is enough to cause death as described by this article that came out in March of this year.

This article, the lack of public knowledge of what happens in your body when you do extreme endurance gaming, and some recent new trends that will make deaths more common are what prompted me to write this article. Hopefully the information herein can be used to not only improve the performance of cyberathletes, but also save lives.

Physiologic Effects of Ultra Endurance Game Play

Exciting games will trigger the "fight or flight" mechanisms of your nervous and endocrine systems. Real time competitive performance-measured games with audiences (like World of Tanks or many multiplayer FPS's) really are capable of pushing us to our absolute physiological limits, which is in part by design since these games are intended to be very exciting and engaging. For short durations (less than an hour) this is not a problem, and can even be healthy.

When dealing with longer durations, participants should be knowledgeable about General Adaptation Syndrome (GAS), which is a pleasant sounding name for something that has three stages. The last stage is generally fatal so I think as more people decide they want to become cyberathletes, education will be important. When I use the term cyberathlete, I really mean these participants are athletes. In traditional athletics, the respiratory system and/or skeletal muscle is highly trained and stressed. When they become exhausted the participant is forced to stop but this is not life threatening. In cyberathletics, the endocrine system is the primarily stressed organ system and when it becomes stressed the General Adaptation Syndrome is initiated. The problem here is that training this system though game play generally makes this system weaker over time, not stronger. So the better you become at cyberathletics, if you dip into ultra endurance activities, the more likely you will have a mishap as you approach elite status.

Cross training as a physical endurance athlete may help strengthen the endocrine system but I think this is essentially non-existent in gamer culture. In my case I started as an endurance athlete and then following my accident crossed over into cyberathletics. I also had the education and clinical experience to take as many protective measures as possible while I engaged in extreme endurance play and my partner during those years was a crack trauma nurse that literally kept an IV set up at my game station. I never ended up needing it, but it was there to threaten me into keeping my fluid intake up. I absolutely would NOT recommend anyone attempt to reproduce any of the feats I describe myself as doing in this paper.

As gameplay continues the human player will progress through the states of the GAS. Epinephrine and norepinephrine will be released early on, giving the player the edge in focus, reaction time, and alertness they need to win. Antidiuretic hormone will also be released to conserve water, lowing urine output. The body will tap into its stores of glycogen in order to guarantee an increased supply of glucose to the brain. Glycogen stores are very limited and generally run out during running marathons in all but the most efficient athletes, causing "The Wall" to be hit. The Wall causes a disruption of glucose supply to the brain and the result is depression and confusion in the early stages. This example from the 1984 Olympic marathon shows what can happen neurologically when you run out of glycogen during competition. I was there in the stadium crying that day as I watched since as a competitive marathon runner competing for Santa Monica College where that race started I knew exactly what Gabriela was going through and she was an amazing athlete.

I once staggered into the burger joint next to the Venice Pier looking like that and started ripping open all the ketchup packets trying to get glucose. The workers looked really scared and probably thought I was high on PCP. Nostalgia isn't the main reason I use this example though. I want you to look at the crowd. I'm going to come back to that and it is important.

Extreme competitive endurance events also trigger the release of your body's endorphins. These are natural opioids that reduce pain and cause numbness. As a former ultra endurance runner, I can attest that after about two hours you are high as a kite. After 5 hours and 64km (40 miles), like when I was asked to escort the torch bearers into Los Angeles in 1984 (I was an officer on the Olympic security team) the euphoria makes you 100% fearless. I've never tried opioids for recreational purposes, but beta endorphin has (according to the wiki) "approximately 18 to 33 times the analgesic potency of morphine". You can imagine how addicting this could be even though your own endorphins are much safer than any injected opioid. Trying to get that high using morphine would almost certainly kill you. There is also evidence that endorphins improve brain function and I always felt smarter on long runs, at least until I hit The Wall. I would often use that time to try to solve complex problems that were vexing me.

Endorphins are also released during game play. I'm sure this is why competitive endurance gaming ended up replacing my running addiction. I doubt there is any real research on what happens during extreme endurance play. The problem with such research is that it's generally regarded as unethical to conduct research on humans that could cause the subject to die or suffer significant harm. Thus some of what I may describe from first hand experience may not be rigorously supported in research yet, or any time soon.

As your gaming session goes on, the effects of Antidiuretic Hormone (ADH) become more pronounced even though they are largely invisible to the player. The effect we are concerned with here is that while this may conserve water to slow dehydration, it also slows kidney function. Thus toxic urea levels are building up in your blood stream during this entire process, even if you go to the restroom regularly.

As you become fatigued your body will start dipping into the nuclear weapon of stimulants, cortisol. Under the effects of this chemical humans are capable of nearly super human feats of focus. Your brain actually speeds up, making the world around you appear to slow down. It's basically a minor form of bullet time. It doesn't mean your body will speed up like Neo in The Matrix, but the rest of the world definitely seems to move slower. This gives you a lot more time to mentally react to various threats. Cortisol also impairs your immune system and reduces pain.

ADH also affects how electrolytes are excreted, which can in extreme cases (like these) cause an electrolyte imbalance that can disrupt heart function.

Biomechanically, sitting in a chair for a long time will lead to back fatigue and hip flexor shortening that can make standing up difficult and painful. Over several days this can lead to chronic back pain that might require rehabilitation.

If all of these warning signs are ignored then the body will move to the third stage of GAS in a last ditch attempt to overcome threat and avert death. The liver is trying desperately to maintain elevated supplies of glucose to the brain. Fatty acids are broken down to keep your muscles alive and maintain a glucose trickle, resulting in a buildup of poisonous ketones which make you smell sweet, sort of like acetone. You won't notice since it is hard to smell your own blood. Amino acids will be broken down to make extra glucose, especially when cortisol is high, causing urea to build up faster and making renal failure more likely.

Death is certain if the third stage of GAS is maintained, though how long that takes can vary widely depending on the circumstances.

I Can Do This, I Just Need a Little Boost

As any parent with gaming children can attest, when a gamer gets "into it" they have a hard time noticing what's going on in real space. After a few hours of high intensity play the effects of cortisol and endorphins mean the gamer is high as a kite. This is a really pleasurable experience, and one that the player is not going to want to voluntarily stop. Players of "casual" or relaxing games may never have this experience.

Under natural conditions a cyberathlete will eventually have to get up to go to the bathroom. At this point, once immersion is broken they might realize that they don't feel good and call it quits. They might "just lie down for a second" and be out for hours. That's good because that is almost always enough to prevent the third stage of GAS. They might not even make it to the bathroom and just pass out on their computer. I've had many a World of Warcraft raid (which in the old days could last 8+ hours, I don't know if that has changed...) where one or more members of the raid became non-responsive because they passed out right there in their chairs during the raid.

The typical solution to the "problem" of sleep is to use a stimulant. There are many legal stimulants that can be used for this purpose, some even marketed specifically for this purpose. Like Red Bull, which I've seen promoted at several E3 conventions. This child decided that was his solution during a 14 hour Call of Duty marathon.

Our World of Tanks player on Twitch decided he just needed more cigarettes.

I never used stimulants during my extreme endurance competitive gaming. Thanks to my degree in exercise physiology and my time doing research on corticosteroid mechanics, I knew that if my own cortisol was not enough to keep me going then I was way over my head. As a good general rule, if you are under threat (including in a competitive computer game situation) and you still are nodding off, then you are in stage 3 of GAS. That stage is called "Exhaustion" for a reason. At this point the clock is ticking. In both of the cases I linked to in this article, the players were dead before they even got out of their chairs. In both cases they felt so bad that they got out of their chairs and started to die. The Twitch player collapsed off camera, did not receive immediate medical attention, and died. The child playing at school went into a coma, got immediate medical attention, and survived after 13 days in the hospital.

If you are going to use a stimulant to improve performance, then you absolutely MUST GET REST AFTER 8 HOURS. If you don't, or if you start using them after 8 hours, then you are playing a very serious game of Russian Roulette. And, every time you play this game, there are more bullets in the barrel because of progressive kidney damage. So it's only a matter of time before you lose.

If you have any related pre-existing medical conditions, then even that 8 hour guideline may be way too much. Being addicted already to caffeine, nicotine, or any other stimulant is a pre-existing condition since these addictions wear you out and leave you "pre-exhausted" before you even start. As with any other athlete, players wishing to compete at this level should see a physician and get a complete physical. You can't adjust for a pre-existing condition if you don't know it exists.

I must add that if a player has hit "The Wall" and is compensating with fat to glucose glucogenesis, and then consumes even a small amount of alcohol, the liver will switch to alcohol glucogenesis as toxin metabolism is prioritized. This is a much slower process and will cause glucose levels to get critically low. The one time it happened to me, when a teammate handed me a wine cooler after a long race, the initial result was severe convulsions. This was the most painful thing I had ever experienced, which is saying a lot. This same teammate (a notorious "drunken runner") identified the crisis immediately ("I've seen this before, this is bad...") and shoved a piece of candy in my mouth. This was exactly the correct response. In this situation glucose or sugar must be administered by IV or orally (sugar can enter the blood stream across the mucous membranes even without being swallowed) immediately or hypoglycemic coma (often called "diabetic coma") will result.

I have not reproduced this effect while gaming because I've never consumed alcohol while gaming. Alcohol would just make an extreme endurance gamer more tired unless it was in a caffeinated alcoholic beverage like Four Loco. Such products were essentially banned in the USA in 2010 but I do not know if they are still available to gamers outside the USA.

Dark Trends

Remember Gabriela from the 1984 Olympics? Yea she totally should have stopped before doing her death march to the finish line. She knew it. The audience knew it and was mortified. The medical team there knew it but they could not intervene unless Gabriela gave them the okay. But...she couldn't do that. Not only was she representing her country, but there were thousands of people in the stands clapping and cheering. Hundreds of millions were watching on TV. This moment would define her life. This is an example of what I call Peer Effects, which are central to my personal research. I'm convinced that Peer Effects stimulate oxytocin, a hormone that might induce an even more intense "high" than any other chemical mentioned in this paper.

The body is incredibly resilient. There is no point in stopping if a tiger is chasing you, no matter how tired you are. We are a winning species because we have cortisol and endorphins that let us keep going even in extreme conditions. Peer effects also push us to fight for each other so that we sometimes win against tigers. In a game of World of Tanks, Call of Duty, or a World of Warcraft raid, you've got teammates that are counting on you. This creates a Peer Effect that can push you to keep going.

When I was studying Chinese competitive pay to win game models in 2009 in order to write my thesis paper (Sustainable Virtual Economies and Business Models, never published) I ended up being the top Western player in a game called Galaxy Online. I didn't have any money, I was a starving student. You know how they say you can still win without spending, but you have to invest more time? Well it was still true in 2009 but that's probably why IGG retired GO and rolled out the inferior GO2 which was impossibly P2W. The rest of the industry followed suit if they weren't there already.

In order to be the top player I played round the clock in addition to being really good at these sorts of games. Ultimately the only way the other team could beat my team was if they could attack me while I was sleeping. So they attacked me literally constantly 24 hours a day. I trained myself to sleep with the volume turned up and to automatically wake up (I lucid dream) if the attack ping frequency exceeded a certain rate. This indicated that it was probably hundreds of players attacking me simultaneously in a real attack, instead of the usual background fakes.

The result was continually elevated cortisol levels over a period of weeks. I had heart "wobbling" for hours every day that felt like premature ventricular contractions which I knew was not by itself immediately life threatening (this was during an 18 year period where I didn't have health insurance, but I previously taught cardiac rehab) for me as long as the PVC's did not get too close together. [Again, I must emphasize that if you get chest discomfort during extended game play, you should seek emergency medical attention immediately] I also developed a very unusual auto immune reaction that, after being misdiagnosed three times, caused an Ebola-like reaction that almost killed me while spraying blood in all directions. Cortisol interferes with proper immune function. I knew I had to quit and I did and my faction was overrun shortly thereafter on that server. Looking back, I was pretty lucky I didn't die back in 2009. I can get a little competitive and now I generally avoid playing FPS's or real time competitive games like World of Tanks even while I am in studios making them. This has caused me to be laid off from more than a couple jobs because "Ramin just wasn't into our game" or "part of the team". The truth of the matter is that I'm really good at these sorts of games but for my health I need to be very cautious about not getting sucked into them again on that level.

The most dangerous kinds of games in existence now are those that put you under threat while you are offline. Other than Galaxy Online (and GO2), the games I mention in this article are not those kinds of games. This class of game includes some of the most highly marketed games in the world including games advertised during this year's Super Bowl. The problem is that they encourage you not to sleep. The idea is that if they can keep you playing, they can keep you paying. They also charge you to sleep through the use of "Shields" that prevent you from being attacked for 8 hours or more. Honestly, it's cheaper in the long run (even if you get free medical care) to pay for one of those shields every night and that cost should be factored in if you want to see what the real cost to play is for these "free to play" games.

Some of these games are very popular with children, are made with cartoonish graphics, and are made simplistic enough to be played by even very young children.

Peer Effects can also backfire, encouraging players to play much longer than they otherwise would. This was a problem in both of the situations linked to here. It used to be that in the past these sorts of deaths were much more common in Asia than in the West. There they tend to play in internet cafes where there is an audience, especially if the player is good. This sort of attention can make you play longer, and pay more. This is a big part of why pay to win performs so much better in the East than it does in the West. In the West we play alone which causes us to have more anxiety, depression, mental illness, drug abuse, and we don't spend as much on F2P. But we are also less likely to "play till we drop".

Twitch and the era of eSports (which I've certainly been working to promote) might be changing that. If a player has an audience while they play, are paid for that audience, and there is anxiety that if they stop broadcasting at any time they will lose audience, then there is strong pressure to not leave the seat. Strong pressure to use stimulants. Strong pressure to ignore those warning signals the body is sending. Players could self regulate but that's probably not going to happen as long as the business and social model rewards them for entering the danger zone.

Amazon (the owner of Twitch) could introduce play caps for those they are paying, similar to what airline pilots have for their work hours. Educating them with something similar to this article might also help too. Have they had a physical? I'm not sure if the lawyers would feel this would limit or enhance their exposure, that's really beyond my expertise. My concern is player safety.

Personally, as a designer, I obviously want to be successful. I realize that getting players more engaged, for longer periods, might mean a lot more money for me especially if I am receiving a royalty. I just can't do this in a way that will jeopardize player health. I can't feign ignorance, this is my area of expertise. On my last project (that reached market) where I used secret sauce to improve commercial performance, I only had 10 weeks to build the meta game for World of Tanks Blitz. That product has become the world's top grossing F2P mobile eSports game and is now going multi-platform.

For my next project, which is completely of my design, I'm going to change some things. I'm lowering the adrenal axis stimulation to put less stress on players and require lower levels of engagement. This will allow the game to be played in a much wider range of environments and conditions. It will also allow it to be played longer with lower cortisol levels. At the same time I am introducing new Peer Effect technologies that should make order-of-magnitude changes to how engaged players feel to the game environment even with those lower cortisol levels.

The risk here is that if we use science (especially neuroscience) to make games vastly more engaging than they are now, we could put player health at risk. This process has already begun all over the world in many if not most leading game development studios. Thus my design has built in mechanisms to cut the player off when they've had too much. Sort of like a bar does if a patron drinks too much. I also anticipate warning players not to try to bypass these protections in creative fashion. I won't reward them for it, certainly. Designing these controls has taken me just as many years as designing the lures. If I didn't do this, I fear that if I am as successful as I would like to be then I could harm people. I realize others won't really care and may copy my future designs without these protections. My hope is that consumers will avoid these products if they have a more consumer friendly alternative, and that by that time regulators and platform operators (and of course lawyers) will be sufficiently sophisticated about these technologies that they will be able to intervene.

In an effort to promote consumer and medical education in this area, I'm determined to open source as much as I can about my methods if they prove to be effective. Thus I've been very careful over the last five years when signing agreements with companies to make sure I still maintain ownership of my technologies even while lending them out.