Adventure travel can be emotionally loaded for many people. Traveling for the purpose of having adventure means placing yourself into new situations with some uncertainty as to how you may react. Few people have anxiety about a trip to Hawaii to lay on the beach, but most people feel some anxiety about a remote trip to Tibet. Part of the reason for choosing such an adventure is the hope that the trip itself may change you in some way—to make you more aware of your limits, or to gain confidence by having accomplished something difficult. The uncertainty of the enterprise, and the absence of standard emotional supports can lead to the risk of psychological trauma. This may simply be disappointment in one’s own performance, or it may lead to a total psychological decompensation. If the emotional or psychological collapse is severe, the entire trip will be disrupted, and even getting the person home will be a severe challenge.

Psychosis is the term we use to describe people who experience a disconnection between reality and their perceptions. The same environment that may help to induce psychosis is fraught with obstacles that prevent the stabilization of a psychotic person. In a remote environment there may not be any medications available for controlling psychosis, and there may be no stable environment in which someone who is out of touch with reality can be safely stabilized. Travelers who are not emotionally or psychologically stable are not allowed on commercial aircraft, and many evacuation insurance companies specifically exclude psychological medical emergencies from their coverage.

Even when psychosis is not a concern, psychological adjustments are often necessary due to stress on the traveler, prior expectations of one’s performance in a new environment, and a feeling of lack of control over one’s surroundings. The adventurous traveler will be dealing with stress. If the stress is too severe, there may be some form of decompensation, or temporary inability to function normally. Other people may have an exacerbation of underlying feelings of depression, or may have traveled to try to alleviate a sense of depression or unhappiness.

Even at the best of times, travel involves a level of stress that is higher than we usually deal with at home. Depending on the destination, one has to deal with jet lag, loss of contact with familiar support systems, bombardment of sights and sounds, beggars, touts, and people who won't get out of your face. Even trying to absorb a particularly beautiful or moving event can be a form of stress. Trying to accomplish simple tasks, such as finding a decent room, buying a bus ticket, or obtaining a visa can lead to hours of frustration and uncertainty. If you are headed to remote areas, you can have a sense of being too far removed from familiar surroundings. You may suddenly realize that you are two-week’s walk from a strange and terrifying capital city, which is still 36 hours of flying time away from your home environment.

We all like to think that we can cope with our surroundings. The heroes that we admire in movies and television all have in common that they are not flustered by unexpected obstacles. They just deal with their changing environment as it unfolds, whether it is a volcano, primitive headhunters, or sleazy bandits. Most of us try hard to avoid the unexpected, to exert control over our surroundings, to expect things to go a certain way. When things don't go as we think they should, we assume that someone will be able to account for it, to take responsibility. We extend this concept of control to most aspects of our existence: we exercise to prolong our lives and prevent illness, we work hard in the expectation that we will be rewarded, we avoid areas of cities where we are likely to encounter trouble, we wear our seat belts. We’ve "learned the rules" and we think that as long as we continue to follow them, we can stay out of trouble.

When one shifts to an environment and culture half way around the world, these rules can change as well. Michael Palin, while trying to travel around the world in 80 days without flying (for a BBC special), summed it up nicely: "What in Europe had been problems to solve, in Asia became limitations to accept." One of the most difficult things for travelers to adjust to is the loss of their sense of control. They may fall quite ill despite all their efforts to avoid it. They may find that they bought the wrong ticket; or they bought the right ticket, but the bus didn’t come at all; or they are on the correct train, but someone else has their seats. Their trip of a lifetime might be scrubbed by three days in a row of bad weather, preventing the flight in. Since we are used to being in control, not having to deal with situations beyond our control, our stress levels can reach astronomic proportions.

Further pressure arises from the concept in the West that we must assert ourselves when things are not going our way. We are taught that we should not passively accept events as being beyond our control. However, in adventure travel, events may truly be beyond anyone’s control. The successful travelers are the ones who can learn to accept the limitations and work within the new systems as they are encountered. What they ultimately learn is that what we had at home was the illusion of control. We assumed that we were in control because things were going our way for a period of time. But we can’t truly prevent illness, accidents, or loss of friends and relatives. If we think about it, travel just becomes an accelerated learning course for accepting things beyond our control. The result of these lessons can be to become much stronger in dealing with our daily lives at home.

Adventure travelers often add an artificial stress to their journeys: the question of whether they will "make it" or not. Adventure travel is often very goal oriented. Setting out to do something that you are not sure you can do is part of the adventure. But linking the attainment of this goal with a psychological sense of worth can be dangerous. I have seen so many neurotically anxious people heading out for routine adventures, heedless of the needs of their traveling companions, oblivious of the local culture, compulsively monitoring their own health, all with the goal of standing on some patch of ground that they have read about.

People who are planning adventurous journeys should think about the psychological aspects of finding a balance. They should train physically to gain confidence in themselves, and so that they can have more fun. They should realize that it is truly the journey, not the destination, that will be their adventure.

Travel to Asia, particularly the Himalayas, seems to have spiritual connotations for many people. It may be their first genuine exposure to religion outside their familiar Christian-Judeo background. They may harbor secret desires to obtain some spiritual teachings or experience. I believe that the popularity of Peter Mathiesen's book The Snow Leopard, is based largely on the fact that he was one of the first writers about Nepal to confess that he had a secret spiritual agenda. There is nothing at all wrong with this attitude, if it is kept in proportion.

The danger arises when people are traveling in order to undergo major changes. People who are unhappy at home or feeling unsuccessful in their lives, may set out to travel in order to "get it together." The stresses of a new culture, the sudden exposure to severe poverty, the pantheon of new deities, and the freedom from normal constraints, may lead to risky behavior, drug-taking, and psychological dislocation. The potential for psychological turmoil, even acute psychosis, is substantial. That is why adventurous travel in exotic locations may not be indicated for people with a substantial psychological history of problems. If people who have had significant psychiatric problems want to start traveling, it makes sense to first go to destinations that are culturally more similar to their own, and have some resources to deal with emotional problems should they occur.

The use of hallucinogenic drugs in the pursuit of religious practice in South Asia fueled the beliefs of many Western travelers that spiritual understanding might follow from an intoxicated state. Although most stable people can handle these experiences, drug use can be the final lever into the abyss of psychosis for some travelers. In addition, some of the drugs may actually be toxic, or adulterated with substances that can truly cause difficulties. These concerns are in addition to the fact that most drug use by foreigners is highly illegal in most destinations.

Sometimes travelers are simply overwhelmed by the sights and sounds and lack of coherence of their environment. The exposure to what appears to be abject poverty is taken personally, as if they have to do something themselves to fix it. The food is perceived as different, unappealing, and unsafe. The rooms are dirty and noisy. Usually, people gradually adapt, but they occasionally go home within a few days, feeling personally defeated.

A gentle approach can be helpful. You can point out that they don’t have to feel responsible for the unpleasant things that they are seeing. You can try to get them to question whether the people they are seeing, who are quite poor, are actually suffering or unhappy. You can point out that they chose to travel to see and experience new things, including food and accommodation. If they can’t recover their composure within a few days, they should either go home, or—less defeating—travel to a less intense part of Asia (for example, Thailand).

One non-psychotic manifestation of stress may be the panic attack. A panic attack is the name given to a recognizable cluster of symptoms that often occur without warning. In various combinations, the person experiences acute chest pain, shortness of breath, weakness, dizziness, and a sense of not being able to get enough air. An overwhelming sense of dread is the hallmark of panic attacks, and the patients often feel certain that they are going to die. Many patients go to an emergency room and have a number of tests to rule out heart attack, pulmonary embolism, pneumonia, asthma, and so on. All the tests are normal, and the puzzled physician may simply suggest further tests, leaving the patient feeling totally anxious. The diagnosis of panic attack is made based on the clinical presentation of the severe symptoms out of proportion to any real findings of disease.

Treatment is based on finding a sympathetic and convincing physician who can help explain what is going on. In the setting of travel, this reassurance is often enough to end the cycle of symptoms leading to a sense of panic. There are specific drugs that help relieve the anxiety that accompanies panic attacks.

Most of the patients experiencing panic attacks cannot pinpoint a cause. My experience with panic attack patients in Nepal was that almost all of them had been having a good trip up to the point of the panic attack. People who had been nervous and unhappy about traveling almost never had a panic attack. The tendency to have panic attacks has been shown to run in families, and the symptoms may not be purely psychological. The body begins to experience unexplained symptoms, and the mind appears to react to the body. In any case, knowing about panic attacks can save days of anxiety in a remote setting, and avoid the risks of an emergency evacuation.

When I was working in Nepal I used to go to bed at night hoping that I would not get a phone call telling me that someone was acting crazy. There is a wide range of behavior that is encompassed by the term "going crazy." It may refer to someone in a near catatonic state, or to a delusional, aggressive, paranoid person who strikes out at all those around them. In developing countries, the psychotic patient is often first encountered in jail, due to their disruptive behavior in public. The police are only too happy to get rid of someone who is not in their right mind, unless they killed someone.

When such a patient is released from jail, or brought to a clinic by a friend, the goals are to find a stable, safe environment, with plenty of people to take turns watching the patient, and to use appropriate amounts of anti-psychotic medication. Embassies cannot take forceful control of their own citizens in other countries, so asking the U.S. Embassy Marine guards to gather up a psychotic 21-year old American man and ship him home on a cargo plane is not an option. The goal is to stabilize the patients as quickly as possible, and to repatriate them, accompanied by reliable people. The value of

anti-psychotic medication cannot be overemphasized in this situation. An injectable anti-psychotic medication should be in every adventure travel doctor’s first aid kit. Hopefully, you will never need to use it. Droperidol (Inapsine) is a particularly useful drug to have available for the acutely agitated or combative psychotic patient. It almost always sedates them within 20 minutes or so, allowing everyone to catch their breath and decide on the next course of action, without four people having to hold the patient down. One can then start them on either injectable or oral anti-psychotic medications when the patient becomes arousable again.

The exact diagnoses in these cases have not been systematically studied by psychiatrists. The majority of episodes occur in people with no prior history of mental illness. Acute situational psychosis is probably the most common diagnosis: environmental stresses and some personal history combine to trigger a temporary disconnection with reality. Acute situational psychosis generally responds very rapidly to anti-psychotic medication.

Schizophrenia is a more severe mental disorder that often manifests for the first time in the late teens or early twenties, a time when many young people are also traveling abroad for the first time. A deceptive form of psychosis may be the first episode of mania, which is part of the diagnosis of bipolar disease. These people will feel that everything has come together in their lives, and every event is loaded with huge meaning. This sense of energy and importance can grow to psychotic proportions.

Severe depression leading to suicide attempts is a very serious problem among travelers, but fortunately quite rare. These people may have traveled as one last hope to deal with their feelings, and when it fails to improve their mood, they become suicidal. They may have broken up a relationship while traveling, or failed while trying to work in a volunteer post. I am aware of a situation in which a disturbed person mailed a postcard from Seattle as he boarded a plane, telling his family that he was going to Kathmandu to kill himself. Luckily, he was found alive in Kathmandu when the American Embassy searched for him.

The treatment of severe depression in travelers should be the same as back home: emotional support, appropriate medication (particularly if anxiety is playing a large role), and repatriation with reliable assistance.

From the above discussion, one can wonder whether there are ways to predict who may have psychological problems on a given trip. There are no systematic studies of people who have had psychiatric problems while traveling, so we know little about the past histories of people who had problems, and whether they could have been recognized in a screening process as someone likely to have trouble. I would be concerned about people who have just undergone major life changes: loss of a lover or spouse, loss of a parent or sibling, the ending of a relationship, or the loss of a job. For many people, however, in these situations, travel has truly had the beneficial and life-reinforcing elements that one would hope for. So, there appears to be no easy formula for deciding who should be brought along on an adventurous trip or not.

I would be concerned about anyone who has a history of having to be hospitalized for psychiatric illness. If this were a recent occurrence, and the person was still on medication, I would not want an adventurous, difficult trip to a remote area to be their first travel experience. Even if they are off medication, one would want to know more about the psychiatric diagnosis, as many psychiatric conditions, such as schizophrenia and bipolar disease (formerly manic-depressive disease) tend to recur over time. In an ideal situation, a person who has done the trip would be able to interview prospective clients as to their past travel history and motivation for going, and get a sense of their general stability and adaptability. But this type of in-depth interview rarely takes place, and not all clients are as honest about their past histories as the adventure travel company would like. Their own doctors may be completely unfamiliar with the stresses of travel to certain destinations, and overestimate their patient’s capabilities. For all these reasons, trip leaders and adventure travel companies should have contingency plans for dealing with psychiatric problems during a trip. At the very least, make sure that the clients have evacuation insurance that does not exclude psychiatric emergencies.

Wilderness Medicine Letter, Volume 18, Number 1, Winter 2001