It's Not Just Cyberpunk, Video Games Need to Take Epilepsy More Seriously

Kanika was in the middle of playing Overwatch, a game they'd previously enjoyed without incident, when it happened—10 seizures in the span of roughly 10 minutes. They started staring off into the distance, as if they were disconnected from their body. Kanika went into a state of shock, before their partner noticed something was wrong. After being taken to the hospital, Kanika was diagnosed with epilepsy. A game, of all things, triggered this discovery.

"I think if those seizures never happened while playing Overwatch," said Kanika, who asked to keep their last name private to avoid the possibility of public harassment, "I wouldn't have ever been diagnosed with epilepsy, so weirdly thankful for it when it did."

Epilepsy is a disorder marked by seizures, but exists on a spectrum and impacts people in different ways, making it harder or easier to live with. Someone can be born with epilepsy, or it can be caused by a brain injury. The seizures triggered by media, like movies and video games, are commonly but not exclusively associated with rapidly flashing lights and colors.

To this day, Kanika isn't sure what exactly happened in Overwatch to trigger the series of seizures, other than assuming overstimulation from "a mixture of sound, stress, and lights."  Kanika isn't alone in having complained about this problem in Overwatch—there's ample evidence of other players experiencing it, too—but it's hardly exclusive to Overwatch, either.

A few days before the release of Cyberpunk 2077, one of 2020's most anticipated (and controversial) video games, Game Informer editor Liana Ruppert revealed she'd 'd experienced "one major seizure and felt several moments where I was close to another one" while playing the game. Cyberpunk 2077, like a lot of games, comes with a generic warning about "flashing lights and images" in its lengthy EULA (End User Licensing Agreement) that no one reads, but does not have a specific warning about this sequence or a way to skip it.

Later, game developer CD Projekt RED said it would add another warning and explore a "permanent solution" to the issue, while thanking the Game Informer writer for discovering it.

It's possible to live many years and be well into adulthood without realizing you have epilepsy. Minor incidents can be ignored or misunderstood. Maybe you were just tired! But with generations of people now growing up with video games as their primary medium of entertainment, it's not shocking they're finding out about themselves through games, too.

Triple Topping co-founder and CEO Astrid Refstrup unexpectedly realized she had epilepsy while testing various games for a work project.

"It’s not like in the movies where people shake a lot," said Refstrup. "I faint, and people can’t wake me for about five minutes. After that I have memory loss for up to two hours before it happened."

Josh, who asked to keep their last name private to avoid the risk of public harassment, had spent much of their life experiencing seizures while playing video games—and didn't realize it. Not every seizure is the same. Some are major, some are minor. Some are noticed by the individual, some are not. It started when they were a child, and Josh could point to one game: Battletoads for NES and the game's infamously hard racing stage. The level's fast, scrolling effects messed with Josh, making them feel a sensation that, later in life, they would equate with being drunk.

"I just always thought that after playing games for a while it was normal to feel drunk and dull," said Josh. "Now I understand it’s because I am having partial seizures."

The big realization happened when Josh was 25, after playing Rock Band with some roommates and things got very weird. After a lengthy virtual music session, the group went to get some food and Josh suddenly had to rush to the bathroom because they felt sick. While playing Rock Band, Josh experienced a series of seizures and didn't even know it.

"I was acting normal as far as they were aware but on my end I just had no idea I was missing time," he said. "I was having absence seizures. I have them a lot when gaming. I always thought that sometimes your vision would just 'jump'—like everything in the room would move three feet to the left. What was happening is I was having an absence seizure and my head or my eyes were moving and I didn’t know."

The concept of missing time was mentioned by a number of people. You blink, and all of a sudden there's a chunk of time you can't account for. It can be extremely dangerous. One person I spoke to broke their collarbone after falling during a seizure. Another watched their brother fall off a stool while playing an arcade game that happened to trigger a seizure.

These days, Josh has someone by his side while playing and takes frequent breaks. For some people, medication makes gaming less scary. Josh still has problems while playing.

"I am not overly pleased that CDPR [CD Projekt RED] seemingly unthinkingly put those sorts of sequences in their game," said Josh, "but them responding to it and rectifying it is better than no response. I seriously doubt it was nefarious or anything but considering the severity of the particular similarity to the epilepsy test thing it seems like a huge blunder."

One big question unanswered, even after CD Projekt RED acknowledged their mistake: how did this happen? Even if this issue slipped past CD Projekt RED, shouldn't Microsoft and Sony, who have "certification" processes to approve games on their platforms, caught it?

"Creating a place that is safe and inclusive is a priority for us," said a Microsoft spokesperson in a statement. "That's why we publish and share our Accessibility Guidelines with all of our gaming partners. We continue to work in partnership with other publishers, industry experts and members of the gaming and disability community to evolve and improve our certification process and we encourage all players to review warnings on all games.” 

Sony did not respond to a request for comment, but I asked a developer who's published games on Xbox and PlayStation search the certification requirements for both and they couldn't find a specific mention of epilepsy. Photosensitivity, a version of epilepsy associated with flashing lights and certain colors, was in Microsoft's documentation under accessibility. 

It was unclear, however, whether either company would actively stop a game from publishing if they had elements that could cause photosensitivity issues with players. Because epilepsy and photosensitivity exist on a spectrum, the answer is mostly likely "it depends."

Interestingly, one company that seems to take it very seriously is Nintendo. Two developers, who asked to remain anonymous to avoid impacting their relationship with the company, said Nintendo has used a "seizure robot" that watches to see if a game's visuals can trigger a seizure. One developer had to edit cutscene because the robot flagged it as a problem. 

"I remember us joking that it was just R.O.B.," said the developer, referencing Nintendo's old toy robot accessory.

That Nintendo would be particularly sensitive to epileptic seizures is not wholly surprising; the company has a history with it. In 1993, the sensationalist UK tabloid The Sun published a story with the headline "Nintendo Killed My Son!" about a 14-year-old boy who'd been playing their SNES, experienced an epileptic seizure, and tragically choked on their vomit. In response, packaging included warnings about the potential for games to cause seizures.

And in 1997, an episode of the Pokémon carton aired in Japan that included a sequence where red and blue lights flashed back and forth like a strobe light. Around 700 kids were reportedly sent to the hospital as a result, and the show was taken off the air for several months. A Motherboard investigation from a few years ago suggested news reports about the incident portrayed the problem as larger than it actually was, but it was still a big deal.

Around the same time, standards were developed to better understand what triggered individuals, and to provide guidelines for how media creators could avoid such problems.

"Triggery effects in games are still commonplace," said accessibility specialist Ian Hamilton, who consults the games industry on such issues. "Some companies have testing policies in place, but most don't. But just as important as testing is awareness of what triggers can entail—far better to just avoid them than to have them flagged by a test late in development and then have to go back and rework them. The issues are usually easily solvable."

Hamilton does not believe CD Projekt RED was "malicious."

"Could they have done a better job?" said Hamilton. "Undoubtedly. Negligent? Perhaps. Malicious? Absolutely not. Replicating a real world device designed to trigger seizures? Highly doubtful." 

But it's true there is a lack of standards across the industry, which is why the certification requirements at companies like Nintendo, Microsoft, and Sony are important: they impose standards. But that's not to suggest every developer is ignoring this potential issue, either.

One developer I spoke to, who worked on a recent open world game and asked to remain anonymous because they were not authorized to speak publicly about their work on the game, said issues of "epilepsy/seizure/migraine concerns" came up over the course of development and addressed in different ways, depending on how the issue was caught.

"[The concern was] things like graphics glitches causing lights to flicker brightly, environmental lightning visual effects being too intense, visual processing done on in-game screens, 'flickering'  lights being cranked up too bright, etc," said the developer. "Bug reports for those issues were usually reported by QA, but sometimes by other members of the dev team. The bugs would typically be set to a high priority and get an 'accessibility' label."

Another developer worked on Ubisoft's open world shooter, The Division 2. Specifically, they worked on a mission set in a nightclub, an area that, by definition, has lots of flashing lights that could, in theory, cause seizures. This was flagged as an issue by the team immediately.

"They [Ubisoft] actually had some software they could run the game through to test for precisely this," said the developer. "We were prepared to change things to accommodate, and only deemed the content fit for release once those QA checks were signed off."

A designer who contributed to The Division 2's interface echoed this sentiment, and mentioned how the team specifically found themselves tuning the user interface animations to avoid the flashing ranges understood to potentially trigger an epileptic seizure. 

"Someone else on the team brought it up," said the developer. "It was not a formal process with testing as [much] it was a 'hey lets eyeball it and try to avoid this.'"

It's perhaps not a coincidence that much like Nintendo, Ubisoft was criticized by a parent after one of its video games caused a 10-year-old to have a seizure in 2008. The company claimed at the time that the game, Rayman: Raving Rabbids, wasn't filled with triggering imagery, but Ubisoft eventually relented and agreed to better test the games it developed.

Basically every developer I spoke to was confused at how the game was approved by Sony and Microsoft without someone raising their hand and wondering if this was a problem.

But over the years, I've heard time and time again that the biggest video games are often given a pass—or, at the very least, some leniency—when it comes to passing certification. This often happens in conjunction with the fabled "day one patch" that's common with most high-profile games, where issues certification flags are ultimately fixed with the patch itself. 

At this stage, we still don't know what happened. Maybe everyone missed it. It happens.

However, Cyberpunk 2077 itself did get a new seizure warning when it launched for players last week, a message that was not present in the version of the game played by critics:

Rupert, the writer who pointed out the original issue, said the update made them cry. 

One developer working on a major upcoming shooter told me the Cyberpunk 2077 incident caused new conversations internally, and hopefully leads to better practices going forward.

"There's a strong precedent of lasting positive change coming from incidents like this," said Hamtilon.

Follow Patrick on Twitter. His email is patrick.klepek@vice.com, and available privately on Signal (224-707-1561).