BJSM Online First, published on September 14, 2017 as 10.1136/bjsports-2017-098170 Br J Sports Med: first published as 10.1136/bjsports-2017-098170 on 13 September 2017. Downloaded from Education reviews

Circulating hormones like testosterone, Fight, flight or finished: forced fitness cortisol, growth hormone, insulin-like growth factors and catecholamines are behaviours in Game of Thrones very important for responses in muscle to exercise and injury. They are a crucial Ryan E Rhodes,1,2 E Paul Zehr1,3,4,5,6,7,8 part of the stress response experienced by pretty much every character inhab- iting GRR Martin’s fantasy world. Even purpose and thrumming with the epineph- the word ‘stress’—with its Latin root Spoiler alert! This paper deals with plot rine rush of combat. ‘stringere’ meaning to draw tight, strain, points found in the GRR Martin books in That thundering of blood, racing heart exert or tax—seems to come right out of the ‘Song of Ice and Fire’ series and the rate, sweating and sense of power are the an episode of ‘Game of Thrones’. ‘Game of Thrones’ television production hallmarks of the fight or flight response— seasons 1–6. If you haven’t yet caught up the ability our nervous and hormonal (and why haven’t you?), please proceed systems have to energise us—briefly—for Awash in a sea of hormones… at your own risk. You have been warned! feats of courage, strength and power in Thriving and surviving in our world and the name of self-preservation. Call it the Martin’s hinge on the concept of homeo- ‘epinephrine rush’, the ‘thrill of the chase’, stasis in our physiological systems. The ‘If you know others and know yourself, it is all part of the acute stress response we concept of homeostasis relates to adaptive you will not be imperilled in a hundred have when faced with scenarios and situa- responses to change that all serve to drive battles; if you do not know others but tions that demand our complete focus and the body back to its comfortable oper- know yourself, you win one and lose attention. And there is no shortage of such ating range (see figure 1). These include one; if you do not know others and do scenarios in Game of Thrones. responses to extreme cold, haemorrhaging not know yourself, you will be imperilled in every single battle’ Both the response to fighting and the blood loss, traumatic pain and emotional ―From ‘The Art of War’ by Sun Tzu training for learning to fight rely heavily distress—basically daily life in pretty (544–496 BC)1 on the ‘fight or flight’ response. This acti- much any scene in Game of Thrones from vation of the sympathetic nervous system just about every season. ‘Storms come and go, the big fish eat the is the ability you have to respond to exer- The stress response concept is part little fish, and I keep on paddling.’ cise stresses, which is a function of the of something pioneering physiologist ―Varys ‘the Spider’ in the second season ‘Game of Thrones’ episode level of regulating hormones in your body. Hans Selye called the ‘general adaptation ‘The Night Lands’ that premiered on Your state of balance—your physiological syndrome’ and which has three stages. The 8 April 2012. homeostasis—revolves around this. first is an ‘alarm reaction’ which mimics

Blood thundering in his ears, Jon Snow raises his broadsword Longclaw in a smooth arc of Valyrian steel that abruptly stops over his head only to then reverse http://bjsm.bmj.com/ course in a deadly slash downward onto the head of the Other and cleaving it in two. All his senses blazing with clarity, the bastard son of the late Eddard Stark, now himself leader of Castle Black, turns to face his next adversary full of power and on September 26, 2021 by guest. Protected copyright.

1Department of Exercise Science, Physical and Health Education, University of Victoria, Victoria, British Columbia, Canada 2Behavioural Medicine Laboratory, University of Victoria, Victoria, British Columbia, Canada 3Rehabilitation Neuroscience Laboratory, University of Victoria, Victoria, British Columbia, Canada 4Division of Medical Sciences, University of Victoria, Victoria, British Columbia, Canada 5Island Medical Program, University of Victoria, Victoria, British Columbia, Canada 6Centre for Biomedical Research, British Columbia, University of Victoria, Victoria, British Columbia, Canada 7Division of Neurology, Department of Medicine, Faculty of Medicine, University of British Columbia, Victoria, British Columbia, Canada 8Department of Human Discovery Science, International Collaboration on Repair Discoveries (ICORD), Vancouver, British Columbia, Canada Correspondence to Dr E Paul Zehr, University of Victoria, Centre for Biomedical Research,Victoria, V8P 5C2, British Columbia, Canada; ​pzehr@​uvic.​ca Figure 1 Regulating bodily balance at King’s Landing.

Rhodes RE, Zehr EP. Br J Sports Med Month 2017 Vol 0 No 0 1 Copyright Article author (or their employer) 2017. Produced by BMJ Publishing Group Ltd under licence. Br J Sports Med: first published as 10.1136/bjsports-2017-098170 on 13 September 2017. Downloaded from Education reviews

Figure 2 Some characters who show adaptability to fight (or not so much) to the finish. the ‘fight or flight’ response. The second either spell continued existence or certain Jaime Lannister, eldest son of Lord stage is one where adaptation occurs, and death in Game of Thrones. George R R Tywin, the powerful Lord of Casterly Rock there is an adjustment and resistance to the Martin’s world is a brutal survival of the and patriarch to the House Lannister, is stressor so that the effect of the stressor is fittest landscape, where characters have to generally considered the best swordsman reduced. If adaptation is insufficient or if possess keen senses or they are dispatched and one of the bravest men in the Seven the stressor is too large, we enter the third to their deaths. Those characters who Kingdoms. Due to these skills, he became stage which is one of exhaustion and cell adapt can thrive, but those who fail to the youngest member of the Kingsguard in death. adapt are finished. history. While his martial prowess has kept A lot of how the bodies of the charac- Of course, like any theatre of war and him alive in many battles throughout West- ters in Martins’ Game of Thrones respond politics, victory requires good luck and the eros, his murder of the Mad King Aerys to daily exercise stress, stress response and support of background teammates. It also branded him the notorious Kingslayer. various hormones. Tiny formations at the does not hurt to be on the winning side This has served to further fuel his lethal or base of your brain called the pituitary and of magical forces in the Seven Kingdoms treacherous reputation depending on how http://bjsm.bmj.com/ the pineal gland are important in all this. or across the seas in Essos, Qarth and one views the act. So is testosterone and is likely one of the Dothrak. Nevertheless, many of the very Gregor Clegane is the elder brother of hormones that you think of immediately. best and most decisive moments in Game Sandor Clegane (the Hound) and a landed Testosterone is a very important medi- of Thrones come down to individual char- knight who serves Lord Tywin Lannister ator for how the body responds and adapts acter actions that follow fight, flight or on retainer. He is considered the largest to exercise stress, and levels of circulating finished consequences. While Game of man in Westeros and called ‘the Moun- testosterone are elevated during and Thrones features a vast number of these tain’ based on his enormous bulk and on September 26, 2021 by guest. Protected copyright. after exercise. As with growth hormone, through its pages and on screen, below height. This size is also complemented the effects are largest with more stren- we highlight exemplars of each (see by a ferocity and savagery that has made uous and prolonged exercise. Central in figure 1 and 2). him the most feared individual in the all of this are the catecholamines—those Seven Kingdoms. Gregor is suspected (and substances like epinephrine—that give us Fight observed) in several murders and torture such a rush and the power to perform in Physical ability and fighting prowess throughout the Westerlands. In combat, fight or flight. They also have the power are generally essential characteristics his strength gives him a huge advantage to make us want more and more of them for survival in the ever warring Seven over almost any opponent, able to over- in our bodies. Kingdoms of Westeros and beyond. power his enemies with brute force rather While Varys ‘The Spider’ and Petyr than rely on his skill. The combination of Fight, flight or finished as it ‘Littlefinger’ Baelish do show that these battle tactics and his fearsome repu- applies to some ‘Goame f Thrones’ there are other ways to survive in this tation has allowed him to ‘survive’ thus far characters world with almost no physical ability, in Game of Thrones. While the fight or flight response skill in combat is a massive advantage Brienne of Tarth begins the Game of describes the energy systems provided by to survival. Three characters epitomise Thrones series as a Kingsguard of Renly our nervous and hormone systems, we the use of fighting skills as a means of Baratheon after winning a tournament. She can extend this to an analogy of survival survival in combat and future intimida- possesses similar attributes to both Gregor conduct in Westeros. The fight or flight tion, thus reducing the need to prove Clegane and Jaime Lannister in that her system guides behaviour in ways that oneself at every possible conflict. height and size are well above normal,

2 Rhodes RE, Zehr EP. Br J Sports Med Month 2017 Vol 0 No 0 Br J Sports Med: first published as 10.1136/bjsports-2017-098170 on 13 September 2017. Downloaded from Education reviews and she has honed superior martial skills. within the Seven Kingdoms. This mix of as when he assumes the role of the Hand While her service to various families in qualities has allowed her to survive in the of the King. Stark is deceived and subse- Westeros has changed across time, she has story thus far. quently outplayed by almost everyone at survived through her fighting prowess, Tyrion Lannister is the second son of the King’s court as he—alone—considers physical stature and good fortune. Tywin Lannister and younger brother to duty and justice as one and the same. He Jaime and Cersei Lannister. He was born eventually finds himself outmatched in a dwarf, and his mother died during his battle and far behind in his understanding Fight and flight birth, which are both sources of persecu- of the political forces in King’s Landing, While skill in combat and battlefield tion and problems. Given the importance which ultimately results in his death. bravery are often necessary to survive in of physicality in the Game of Thrones Joffrey Baratheon claimed the throne Westeros, the ability to anticipate conflict world, his father and others of high and from his legal father, Robert, but he was and manoeuvre out of harm’s way proves low birthrights frequently belittle him. actually the illegitimate son of Jaime to be equally important in the Game of Furthermore, his sister and father blame and Cersei Lannister. Joffrey repeat- Thrones. This ‘flight’ behaviour is the hall- him for the death of his mother. Survival edly demonstrated poor fight and flight mark of survival skills for characters who for Tyrion across the Game of Thrones story behaviours before and throughout his know when they are outmatched in phys- has been from his intelligence and wit. He troubled reign. Ultimately, he survives ical prowess at certain points of conflict. has a gift for determining the motives of in Game of Thrones as long as he does Many characters show intellect and others and using this to his advantage as simply due to his noble heritage and the cunning throughout the Game of Thrones well as his understanding of both sides assortment of vicious and clever charac- story, but four popular characters have to any conflict. Tyrion uses these skills to ters who seek to retain him on the throne represented a strong mix of battlefield manoeuvre out of numerous certain death for their own ends. In terms of his lack of bravery and manipulation when survival situations (eg, death sentences, corruption fighting bravery, Joffrey is bested by Arya in on the line. as hand of the king); however, he is also a Stark early in the story during a swordplay Jon Snow is the bastard son of Eddard brave character who will engage in combat scuffle and proves no match for leading Stark, and his illegitimate status makes when this is the choice for survival and to the Battle of Blackwater. He showed him an outsider to the Starks in Winter- retain a brave reputation (eg, the Battle of little courage during upheavals in King’s fell. Based on this status, he chooses to Blackwater, battle with the Starks). Landing among the crowds and frequently join the Night’s Watch. Yet his wealthy Arya Stark is the youngest daughter of relied on his Kingsguard to remove him upbringing, combat training and educa- Eddard Stark. She represents one of the from danger. King Joffrey also shows no tion with the Starks of Winterfell place best examples of how survival in Game of sense of when to avoid conflict and abso- him as an outsider to those of the Night’s Thrones is based on quick decision making lutely no mastery of subterfuge or decep- Watch. Cast as the outsider throughout his of when to flee from danger and when to tion. His taunts of his uncle Tyrion, the life, Jon Snow has had to use his martial take a stand. Arya begins her story arc as a torture of Sansa Stark and other members/ skills and his wits to survive across various feisty child with no interest in diplomacy guests of the court, as well as the belittling situations. When taken captive beyond or leadership but soon finds herself on the of many common folk were all made in the wall, Jon has even needed to switch run after the execution of her father. Using the open. Although Joffrey succumbs to allegiance, show humility and engage in disguise, building strong allies and devel- a poison that could have dispatched any subterfuge in order to ensure his survival oping her fighting skills from the Faceless monarch, his behaviours ensured that http://bjsm.bmj.com/ when he is outmatched. Snow, however, Man, Arya has become one of the stron- almost anyone in King’s Landing had is a strong leader who also understands gest survivors of the Stark family. motive to remove Joffrey from the throne. the importance of conveying bravery and battle prowess to his followers in the Night’s Watch. While his mix of fight and Finished Does watching and reading Game flight qualities has not always ensured It would be hard to find a rival for the of Thrones activate our own

loyalty from all, he has found enough sheer number of lead characters regularly fight or flight systems? Mirror, on September 26, 2021 by guest. Protected copyright. allies to survive (or at least be revived) in dispatched in the Game of Thrones. Some mirror in the brain—can seeing the story thus far. come to an end through bad luck or high shape thinking? Daenerys Targaryen is the child of King magic, but several characters simply fail at Back in the early 90s, di Pellegrino and Aerys II and was smuggled to safety during fighting or fleeing from various conflicts— colleagues at the University of Parma, Italy, the fall of the king’s reign and demise, they fail at survival. While there are lots made a chance observation that revolu- which takes place before Game of Thrones to choose from, two cases are particularly tionised neuroscience.2 It had been known (season 1). Although Daenerys begins the strong exemplars of the failure to engage for a long time that neurons (premotor Game of Thrones story as a naive character, in the correct flight or fight behaviours. cortex) in the part of the brain that sends who is seemingly exploited by her brother, Eddard ‘Ned’ Stark was the Lord of inputs to the final output centre for move- she gradually learns how to become an Winterfell, and his noble line stretched ment (motor cortex) were active to tune effective leader and conqueror as she seeks back 8000 years in the North of Westeros. movements. While recording from this to regain her family’s kingdom. Daenerys He had proven himself a very capable part of the brain in macaque monkeys, the shows a mixture of swift punishment to warrior and soldier during the Targaryen Italian researchers discovered that those usurpers and merciful conquests when campaign and thus a friend of the eventual same neurons in the premotor cortex freeing slave-based cities. She develops a new King (Robert Baratheon) of Westeros. active during a monkey’s own movement strong understanding of how to use diplo- While his battle prowess and honour kept were also active during observation of macy, sexuality or force (including an army him alive during that campaign, his rigid another monkey doing the same action! and three dragons under her command) to sense of the boundaries between right and Thus, the concept of the ‘mirror neuron’ obtain and secure her survival beyond and wrong prove disastrous in King’s Landing system was born, a name that came from

Rhodes RE, Zehr EP. Br J Sports Med Month 2017 Vol 0 No 0 3 Br J Sports Med: first published as 10.1136/bjsports-2017-098170 on 13 September 2017. Downloaded from Education reviews the way that a visually observed move- students of similar abilities). Still, vicarious our basic needs for fight or flight from ment seemed to be reflected in the brain experiences are likely to occur through our living room, we would all be served representation of the same movement popular media with great frequency, and the well to get out and have some safe adven- in the one doing the observing. Since thrills of brutal adventure shows are likely tures of our own from time to time. this discovery, extensive and convincing to fulfil certain human needs. Edward Deci evidence of this ‘mirror neuron’ system and Richard Ryan,7 for example, suggest and related neurons has accumulated in that behaviours are performed to fulfil three Addicted to life in the many non-human animals. In humans, the basic human needs that ultimately create Middle Ages? evidence is less direct but very compel- passionate motivation and flourishing: Being alive and staying alive in Martin’s ling that we also have elements of mirror autonomy, competence and relatedness. landscape means performing at a high neuron activity in our brains.3 The need for autonomy refers to the level on a daily basis. Battles, attacks, Here, the relevance of the mirror desire to be self-initiating in personal traps and ambushes are regular occur- neuron system is that they are activated behaviour. This suggests that the freedom rences. And the rush of dealing with each by actions regardless of whether you to choose our entertainment itself is and every one, while very stressful, could are doing something, anticipating doing important. Despite our fascination with the also be very addictive. It has been known something or watching someone else do subject matter, Game of Thrones is not for for quite some time that our human brains something. Mirror neurons basically help everyone! The need for competence reflects are ‘wired’ for many addictive behaviours enable us to predict the consequences of a desire to interact effectively within an envi- that notably include drugs like cocaine, our own actions. This raises the possibility ronment. This is likely a critical factor in the nicotine and alcohol and also activities that this system might contribute to our appeal of vicarious experience in Game of like exercise. (in)ability to understand the meaning of Thrones as we see heroes vanquish villains In a way, we really are wired for work the actions of others. and sit on the edge of our seats as we read and exactly where in the brain comes from Since understanding what others do whether Tyrion will escape what seems like some work on those ubiquitous laboratory is central to all our social interactions— certain death. Finally, the need for related- mice. Back in 2003, Justin Rhodes, a zool- and paramount in Game of Thrones— ness reflects the fact that individuals want to ogist at University of Wisconsin-Madison, this has implications for understanding feel connected to others.8 Game of Thrones, and his colleagues studied two strains of and communication between individuals. at this juncture, represents a cultural event mice, one that had the ‘normal’ interest Perhaps this system is extremely highly where fans can interact through discussion in running on a wheel and one that were functional in those who are success- of the material. bred to be extra motivated to run.16 17 He fully thriving in Game of Thrones (such Finally, watching or reading Game of and his team observed and monitored the as Tyrion Lancaster) and very poorly Thrones may provide a kind of catharsis two groups for 6 days of exercise bouts functional in those who were so ineptly to activate our flight or fight systems from and found that the ‘extra motivated’ group dysfunctional (such as Joffrey Baratheon)? the safety of the couch. Catharsis comes had run about three times the distance of Clearly, George R R Martin’s rich from the Greek, meaning ‘purification’ the other group. detail, interesting landscapes and dynamic or ‘cleansing’,9 and was originally applied The interesting thing is what they did yet tragic characters move viewers and to understanding emotional and aesthetic next—they blocked half of the running readers on many levels. One possible creation through art forms. The term wheels from working so it then became mechanism for the appeal is the vicarious has now been used in several different impossible for half the mice in either http://bjsm.bmj.com/ experiences Game of Thrones provides. streams to describe the experience of deep group to exercise. They then examined Albert Bandura, one of the most influ- emotion brought on via some other, rather activity in brain circuits that are related ential psychologists of the 20th century, than authentic, means. to ‘reward’ activity in the brain. These are demonstrated how people can gain much There is definitely much debate in the same reward circuits that are so power- from observing others.4 5 While personal whether media can help abate aggres- fully activated by opiates like cocaine and mastery or failure experiences are consid- sion or whether it actually contrib- morphine. These regions are also highly 10 11

ered the single most powerful influence utes to it. One thing is for certain, activated when rodents become addicted on September 26, 2021 by guest. Protected copyright. on our thoughts and future actions, vicar- however; the vicarious experience of to opiates and then denied their ‘fix’— ious experience through watching the activating your flight or fight systems they crave the drug. actions of others—particularly those we from the couch will not have the same Basically, the mice could not get the can make a connection with—is thought behavioural health outcomes as acti- running fix needed to activate the cascades to be the next most powerful form of vating this system in real life. The conse- of neurohormones in the brain that would influence. Thus, if we identify with Jon quences of sustained sedentary behaviour activate the reward circuitry. They were Snow’s aggression as he clashes with wild- has been described as ‘the new smoking’ addicted to running but blocked from lings or Tyrion Lannister’s shame as he is in terms of its overall poor health side doing it. How much this exactly parallels being insulted by his father, these experi- effects.12 13 All-cause mortality, cardio- our human brain circuits remains to be ences may be very influential on our own vascular disease and cancer mortality fully explored. thoughts, feelings and actions. are 1.2 times more likely among those But if you simply flip exercise with Bandura’s6 theory is typically not exam- who engage in prolonged sedentary fighting to stay alive or fleeing for your ined within the context of popular televi- behaviour.14 The effects also get a lot life as happens in Game of Thrones, you sion or literature. Indeed, much of the work larger for those who do not engage make the argument that everyone in on the power of vicarious experience is in in any moderate to vigorous physical those times was actually in need of the health behaviour intervention (eg, exercise activity as this is associated with over stress fix to feel ‘normal’. Maybe this is classes with similar others), psychotherapy 25 chronic conditions and poor mental why they constantly seek conflict and (eg, watching a person similar to you handle health outcomes.15 Overall, this suggests intrigue—to keep the reward circuitry a spider) or education (eg, classrooms with that while Game of Thrones may fulfil fully functional!

4 Rhodes RE, Zehr EP. Br J Sports Med Month 2017 Vol 0 No 0 Br J Sports Med: first published as 10.1136/bjsports-2017-098170 on 13 September 2017. Downloaded from Education reviews

This also may explain why we love to Open Access This is an Open Access article 6 Bandura A. Self efficacy, the exercise of control. New read the books and watch the shows so distributed in accordance with the terms of the York: Freeman, 1997. 7 Deci EL, Ryan RM. Intrinsic motivation and self- much. We get a vicarious fix of the stress Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and determination in human behavior. New York: Plenum and thrills that happen to the characters build upon this work, for commercial use, provided Press, 1985. without the real danger. Whether we are the original work is properly cited. See: http://​ 8 Baumeister RF, Leary MR. The need to belong: desire the control mice of Justin Rhodes’ study creativecommons.org/​ ​licenses/by/​ ​4.0/​ for interpersonal attachments as a fundamental or the exercise-addicted ones is up to our human motivation. Psychol Bull 1995;117:497–529. © Article author(s) (or their employer(s) unless 9 Merriam Webster. Merriam-Webster's Encyclopedia of own personal history and genetics. But otherwise stated in the text of the article) 2017. All Literature (Internet): Catharsis, 1995. understanding that the fitness behaviours rights reserved. No commercial use is permitted unless 10 Bushman BJ, Baumeister RF, Stack AD. Catharsis, forced onto the characters in the Game of otherwise expressly granted. aggression, and persuasive influence: self-fulfilling Thrones are actually still biologically part or self-defeating prophecies? J Pers Soc Psychol 1999;76:367–76. of our makeup is an important realisa- 11 Baron RA, Richardson DR. Catharsis: does ‘getting it tion. Those same forced fitness behaviours out of one's system’ really help? Human Aggression: that keep our favourite characters from Springer, 2004. meeting unfortunate early ends could also To cite Rhodes RE, Zehr EP. Br J Sports Med Published 12 Healy GN, Dunstan DW, Salmon J, et al. Objectively be usefully channelled by us to increase Online First: [please include Day Month Year]. measured light-intensity physical activity is doi:10.1136/bjsports-2017-098170 independently associated with 2-h plasma glucose. our own activity time. Diabetes Care 2007;30:1384–9. Accepted 4 July 2017 So, maybe the next time we rewatch 13 Ford ES, Kohl HW, Mokdad AH, et al. Sedentary an episode we might do it from the (dis) Br J Sports Med 2017;0:1–5. behavior, physical activity, and the metabolic syndrome comfort of a treadmill or stationary bike. doi:10.1136/bjsports-2017-098170 among U.S. adults. Obes Res 2005;13:608–14. 14 Biswas A, Oh PI, Faulkner GE, et al. Sedentary time We can combine both fantasy physiology and its association with risk for disease incidence, and real-life neurochemistry in a clever mortality, and hospitalization in adults: a systematic combination that would make even Varys References review and meta-analysis. Ann Intern Med 1 Tzu S. Art of war, the. New York, NY: Fine Creative ‘The Spider’ proud. 2015;162:123–32. Media, 2004. 15 Warburton DER, Nicol C, Bredin SS. Health benefits 2 di Pellegrino G, Fadiga L, Fogassi L, et al. of physical activity: the evidence. Can Med Assoc J Competing interests None declared. Understanding motor events: a neurophysiological 2006;174:801–9. Provenance and peer review Not commissioned; study. Exp Brain Res 1992;91:176–80. 16 Rhodes JS, Garland T, Gammie SC. Patterns of brain externally peer reviewed. 3 Cook R, Bird G, Catmur C, et al. Mirror neurons: from activity associated with variation in voluntary wheel- origin to function. Behav Brain Sci 2014;37:177–92. running behavior. Behav Neurosci 2003;117:1243–56. 4 Bandura A. Self-efficacy: toward a unifying theory of 17 Rhodes JS, van Praag H, Jeffrey S, et al. Exercise behavioral change. Psychol Rev 1977;84:191–215. increases hippocampal neurogenesis to high levels 5 Bandura A. Social foundations of thought and action: but does not improve spatial learning in mice bred for A social cognitive theory. Englewood Cliffs: NJ: increased voluntary wheel running. Behav Neurosci Prentice Hall, 1986. 2003;117:1006–16. http://bjsm.bmj.com/ on September 26, 2021 by guest. Protected copyright.

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