Adventure travel can be emotionally loaded for many people. Part of its attraction is the chance to be put through a crucible and come out as someone you weren't before. But there is risk too — from disappointment in your own performance at best, to psychological decompensation at worst. When people ask me what the hardest part of working at CIWEC is, I always think of the psychotic travelers we've had to care for. An unfamiliar developing-country environment can help induce psychosis, and is full of obstacles to stabilizing someone who is psychotic. The possibility of meeting — or traveling with — someone who could become psychotic should be part of every traveler's awareness. Even when psychosis isn't a concern, adjustment is often needed because of the stress of travel, expectations of how you'll perform in a new environment, and a feeling of having lost control of your surroundings.
Travel is stress
Even at the best of times, travel involves more stress than we usually deal with at home. Depending on the destination, there's jet lag, the loss of familiar support systems, a bombardment of sights and sounds, beggars, touts and people who won't leave you alone. Even absorbing a particularly beautiful or moving experience can be stressful. Simple tasks — finding a decent room, buying a bus ticket, getting a visa — can mean hours of frustration and uncertainty. In remote areas you may feel very far removed from anything familiar: two weeks' walk from a strange capital city that is itself 36 hours' flying from home.
We all like to think we can cope. The heroes we admire on screen are never flustered by the unexpected — they deal with the volcano, the headhunters or the bandits as things unfold. Most of us try hard to avoid the unexpected, to control our surroundings, to expect things to go a certain way. When they don't, we expect someone to account for it. We extend this idea of control to most of life: we exercise to stay healthy, work hard expecting reward, avoid the dangerous parts of town, wear our seat belts. We've learned the rules, and as long as we follow them we think we'll stay out of trouble.
Halfway around the world, the rules change. Michael Palin, traveling around the world in 80 days without flying, put it nicely: "What in Europe had been problems to solve, in Asia became limitations to accept." Losing their sense of control is one of the hardest things travelers adjust to. They may fall ill despite every precaution. They may buy the wrong ticket — or the right one, and the bus never comes, or someone else is in their seats. The trip of a lifetime might be scrubbed by three days of bad weather that stop the flight getting in. Because we're used to being in control, our stress can reach astronomic levels. And in the West we're taught to assert ourselves when things aren't going our way, not to accept events passively.
In adventure travel, though, events may truly be beyond anyone's control. Successful travelers learn to accept the limitations and work within the systems they find. What they ultimately learn is that what we had at home was the illusion of control — we assumed we were in control because things had been going our way. We can't truly prevent illness, accidents or the loss of people we love. Travel becomes an accelerated course in accepting what's beyond our control, and those lessons can make us much stronger in daily life back home.
Personal physical goals
Adventure travelers often add an artificial stress to their journeys: will they "make it"? Adventure travel is very goal-oriented — the viewpoint of Kala Patthar near Everest, the confluence of glaciers at the base of K2, a complete traverse of Dolpo. Setting out to do something you aren't sure you can do is part of the adventure. But tying that goal to your sense of self-worth can be dangerous. I've seen many anxious people set out on routine adventures heedless of their companions' needs, oblivious to the local culture, compulsively monitoring their own health — all to stand on a patch of ground they've read about.
If you're planning an adventurous journey, think about the psychological side, and find a balance. Train physically so you have confidence in yourself — and more fun. It truly is the journey, not the goal, that will be your adventure.
Spiritual concerns
Travel to Asia, particularly the Himalaya, has spiritual connotations for many people. It may be their first real exposure to religion outside a familiar Judeo-Christian background, and they may secretly hope for some spiritual teaching or experience. I believe the popularity of Peter Matthiessen's The Snow Leopard rests largely on his being one of the first writers about Nepal to admit to a secret spiritual agenda. There's nothing wrong with this, if it's kept in proportion.
The danger comes when people travel in order to undergo major change. People who are unhappy at home may set out to "get it together". The stress of a new culture, sudden exposure to severe poverty, a pantheon of new deities and freedom from normal constraints can lead to risky behavior, drug-taking and psychological dislocation. The potential for turmoil — even acute psychosis — is substantial. People with a significant history of psychosis should probably not travel in developing Asian countries.
The use of hallucinogenic drugs in pursuit of religious experience in South Asia fed many Western travelers' belief that a kind of nirvana could be inhaled or swallowed. Most people can handle these experiences, but we have seen drug use be the final push into psychosis for a number of travelers.
Decompensation
Sometimes travelers are simply overwhelmed by the sights and sounds and the seeming lack of order around them. They take apparent poverty personally, as if they must fix it themselves. The food seems different, unappealing and unsafe; the rooms are dirty and noisy. Most people gradually adapt, but occasionally someone goes home within days, feeling personally defeated.
A gentle approach helps. You can point out that they don't have to feel responsible for the hard things they're seeing. You can gently question whether the people they see, who are poor, are actually suffering or unhappy. You can remind them 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 go home — or, less defeating, travel to a less intense part of Asia, such as Thailand.
Panic attacks
One non-psychotic sign of stress is the panic attack. It's fairly common among travelers today, perhaps partly because it's better recognized. Healthy people of all ages may arrive with severe symptoms, occasionally needing helicopter evacuation. The symptoms are familiar to most physicians: some combination of breathlessness, chest pain, weakness, dizziness, hyperventilation and cramps in the hands and feet. An overwhelming sense of dread is part of the syndrome, and patients are often certain they're dying. In this group, reassurance has worked well; many patients prefer not to take anti-anxiety medicines such as alprazolam, though medication can help in severe or recurrent cases.
Most people who have panic attacks can't pinpoint a cause. They genuinely feel things were going well; some admit to a vague sense of being out of their element. Remember that a specific cause usually isn't found. Panic attacks are a bit like unexplained skin rashes: they come, they're annoying or frightening, and their cause often can't be determined. What matters most is recognizing that nothing life-threatening is happening, then treating the symptoms if necessary. A reassuring talk with a doctor can be curative in many cases of travel-related panic attacks.
Psychosis
When I'm working in Nepal, I dread the phone call telling me someone has lost their mind. A delusional, aggressive psychotic patient is often first encountered in jail, after disruptive behavior in public. The police are usually only too happy to hand over someone who isn't in their right mind. But then what?
The two goals of immediate treatment are a stable, safe environment, with plenty of people to take turns watching the patient, and generous use of anti-psychotic medication. Embassies can't take forcible control of people in another country, so simply shipping someone home isn't an option. The aim is to stabilize the patient as quickly as possible and repatriate them with reliable companions. The value of anti-psychotic medication in this situation can't be overemphasized; an injectable anti-psychotic deserves a place in the adventure-travel doctor's kit — hopefully never used.
The exact diagnoses in these cases haven't been systematically studied by psychiatrists. Most episodes happen in people with no previous mental illness. Acute situational psychosis is probably the most common diagnosis. Other cases may be the first sign of schizophrenia in a susceptible young adult, or of bipolar disorder, with manic symptoms sliding into psychosis — people who feel everything in their lives has come together and every event is loaded with huge meaning. Fortunately, the treatment is the same for all of these.
Depression
Severe depression leading to suicide attempts is a very serious problem among travelers and expatriates, but fortunately quite rare. Some people travel as a last hope of dealing with their feelings, and become suicidal when it doesn't help. Others have ended a relationship while traveling, or struggled in a volunteer post. I know of one man who mailed a postcard as he boarded his flight, telling his family he was going to Kathmandu to end his life; fortunately he was found alive in Kathmandu after his embassy searched for him.
Severe depression in travelers should be treated as it would be at home: emotional support, appropriate medication (particularly if anxiety plays a large part), and repatriation with reliable assistance.
If you're having emotional difficulties and don't know how to handle them, please come and talk to one of our psychiatrists or doctors. We offer completely confidential professional advice, and medication if needed.