Mental Health in the Wilderness

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Chapter 35 Mental Health in the Wilderness

Wilderness environments often have beneficial effects on the overall emotional health of many individuals. Individuals who choose to pursue wilderness activities are often seeking relief from the stress of their hectic urban lives (Figure 35-1). However, remote wilderness environments can present unique stresses of their own. Mental health and mental health problems might improve in the wilderness, but psychiatric problems can emerge or become worse in response to the demands of wilderness experiences. This chapter discusses the diagnosis and management of emotional problems in the wilderness, including the use of psychotropic medications, both in people who have preexisting psychological difficulties and in those who develop new emotional problems in the wilderness.

The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision1 (DSM-IV-TR) is the most recent and widely used compendium of the nosology of psychiatric disorders. Most mental health problems can be thought of as falling into six broad groups of disorders: (1) anxiety disorders; (2) mood disorders; (3) psychotic disorders; (4) organic mental disorders; (5) personality disorders; and (6) substance abuse disorders. Specific diagnostic assessment with the use of the DSM-IV-TR and psychological testing in a wilderness setting is not practical. Appropriate triage and management in a wilderness setting depends on classifying emotional and behavioral problems as falling into one or more of these broad categories. Separating normal from abnormal human behaviors is the first step in the triage of emotional problems. It is not straightforward to differentiate what may be considered an adaptive response to the challenge of a wilderness experience from responses that are maladaptive and signal the onset of new emotional problems or the exacerbation of preexisting psychiatric problems. For example, at the end of a physically challenging day of backpacking with a group, one member of the group breaks down in tears. Such crying may be a healthy and adaptive response, or it may be a sign of depression or panic. The process of crying can relieve stress and result in the tearful backpacker receiving needed emotional support. Alternatively, such tears may suggest that the person feels mentally and physically overwhelmed. The person might be approaching a panic state, and, if appropriate interventions are not undertaken, the person’s mental state will deteriorate. The challenge is to determine whether a pat on the back and some encouraging words are all that are needed or if the individual has to be assisted out of the wilderness to prevent further emotional deterioration. In the following sections, four important topical areas for assessment and management of emotional problems in the wilderness are discussed: (1) the common characteristics of the six major categories of psychiatric disorders; (2) suicide and violence potential; (3) psychosomatic complaints; and (4) response to crisis (i.e., disasters and survival psychology). At the end of the chapter, Table 35-1 summarizes the triage of psychiatric problems in the wilderness.

TABLE 35-1 Mental Health Triage in the Wilderness

Anxiety disorders Provide reassurance, support, and lorazepam
Mood disorders, mild Provide support and encouragement
Mood disorders, severe (e.g., mania, suicidal ideation, violence) Observe constantly, contain or restrain, give lorazepam and haloperidol, and evacuate
Psychotic disorders Observe constantly, contain or restrain, give lorazepam and haloperidol, and evacuate
Organic mental disorders Identify the cause and eliminate it if possible, observe constantly, contain or restrain, give lorazepam and haloperidol, and evacuate
Personality disorders, mild Avoid overreacting to annoying behaviors and intercede to prevent conflicts within the group
Personality disorders, severe (e.g., violence, extreme behaviors) Expel the individual from the group if possible or obtain assistance and terminate the outing
Substance abuse (i.e., no delirium or psychosis) Confiscate drugs and alcohol
Substance abuse or withdrawal, severe (e.g., unstable vital signs, delirium, psychosis) Give lorazepam for withdrawal and haloperidol for psychosis or delirium, observe constantly, contain or restrain, and evacuate
Suicidal or violent behaviors Observe constantly, contain or restrain, give lorazepam and haloperidol, and evacuate
Somatic symptoms of psychological origin Exclude an organic cause and provide support, reassurance, and firm expectations
Disasters and post-traumatic stress disorder Ensure physical and psychological security and safety, provide support, and discuss the disaster as guided by the victim
Wilderness survival Stop, take time to develop a plan, attend to physical security (e.g., shelter, warmth, water), and avoid panic

Psychiatric Disorders

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.

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