Anxiety Disorders

Anxiety is a universal emotion that is usually a normal and adaptive response to everyday life. Anxiety motivates us in myriad ways to complete tasks, study for tests, have a reliable belay partner when rock climbing, and work to earn a living. The experience of anxiety is physical as well as psychological. Increased heart rate, blood pressure, and respirations; sweaty palms; and muscular tension are common physical manifestations that accompany the psychological feelings of anxiety and tension. Rarely is anyone totally free of anxiety; however, for most people, anxiety is mild. There are many ritualized and socially condoned means of diminishing everyday forms of anxiety, such as jogging, athletics, socializing with friends, drinking alcohol, and engaging in sexual activity.

In response to threat or danger, an extreme form of anxiety that is triggered in everyone is the fight-or-flight response. This response occurs automatically and without conscious control. Athletes, extreme sports enthusiasts, military combatants, crime victims, and anyone confronting serious injury or death will have this response triggered. The fight-or-flight response is mediated through the autonomic nervous system, which, when triggered, causes blood to be diverted from the internal organs to the skeletal musculature. Heart rate, blood pressure, and respiration rate dramatically increase. A person in a fight-or-flight state often acts with little or no reflective thinking to preserve his or her life or the lives of others. Memories of these episodes may be unreliable, because an individual is often on “automatic pilot.” Episodes of autonomic arousal in response to danger or threat are normal. However, some people experience anxiety in ways that interfere with their ability to function, to complete everyday tasks, and to respond appropriately to danger.

The several types of anxiety disorders include generalized anxiety disorder, specific phobias, panic disorder, obsessive–compulsive disorder (OCD), and acute and post-traumatic stress disorder (see Response to Crisis, later). People with generalized anxiety disorder worry a lot. Their anxiety is out of proportion as compared with what most people would experience in similar circumstances. The afflicted individual may find it difficult to keep worrisome thoughts from interfering with attention that needs to be paid to current activities. The focus of the worries among people with generalized anxiety disorders are mundane and include such concerns as getting up on time for work, making appointments, and doing chores. These individuals experience somatic symptoms, such as sweating, nausea, and diarrhea. The prevalence of generalized anxiety disorders is approximately 1.5%.⁵ In a wilderness setting, the foci of worries might be bear attacks, getting lost, not keeping up, flash floods, and so forth. These anxieties will likely diminish the person’s enjoyment of a wilderness experience, affect his or her concentration, and drain his or her energies. People with generalized anxiety may negatively affect group morale. However, generalized anxiety problems are not emergencies; they are chronic problems that can be managed in the field. People with a generalized anxiety disorder require ample reassurance. A good leader can provide reassurance and appoint other group members to assist with reassuring the anxiety-ridden individual.⁴ Building rapport and trust with the afflicted person is a good first step to helping them. Trying to talk someone out of his or her worries is unlikely to be productive. In the field, a benzodiazepine (e.g., 0.5 to 2 mg of lorazepam two to three times a day) can be useful.¹¹ Side effects include sedation, memory difficulties, and impairment of motor coordination. Sustained benzodiazepine use can lead to physical dependence and withdrawal symptoms with abrupt discontinuation. Thus, such medications must be used cautiously in the field, but they can provide short-term relief of anxiety-related symptoms.

Probably one of the more common specific phobias encountered during a wilderness outing is a fear of heights or exposure (e.g., to an edge with a drop-off). Other common phobias are to snakes, spiders, and water. A specific phobia is an unreasonable fear in anticipation of or on exposure to a particular object or situation.¹ The intensity of anxiety with the exposure may vary from relatively mild to extreme panic. In some instances, phobias to heights cannot be overcome in the wilderness. For instance, a trail that crosses a bridge over a chasm or that involves a section of precipitous exposure might be more than can be managed by an individual with a specific phobia to heights. I have personally guided people who were so terrified of exposure that they were unable to complete some trails. Sometimes, gentle reassurance or distraction may be all that is required. Engaging height-phobic people in distracting conversations while backpacking in areas that involve dizzying exposure can be successful. However, if an individual is likely to respond with extreme anxiety and become unbalanced, then it is not safe to use such psychotherapeutic measures.

Individuals with panic disorders experience recurrent and unexpected panic attacks. A panic attack occurs during a discrete period of time that lasts approximately 10 to 30 minutes, and is manifested by one or more of the following symptoms: pounding heart, sweating, trembling, chest pain, nausea, dizziness, numbness, chills, hot flushes, and shortness of breath. During a panic attack, a person may fear that he or she is dying, having a heart attack, going crazy, or losing control. Such individuals often visit emergency departments out of fear that they have had a heart attack or that something is seriously physically wrong. Any person with one of the anxiety disorders described in this section may experience a panic attack, but the person with a panic disorder experiences recurrent and unexpected panic attacks. These attacks occur without warning and seem to come “out of the blue,” which is in contrast with being in response to a specific trigger (e.g., as with specific phobias, which were described previously). As a result of recurrent attacks, people may develop avoidant behaviors, because they do not want to be in situations in which escape might be difficult or embarrassing or in which help might not be available (e.g., agoraphobia). When these people are caught in these situations, they have a desperate desire to flee. Agoraphobia may lead people with panic disorders to avoid leaving their homes, or they may leave only in the company of trusted companions.

Panic disorders occur in approximately 1.6% to 5% of the population.⁵ Treatment with selective serotonin reuptake inhibitors (e.g., fluoxetine, sertraline) or benzodiazepines (e.g., alprazolam, clonazepam) or with a combination of the two and with psychotherapeutic intervention can be successful for controlling panic disorder and agoraphobia.⁵ People with panic disorder whose symptoms are not problematic may safely enjoy a wilderness adventure without difficulty. However, remote locations, bad weather, or physical challenges may increase the stress on such individuals, thereby causing them to experience a resurgence of symptoms. Having panic attacks in the wilderness may precipitate agoraphobia. The afflicted person may want to escape from the wilderness, and he or she may be completely intolerant of being left alone, even for brief periods.

A person who is having a panic attack in the wilderness may present a diagnostic dilemma. He or she may look like he or she is having a heart attack or experiencing acute respiratory distress caused by pulmonary edema. A careful history that indicates that the person has a history of panic disorder and does not have a history of heart disease may help. However, for an older person who may have risk factors for heart disease, the distinction between panic disorder and symptoms of a myocardial infarction may be nominal. People who have a panic attack usually begin to calm down within 30 minutes to 1 hour. Symptoms often respond to a benzodiazepine (e.g., lorazepam), reassurance, and support. Providing regular doses of benzodiazepines to an individual with a panic disorder or increasing the dosage of currently prescribed benzodiazepines may be enough to allow for the completion of the trip.

Obsessive–Compulsive Disorder: Repetitive Behaviors

A person on a wilderness trip is observed constantly stopping to wash his hands in a stream or lake or with water that he is carrying. His hands are observed to be raw from frequent washing, and the time consumed by this activity is slowing the group’s progress to a crawl. When asked about the hand washing, the individual apologizes and acknowledges that the behavior is irrational but explains that he is deathly afraid of germs and cannot cease the behavior. Another person on a wilderness trip is frequently overheard counting in a whispered voice. When asked about the counting, the individual (with considerable embarrassment) explains that she is afraid that she will attack someone, so every time that she has a violent thought, she counts to 100. The obsessions and compulsions of a person with OCD are usually seen as irrational by the person who is experiencing them, but at the same time he or she feels helpless to stop them. If a person with OCD is prevented from performing ritualistic obsessions and compulsions, he or she may near panic or experience full panic attacks.

A person with OCD may not be able to adhere to the requirements of a wilderness trip. For instance, the chronic hand washer may slow a group so profoundly that the group cannot make reasonable progress. The example of the person who tries to control his or her anxiety about acting violently by counting may present less of a problem. People with OCD are not typically violent, but a person who is observed to be constantly counting to ward off violent behaviors may have difficulty fitting in with a group. In the general population, the prevalence of OCD is 1% to 2.5%.⁵ People with OCD are often successfully treated with clomipramine and psychotherapy.⁵ It is unlikely that OCD symptoms will appear suddenly on a wilderness trip. Frank disclosure to a wilderness group about the OCD symptoms of a member of the group can diminish the group’s anxieties about the person’s odd behaviors and make the afflicted person less likely to be isolated by the group.

Mood Disorders

Sadness, moodiness, happiness, and elation are normal emotions within the human experience. However, when they become extreme and prolonged and interfere with normal functioning, they are considered mood disorders. People with severe depression or unstable bipolar disorder (i.e., manic–depressive illness) will not usually venture into the wilderness. However, people who are being successfully treated or who have relatively mild symptoms may participate in wilderness adventures. Seriously depressed people feel sad, useless, and bad about themselves and the world. Their view of the world is dark, and they have difficulty believing that their lives will improve.

Depressed people have difficulty sleeping, lose their appetites, have poor energy levels, lose concentration, withdraw socially, cry for no reason, and have difficulty enjoying anything. The most common diagnostic term for this type of depression is major depression; the prevalence of this disorder is approximately 2.5% to 10%.⁵ At their worst, people with severe depression may become psychotic and suicidal (see Suicide and Violence Potential as well as Psychotic Disorders, later).¹ People who are having mild problems are unlikely to develop severe symptoms rapidly, because severe symptoms gradually appear over a period of weeks or months. The more likely problem on a wilderness adventure is finding someone who started out with mild symptoms that are becoming worse. Such individuals may already be taking antidepressant medications (e.g., citalopram, paroxetine). These medications work slowly over a period of weeks, so a change in dose in the midst of a wilderness trip probably would probably not provide significant benefit. The most common problem that the wilderness group may face with a depressed person is that person’s overall impact on group morale. Emotional outbursts, crying for no apparent reason, and offhand comments about suicide will likely concern and distress others in the group. If group members provide encouragement and emotional support, this may help the depressed person to get through the trip safely. However, severe symptoms may not respond to ordinary support. A lack of response can anger others, who may begin to feel conflicted, because they recognize that they are punishing someone who is already suffering. As the symptoms grow worse, it may become necessary to hasten the depressed person’s departure from the wilderness, especially if there is suicidal ideation.

Individuals with bipolar disorder experience episodes of major depression that alternate with periods of mania over a period of months, often with normal functioning occurring between the abnormal episodes. The prevalence of bipolar disorder is approximately 1%.⁵ During periods of normal mood or during the early stages of a manic phase (i.e., hypomania), bipolar persons may participate in wilderness adventures with no difficulty. During a period of hypomania, a person is very positive, productive, hardworking, energetic, and expansive. However, as the person becomes manic, problems become readily apparent. There is often rapid and pressured speech that is difficult to interrupt. Sufferers might not sleep at all, or they may be excessively gregarious and begin to believe that they have superhuman powers. An individual may try to awaken a wilderness group in the middle of the night to hike up a nearby peak. When rebuffed, the manic person might take off alone with no water or protection from the weather because of the belief that he or she is superhuman. A guide described a participant on a wilderness trip who became manic and could not be dissuaded from climbing to the top of a mountain to talk with God. An individual with mania who is in the wilderness should be considered a medical emergency and should be evacuated as rapidly as possible.

Careful questioning may reveal that the manic person is taking psychiatric medications such as mood stabilizers (e.g., lithium, divalproex), antipsychotic medications (e.g., risperidone, olanzapine), or both. People who take lithium must avoid dehydration, which can result in lithium toxicity. Lithium toxicity begins with tremulousness and can proceed to seizures and death. If lithium toxicity is suspected, the lithium should be stopped and the person should be well hydrated. The patient may require dialysis to resolve the toxicity, so evacuation is required. People with bipolar disorder sometimes stop their medications because they enjoy how they feel when they are hypomanic. The use of a benzodiazepine (e.g., lorazepam) or an antipsychotic medication (e.g., risperidone) can control some of the symptoms. Risperidone (2 to 6 mg) and lorazepam (4 to 8 mg) spread over the course of a day may be required to keep a manic individual calm.⁵ It may be possible to coax a manic person out of the wilderness with the use of encouragement and enticements. Manic individuals can be extremely irritable and sometimes aggressive. Weapons should be confiscated. If a manic individual will not voluntarily leave the wilderness, then assistance—including law enforcement—should be obtained as soon as possible. An evacuation may require the individual to be forcibly restrained and medicated. While waiting for help to arrive, members of the group must constantly contain the manic individual’s excesses to keep both the affected individual and the group safe.

Psychotic Disorders

Individuals with severe mental illnesses (e.g., schizophrenia, schizoaffective disorder) do not typically venture into the wilderness, especially if they are in a deteriorated state. Their overall functioning is too low for them to organize themselves to the point that they could join a wilderness group. Those persons who have been able to benefit from treatment, usually in the form of antipsychotic medications, sometimes venture with groups into the wild. There is an approximate 1% prevalence of schizophrenia worldwide.⁵ Tragically, the illness often manifests during young adulthood. The hallmark of these disorders is a substantial period, usually of at least 1 month, during which the individual becomes unable to rationally perceive reality. A person who believes that a sinister group worshiping the devil has implanted a transmitter in his mouth (delusion) and who hears mysterious people talking about him and saying that he is pathetic and should kill himself (auditory hallucination) is considered psychotic. People with delusions and hallucinations cannot be talked out of them. People who are successfully treated with medications may still have some unusual or even delusional beliefs, but the psychotic symptoms have receded into the background and are not an active concern for the individual. In addition to psychotic symptoms, people with schizophrenia or a schizoaffective disorder often seem awkward or distant interpersonally. Their thoughts may be jumbled and disorganized. Concrete thinking that is literal or obvious with little ability for abstraction is common. If they are receiving adequate treatment, such individuals might enjoy a wilderness adventure with no difficulty, although their personal contribution to the group may be nominal. Antipsychotic medications—especially older ones such as haloperidol—that are required for the treatment of symptoms cause a wide range of side effects, including extrapyramidal symptoms (e.g., Parkinsonism), acute dystonias, insomnia, sedation, and orthostatic hypotension.¹¹ Side effects alone may preclude a person from participating in a wilderness adventure, but people who have been taking medication for weeks or months may have adapted to the side effects. Newer antipsychotic medications (e.g., aripiprazole [Abilify]) have fewer side effects.

Problems arise for the wilderness group if a member of the group becomes acutely or floridly psychotic. Symptoms may range from mild issues (e.g., a person asking the group why they are always talking about him) to paranoid beliefs that snipers are in the woods trying to kill the psychotic individual. Very mild symptoms may be tolerable, or the individual may respond to periodic gentle reassurance (i.e., reality orientation). An increase in the dose of the individual’s already-prescribed antipsychotic medication may help, or a benzodiazepine may have a calming effect, at least temporarily. If psychotic symptoms become more severe with prominent paranoia or agitation or if the victim begins to make bizarre accusations toward others in the group, the situation should be treated as a medical emergency, and the person should be evacuated as soon as possible. Psychotic individuals’ behaviors may be unpredictable and violent toward themselves or others. The many causes of psychotic symptoms include schizophrenia, schizoaffective disorder, mania, illicit drugs (e.g., methamphetamine), and organic causes (e.g., brain tumor, metabolic disturbance). A good history may help with the differential diagnosis, but it may be difficult in the field to determine the cause of psychosis.

Organic Mental Disorders

There any many medical problems in the wilderness that can cause behavioral symptoms, and these range from mild confusion that is associated with high-altitude hypoxemia to delirium that is associated with high-altitude cerebral edema. A person in the wilderness may have fallen and hit his or her head on a rock, which initially results in a minor scrape and a headache; however, this may progress to a subdural hematoma and delirium that may become life threatening. It is crucial to recognize which signs of delirium in the wilderness are true medical emergencies. A person with delirium has a fluctuating level of consciousness; he or she may be awake and alert for a few minutes and then become inexplicably sleepy. People with delirium are often confused and disoriented with regard to date, time, and place. Concentration, memory, and calculation ability may be impaired, and visual, tactile, or other types of hallucinations may appear. Paranoid delusions might be reported.⁵ The key sign for differentiating delirium from psychosis is that the psychotic person remains alert with no change in level of consciousness, whereas the delirious person’s level of consciousness fluctuates over minutes or hours.

If delirium is suspected, a cause must be determined as rapidly as possible. Dehydration, hypoglycemia, high-altitude cerebral edema, head injury, meningitis, encephalitis, drug or alcohol withdrawal, and heat illness—to name but a few conditions—can cause delirium. In their confusion, people with delirium can easily injure themselves, so they must be watched constantly. Especially with delirious patients, physical restraint may be needed. In the wilderness, physical restraint can be accomplished by applying duct tape over cloth (so that the person does not injure himself or herself by struggling against the restraints) to each limb and possibly to the trunk as well, with the person being restrained in a side- or face-down position to prevent aspiration. Physical restraint is certainly potentially hazardous and should only be done as a last resort. Grand Canyon rangers have had to physically duct tape combative and delirious individuals (who have become that way as a result of dehydration) to litters before putting them on a helicopter for evacuation. If an easily treatable cause of the delirium cannot be identified and treated, then evacuation is necessary. I personally reviewed a Grand Canyon backpack trip during which a member of the group became increasingly unsteady and confused as he progressed down the canyon. He would be fine for a few hours and then would become obtunded. He fainted and fell a couple of times, but he was not seriously injured from the falls. Shortly after the group made it to a beach on the Colorado River, the man became semicomatose. A helicopter eventually evacuated the victim to a nearby hospital, where he was treated successfully in an intensive care unit for pulmonary edema.

Personality Disorders

Personality disorders are psychiatric disturbances that can cause considerable difficulty in the wilderness, although they rarely present as emergencies. Personality disorders are common, with an approximate 12% prevalence.⁵ There are 10 different categories of personality disorders that are described in the DSM-IV-TR. People with personality disorders have enduring maladaptive patterns of behavior that usually date from adolescence. The use of a narrow set of adaptive strategies inflexibly leads these individuals to have chronic problems at school and work and in their interpersonal relationships. Ironically, people with personality disorders do not tend to see themselves as having problems; rather, they blame others for their difficulties. Individuals with personality disorders unwittingly create their own special circle of misery. Depression and substance abuse are common in this population.

People with schizoid personality disorders are loners, and they tend to avoid relating to others, except on a shallow and superficial level. People who are schizotypal have odd and eccentric preoccupations and manners. They may be enamored of astrology, spiritual vortices, or numerology, and they tend to relate in an awkward or uncomfortable way. Annoying, aloof, and unable to join in comfortably with a group, these individuals do not usually cause major problems. People with a paranoid personality disorder are constantly suspicious of others and believe that others have malevolent intentions toward them. Their suspicions are not totally absurd, as they are with someone who is psychotic. For example, these individuals may believe that fellow travelers do not like them or will steal from them, but they do not believe that transmitters have been implanted in their brains or that the Federal Bureau of Investigation is conspiring to kill them. A person with persistent suspicions of others can be problematic for a wilderness group, because the successful functioning of such a group depends on trust among its members. Group leaders need to work doubly hard to draw such individuals into the group and to avoid having the group isolate these people; such isolation serves only to amplify the paranoia and discomfort between the affected person and the group.

Another group of personality disorders is sometimes referred to as the “dramatic and erratic” personality disorders. The person with narcissistic personality disorder is one who considers himself or herself special and unusually talented and therefore deserving of special praise or attention. The person with a histrionic personality disorder is colorful and dramatic and demands to be the center of attention. He or she may be perceived as vain and shallow and often exaggerates physical complaints. For example, a small blister can cause excruciating pain and discomfort for this type of individual. The person with a borderline personality disorder is unstable and has a fragile sense of identity. Relations with a borderline person tend to be stormy; he or she may be exquisitely sensitive and react with rage at the slightest sign of rejection. The person with an antisocial personality disorder is a “confidence man” who may manipulate, intimidate, or steal to obtain what he wants. He can be superficially charming, but he is irresponsible, unreliable, and sometimes aggressive and violent if his wishes are thwarted.

A third group of personality disorders includes the avoidant, dependent, and obsessive–compulsive personality disorders. The person with an avoidant personality disorder is constitutionally shy but desires relationships with others. The person with a dependent personality disorder is someone who looks to others to make decisions and to care for them. The person with an obsessive–compulsive personality disorder is task oriented and hardworking, but he or she is also perfectionist, moralistic, and humorless. The obsessive–compulsive personality disorder is to be contrasted with OCD, which was described previously.

A psychologically intuitive leader may be able to run interference between the afflicted person and the rest of the group. At other times, the maladjusted individual can be so disruptive that the leader or the rest of the group must insist that the person leave. If this is the case, the person should be assisted with exiting the wilderness. These individuals may not willingly accept being dismissed from the group, and they may become physically or verbally combative. They may be enraged and report that they are going to kill themselves, sue, or seek some other form of retaliation. Nevertheless, if the individual cannot safely function as part of a wilderness group, the leader must remain firm in dismissing the person from the group and assisting him or her safely out of the wilderness.

Substance abuse Disorders

People who abuse illicit drugs or alcohol should not be on wilderness adventures; they are a hazard to themselves and others. It is not uncommon for a wilderness traveler to appropriately enjoy a small quantity of alcohol after a long day. However, the use of methamphetamines, cocaine, heroin, lysergic acid diethylamide, and other illicit drugs on a wilderness trip is dangerous. If someone is unwilling or unable to stop using these drugs, then he or she should be escorted out of the wilderness. More problematic is a person who is prescribed narcotic medications (e.g., oxycodone, OxyContin) to control pain. Narcotics are central nervous system depressants that can impair concentration and coordination. In modest doses, such medications may be reasonable; however, at higher doses or if the individual is abusing prescription narcotics, then it is not safe to have him or her continue a wilderness journey, and he or she must be escorted out of the wilderness.

Some people may be unaware that they have a substance abuse problem when they start a wilderness trip until they start to experience physical or psychological withdrawal. A careful history can establish if someone is experiencing alcohol or drug withdrawal. Alcohol withdrawal is considered a medical emergency because of seizures, psychotic symptoms, and delirium tremens.² Withdrawal symptoms usually start with shakiness and increased heart rate and blood pressure. Withdrawal from barbiturates or benzodiazepines can manifest similarly to alcohol withdrawal, and can also be life threatening. If withdrawal is suspected, a benzodiazepine (e.g., lorazepam) can be given; several milligrams may be needed before the vital signs stabilize. Alcohol can be used to stop withdrawal symptoms, if necessary and available. People who abuse cocaine, methamphetamines, or narcotics will not experience life-threatening withdrawal, but their symptoms can be extremely uncomfortable and disabling. Withdrawal from substances such as cocaine (i.e., crashing) is associated with extreme irritability and fatigue. Aches and pains that are typical of influenza are seen in association with withdrawal from narcotics. Withdrawal symptoms may last several days. Individuals who are experiencing alcohol or drug withdrawal should be evacuated.

On a wilderness trip, someone may experiment with natural plants in hopes of achieving an induced high. Tea made with jimson weed or certain other plants can induce florid psychosis and delirium. Such individuals may shed clothes, develop severe sunburns, become dehydrated, and expose themselves to all manner of risks. Plants that can cause psychotic symptoms and delirium are common (see Chapter 64) and should be avoided.² People who are experiencing psychotic symptoms or delirium as a result of the ingestion of toxic plants must be watched constantly until evacuation to a hospital can be arranged.

Disasters

Avalanches, storms, rockfalls, climbing, whitewater accidents, and many other untoward events can lead to the death or serious injury of one or more group members. People who venture into the wilderness usually do not anticipate someone being seriously injured or killed (Figure 35-2). Even persons who have taken wilderness first-aid courses do not enter the wilderness expecting the worst, or else no one would participate in these types of activities. There are many descriptions of outdoor trips that have involved crises.¹⁰

FIGURE 35-2 A Sierra Club group enjoys dinner in the Wind Rivers Wilderness.

Humans wrap a cloak of denial around themselves. Thus, when a crisis or tragedy occurs, it is almost always an emotional shock. When you watch your climbing partner fall and die or when your friend drowns when his kayak flips in whitewater, there is a reaction of horror, dread, and disbelief. The situation is overwhelming, and survivors or witnesses of these types of tragedies often describe a sense of unreality that is associated with the horrible event. People who are involved in tragedies often need to replay the event to put it into some type of meaningful personal context. People who are relatively intact psychologically and who have good social support can usually mentally process a trauma successfully without long-term mental health problems. As the size of a disaster grows and its impact on a person or a community’s support networks increases, the likelihood of long-term mental health problems grows. People who handle trauma by psychological avoidance and casting blame may have poorer outcomes.¹³

In response to natural disasters, some individuals develop acute stress disorder or post-traumatic stress disorder (PTSD). Estimates of the frequency of these disorders after disasters—either manmade or natural—vary from 2% to more than 50%.¹³ The symptoms that are typical of these disorders include efforts to avoid reminders of the traumatic event and markedly increased anxiety during exposure to such reminders. The affected person may be flooded with uncontrollable memories, including bad dreams and flashbacks (i.e., feeling and behaving as if the trauma was happening again). The person may feel a sense of emotional detachment from others. He or she may have difficulty concentrating and sleeping, feel restless, and be easily startled. Symptoms can begin immediately after a disaster. If they persist for more than 2 days but for less than 1 month, the disorder is called acute stress disorder; if the symptoms are present for more than 1 month, the disorder is called PTSD.¹ For most people, symptoms diminish as time passes, although there is commonly intensification of symptoms around the time of the 1-year anniversary of the tragedy. Symptoms may become chronic and require ongoing psychiatric care. I have personally evaluated men who were held as prisoners of war during World Wars I and II and who were subjected to cruel deprivation or torture. Some did not experience symptoms of PTSD until they retired, which was many years after they were traumatized (i.e., delayed PTSD).¹

There is no evidence-based consensus for mental health interventions during the immediate aftermath of a disaster. Available evidence indicates that psychological debriefing is not associated with benefits and may in fact complicate recovery after a disaster. Debriefing, which usually involves some review of the disaster, may increase physiologic hyperreactivity, increase the coding of traumatic memories, and promote rumination about the tragedy; debriefing can thus interfere with more adaptive and natural healing mechanisms (e.g., avoiding thinking about the trauma). If debriefing is used, it should be voluntary, involve clinical assessment, and only be performed by experienced and well-trained individuals. Clearly, more systematic research is needed in this area.¹³ However, despite a lack of systematic research, there have been attempts to promulgate a clinical consensus regarding desirable mental health interventions in the wake of disasters on the basis of current empiric evidence.⁸ The immediate and first response to a wilderness disaster should emphasize ensuring the safety and security of the survivors; this includes provision of food, water, warmth, and shelter. Second, efforts should be made to calm everyone who was involved in the disaster. Survivors should be accurately informed about what has happened and about what rescue efforts are underway. It is important to advise survivors about the status of others who were involved in the disaster and about the safety of family and loved ones. Communication with loved ones should be facilitated as soon as possible. Victims should be provided with a calm setting to decrease arousal as much as possible. Encouraging deep breathing and muscle relaxation may be helpful. Reassurance should be provided regarding any distortions that a survivor may experience, such as feelings of weakness or guilt or catastrophic perceptions that the world is a malevolent and dangerous place. Medication use is controversial, with selective serotonin reuptake inhibitors demonstrating some benefit during the weeks and months after the disaster. However, using psychotropic medications during the immediate aftermath may not be necessary and may even be harmful, particularly if the sedative properties interfere with survival behavior or motivation. It is expected that survivors will be very emotional after a disaster, but the experience of those emotions may be naturally adaptive, so artificially dampening them with medications can be counterproductive. Survivors should be approached with the expectation that they will recover psychologically, and they should be reassured about their future mental health. Further interventions are required in the initial aftermath of a disaster. Promoting a sense of self-efficacy is recognized as an important component of recovery efforts, and this includes providing survivors with continuing information about the effects of the disaster and the means to contact other survivors. Making psychological intervention accessible can be very useful during the weeks and months after a disaster. Specialized crisis counseling services were developed after Hurricane Katrina that proved very useful.⁷ Cognitive behavioral treatments have also demonstrated considerable value for survivors of disasters. Finally, promoting a sense of connectedness with the broader community and instilling a sense of hope (i.e., avoiding social withdrawal and hopelessness) can be crucial for people who are recovering from a disaster. Pragmatically, a feeling of hope can come from prompt reparation payments, which may allow someone to rebuild a home that was destroyed in a disaster.

Survival Psychology

It is not uncommon for people to become lost in the wilderness. Human spatial orientation abilities are limited; we often function under the illusion that we know exactly where we are when that is absolutely not the case.³ People rationalize disorientation in the wilderness by explaining away inconsistencies between their topographic map and the actual landmarks before them. As a person becomes convinced that he or she is completely lost, he or she may experience intense fear, panic, and disorientation that are unique to this type of dilemma. Lost people have been shown to tend to walk in circles.¹² Even people with considerable experience in the wilderness may demonstrate inexplicable behaviors, such as abandoning provisioned backpacks or other potentially valuable items. Some have even removed clothing, which increased their exposure to the elements.³

After becoming lost, some persons develop a strategy and carry it through; however, when this plan fails, these individuals may abandon hope and resign themselves to fate. Ironically, children who are less than 6 years old fare better when they are lost as compared with older children and adults. The explanation for this paradox might be that younger children act on instinct and seek shelter when cold and water when thirsty, whereas older children and adults panic and sometimes overlook obvious and simple means to help them to survive.³ In groups that become lost, good leadership is often a key component of the survival of the group. Perhaps the most famous survival story is that of Ernest Shackleton’s ill-fated voyage to reach the South Pole in 1914. His ship, the Endurance, broke up in the ice. Under his leadership, the group survived months of incredible hardship. Against all odds, all 27 men survived.⁹