16 Psychological and psychiatric problems

Expeditions by definition involve travel, usually into remote areas, and include activities unlikely to form part of a normal working week. Any change from the normal pattern of life can be stressful, and participants must adapt to a multitude of novel experiences, enjoyable and otherwise. Most fit, healthy, and well-prepared individuals should adapt readily to the physical and psychological effects of stress, but occasionally travellers encounter circumstances that result in long-term psychological issues.

Small groups are likely to consist of companions who are previously acquainted in other settings, and an informal process of selection may have occurred. Those in larger groups may have had little or no contact with other participants prior to the journey, especially if the group has been organized as a charity trek, adventure race, or commercial expedition. The longer the expedition, the more stressful or arduous the activity, the greater is the likelihood that psychological problems will surface.

The physical demands of the expedition are likely to cause a lowered reserve for dealing with other stressors, including making new relationships within the group.

If participants have joined their first expedition they may be unprepared for the intensity of contact involved in sharing tents or cramped sleeping accommodation. Experienced members may be intolerant of the difficulties experienced by those unused to, e.g. close quarter living, jungle style sanitation, the reduced opportunity for keeping clean, and the absence of home comforts. In polar extremes 24-h daylight or darkness are well-recognized causes of stress, leading to illnesses such as ‘seasonal affective disorder’ (SAD)—a problem documented by early explorers. If possible, plan a team-building exercise before the expedition that introduces some of these stressors to observe how people may adapt to the physical demands of the expedition.

During an expedition, contact with indigenous peoples may be limited or very intense. The opportunity for developing understanding of different cultural values may be limited by language barriers unless fluently bilingual interpreters are present.

Factors which may reduce cultural transitional stress include:

All these factors should be borne in mind when screening potential expedition team members.

Increasing numbers of individuals with a prior medical history of mental health problems are undertaking expeditions, and this can result in problems during the expedition and possibly a need for repatriation. Problems are most likely if members have a pre-existing psychological morbidity that was either not declared, or considered unimportant, during the selection process (see this chapter; Creating expedition teams, p. 26; Medical screening, p. 46).

Some form of psychological health screening of potential expedition members is highly desirable and becomes increasingly important for longer expeditions. An acute psychosis, although rare, may cripple the progress of an expedition until repatriation can be organized. Losing a member of the team because of illness may affect the overall skills of the group.

No screening process will ever distinguish perfectly between those who will thrive on an expedition and those who will develop problems; however the risks of serious adverse events can be reduced with some simple measures. Information should be sought from several sources.

These should be constructed carefully so that all questions have to be answered (see Advising those with common pre-existing conditions, p. 50). GPs completing medical forms should be informed that any prior psychological history is fundamentally important, and that non-disclosure could be detrimental to the safety of both the applicant, and the rest of the team. Non-disclosure may invalidate medical insurance. However, it is also important to stress that disclosure of mental health issues is primarily to enable individuals to prepare for the rigours of expedition life and not necessarily to prevent them from participating.

Work references are particularly important because they are provided by people in regular contact with the candidate who see them when they are not trying to create a specific impression.

Interviews should be at the core of any selection process. Panel members must include those involved in the expedition, individuals who have previous experience in the field in similar situations, and are aware of small group dynamics and their influence on morale and psychology of the group. The interview can include:

Each expedition will be different, and the ability to help those with complex psychological needs will depend on the location, purpose, duration, staffing levels, and medical competence of the team.

As with any other pre-existing medical condition, individuals with a mental illness should have coping mechanisms and appropriate treatment planned prior to departure. In some instances it might be prudent to create a contract between the individual, the team leader and a medical professional detailing:

For example, for a person with anorexia nervosa:

All parties involved should sign this agreement. It will also be necessary to review insurance policies and ensure individuals have appropriate repatriation cover.

Expedition leaders or medical officers should receive some form of mental health first-aid training. See Chapter 2.

Human resilience increases when basic needs are attended to: food and water, shelter, rest, and time for recreation. Poor living conditions and excessive tiredness result in poor decision-making. Common causes of stress include relationship problems, poor leadership, lack of control, poor understanding of roles and a lack of support. Such stressors should be explored before departure to try to match expectations to organization. Appropriate pressure leads to excitement and improves performance; although excessive pressure can cause team members to feel overwhelmed and exhausted. Strategies that can boost resilience include:

Psychopathology in people working overseas, even after rigorous selection, is common, and those engaged in expeditions and other prolonged visits into wilderness locations are at risk.

Anxiety may be generalized or focused on particular concerns such as snakebite or flying. Features are as for panic disorder (see Anxiety disorders, p. 522).

Anxiety about health is normal when travelling internationally, but can be a problem if it becomes extreme or remains, despite reassurance. It may be made worse on expeditions which are isolated from competent medical help.

Aviophobia (fear of flying) is experienced by up to 20% of air passengers. Behavioural therapy and, in particular, systematic desensitization, is a very effective treatment, and medication such as beta blockers or one-off doses of benzodiazepines can complement physical techniques and cognitive strategies to overcome the fear. There are several UK-based courses such as  http://www.virtualjetcentre.co.uk/fear-of-flying (South west) or  http://www.gatwickairport.com/booktrip/Travel-advice/fear-of-flying

Panic disorder is the presence of recurrent panic attacks; a discrete period of intense fear or discomfort, involving at least four of the following symptoms:

Management of anxiety or panic consists of calm reassurance and, in the case of rapid breathing, breathing in-and-out of a paper bag, cupped hands or abdominal breathing (all intended to help slow breathing down). If symptoms persist, an expert opinion should be sought. Anxiolytic drugs, psychological therapies, or both may be advised.

It is important to distinguish clinical depression from the low mood which all people experience from time to time. Homesickness, concerns about how one may cope, environmental stressors, and fatigue may all produce similar symptoms during an expedition. Depression may follow a clear trigger such as bereavement but it may have no obvious precipitant. Characteristic features of clinical depression include:

Management of depressed people is likely to require expert help in the form of psychological therapy and/or medication, particularly if there are suicidal features. Repatriation may be required.

Psychoses are severe mental illnesses and are rare, but they can develop while travelling and may be provoked by medication such as mefloquine (Lariam^®) or illicit drugs such as marihuana, amphetamines, and cocaine. However, it is important to remember that physical illness may be the cause for abnormal behaviour: see Delirium/confusion, p. 252.

Features of psychosis/acute confusion include:

A psychotic or confused patient may not be cooperative with treatment or safety procedures. Approaches to increase engagement include:

Someone with an acute psychotic illness should be evacuated for expert assessment and treatment, usually with a psychotropic medication. Consider sedation with olanzapine 5–10 mg PO (available in orodispersible form). Haloperidol 0.5–3 mg two or three times daily is an alternative and can be used in delirium; it must be given with an anticholinergic such as benzhexol or procyclidine. Mental health laws differ between countries, or may be absent.

Approximately 2% of adult females and occasionally males have been diagnosed with an eating disorder. The main eating disorders are:

Eating disorders are both complex and chronic in nature. It is unlikely that issues causing these illnesses will be resolved on expedition. Successful management will hinge on the individual’s concordance with either pre-arranged management plans, or those formulated whilst away. It is not unusual for the care of an individual suffering from an eating disorder to become stressful, particularly around meal times, as they seek increasingly more covert ways of reducing their calorific intake. Mealtime behaviour might include:

Strategies for managing mealtimes may include:

It is important to avoid the emotional game of dietary chess, where success or failure rides on an individual’s ability to hide food or make someone complete a meal. Firm but supportive care, where there is clarity of boundaries and consequent repercussions, must be paramount.

Increasing numbers of adolescents embark on youth expeditions. Between 2% and 8% of this age group have been diagnosed with a learning or intellectual disorder, so it is not uncommon to encounter these issues whilst away. Such disorders can have multiple physiological, social, and environmental components, the most common conditions being:

Preparation is the key to the effective management of learning or intellectual disabilities, but relies on individuals disclosing sensitive and often stigmatized conditions prior to departure. As with some psychological conditions, contracts detailing acceptable behaviour, boundaries and repercussions are important. Whilst away, management strategies should include:

Individuals with learning or intellectual disorders are often misunderstood, feel stigmatized, and become marginalized. These issues become a barrier to effective communication and support. Fostering an atmosphere of mutual respect will maximize effective management.

See  http://www.rcpsych.ac.uk/healthadvice/problemsdisorders.aspx for useful information and further reading about these conditions.

1–2% of adolescents over the age of 15 suffer from bed-wetting. Although the causes can be physiological, the effects are psychological, affecting self-esteem and confidence. Whilst on an expedition individuals may attempt to control the volume of urine created by drinking less which can, in the expedition setting, lead to potentially hazardous dehydration.

Desmopressin (1-deamino-8-D-arginine vasopressin or DDAVP^®) is a potent antidiuretic used in the management of nocturnal enuresis, causing increased water reabsorption in the renal tubules. If taken too often (something a nervous or embarrassed expedition member might do), or taken alongside the increased fluids often required in hot or humid climates, it can result in a significant and hazardous risk of hyponatraemia (see also Fluid-induced hyponatraemia, p. 762).

Hyponatraemia may also be induced with the concomitant use of NSAIDs.

(See also Death on an expedition, p. 166; and Sexual assault, p. 165.)

Most expeditions will be completed with only minor untoward events. However, anyone taking a group into the field, particularly those responsible for young people, must be aware of how to care for the group’s psychological welfare should illness, accident or, at worst, death occur. These events might occur within the group whilst on expedition, but it is also possible that leaders might be responsible for informing an expeditioner of events that have occurred at home. Possible traumatic events include:

In some situations the whole group will have witnessed what has happened. In others, the leader may have to inform the members of the group about the traumatic event or its repercussions. Box 16.1 on ‘Breaking bad news’ gives some guidance on how to do this (See Box 16.1). Further details are available at:  https://dartcenter.org/sites/default/files/breaking_bad_news_0.pdf

When a traumatic event occurs, leaders should assume that some people may be stunned and bewildered, or react with incapacitating anxiety or hysteria. The leader and/or medic needs to identify quickly how people are reacting and use them appropriately. Those reacting effectively may be needed to help in rescue efforts or to ensure the safety of the others.

In the event of a disaster, care of the victim is the first priority; however, other group members, the leader, rescuers, family and friends, and expedition organizers will all experience different psychological reactions. The psychological care of the victim and the rest of the group and self-care are the leader and medic’s responsibility. They should provide accurate information in a timely fashion for the rest of the group.

Whilst an ill or injured group member is awaiting evacuation, their physical comfort, security, and dignity must be maintained; e.g. ensuring they are covered and have privacy. If the person is conscious they should be kept informed of what is happening. They may be very distressed or bewildered. It is important to be patient, honest, to allow them time to talk, and to accept what may be muddled and rapidly changing thoughts and emotions, and reassure them these are normal.

If the victim is unconscious, their right to privacy and dignity must still be respected. It should also be assumed they can hear; they should have company, be kept informed, and be spared pessimistic conversations happening around them.

Psychological first aid (PFA) should be offered to the rest of the group. This includes:

An important aim is to reduce arousal levels as this will reduce the risk of post-traumatic stress disorder developing ( Post-traumatic stress disorder, p. 530). A free manual on PFA is available at:  http://www.ptsd.va.gov/professional/manuals/psych-first-aid.asp

Having ensured the initial safety of the group, the leader is responsible for ensuring their needs for food, water, and shelter are met, and then for providing a supportive environment. In a small, functional group this may be relatively simple and possible on a one-to-one basis.

In a larger group, particularly if fault or blame might be apportioned around the cause of the traumatic event, the task will be more difficult and the leader might choose to arrange a debriefing meeting 24–72 h after the event, after the practicalities of medical care, evacuation, and informing relatives have been completed. The primary aim of this meeting would be to facilitate a supportive emotional environment and get a functional team home. In most instances it is inappropriate to attempt to establish causality of an event, or attribute blame, immediately after it has occurred. Many facts surrounding critical incidents only become visible after proper investigation and without the added complications of acute emotional attachment.

An operational debriefing concentrates on evaluating procedures and tasks, and dealing with practical matters. The team may also agree on the next steps (e.g. whether to continue the expedition or return home).

A critical incident debriefing provides an opportunity for the group to talk about the facts of what has happened, and their thoughts and feelings. The process is non-judgemental. Common responses to trauma are normalized, and people are taught that these usually disappear naturally with time. Information is provided about helpful coping mechanisms. Group support is encouraged, future plans are discussed, and people are told how to obtain further help if it is needed. Critical incident debriefing should not take place too soon (within 24 h of a traumatic event), and sufficient time should be allocated for the process (at least 2 h). It can occur remotely (e.g. over the Internet).

Debriefing should be facilitated by an individual with sufficient skills or experience as, done incorrectly, it can cause significant short or long-term distress.

Group members witnessing or being involved in a traumatic event and an expeditioner given bad news from home may react in similar ways.

To be bereaved is to be deprived of someone or something of value. We may grieve for a person, but we may also grieve for other losses, such as friendship, hope, or our perceptions of safety and immortality. People who are grieving may have feelings of numbness, sadness, anxiety, anger, guilt, or yearning; they may experience physical sensations of a ‘flight or fright’ reaction, with dry mouth, hollow stomach, breathlessness, or tachycardia; they may be confused, bewildered, disbelieving, and disorientated. In close relationships they may even have auditory or visual hallucinations of the person who has died. Their behaviour may be altered, with crying, restlessness, loss of appetite, sleep disturbance, and absent-mindedness, which could compromise the individual’s safety on an expedition.

The vast majority of people who are bereaved of someone close to them, or who experience a traumatic event, recover with time and the support of family and friends. Bereavement and loss are a normal part of life. In the aftermath of such an event, individuals should be reassured that the jumble of emotions, sensations, thoughts, and behaviours they are experiencing are normal and does not mean there is something wrong with them or they are ‘going mad’. Expeditioners who are so distressed by grief they might compromise their own or the group’s safety might have to be evacuated, but there may be good arguments for keeping a supportive group together. Evacuation may also be necessary to facilitate attendance at a funeral, which is an important part of the grieving process.

It is important to stress that difficulty with grieving or PTSD may occur even with good leadership, because of the person’s pre-existing personality or mental health, or because of the nature of the event. The leader’s job is to provide a supportive environment so that recovery is encouraged, where possible, and to get the team home safely.

Symptoms of PTSD may develop after experiencing ‘a stressful event of an exceptionally threatening or catastrophic nature’. Sufferers involuntarily re-experience the event or aspects of it and these ‘re-experiencing symptoms’ may feel very real, frightening, and distressing. Victims often have recurrent flashbacks or nightmares and may avoid triggers reminding them of the event, or return continuously to why it happened or how it could have been avoided. They may have emotional numbing or be in a constant state of alertness, being fearful, irritable, easily startled, and having difficulties with concentration and sleeping. Such symptoms are normal up to 6 weeks after an incident. Persistent problems indicate the need for psychiatric or psychological input.

The chances of developing PTSD are higher in women than men and differ according to the traumatic event. The risk of developing PTSD is highest after rape (about 20% in women), other sexual attack, being threatened with a weapon, and kidnapped or taken hostage. About 10% of people seeing accidents, death or injury, and natural disasters will go on to develop PTSD.

When the tragedy becomes known to the expedition, team members may go through a variety of reactions: grief, guilt, acceptance and then resolution:

Psychological debriefing is the generic term for immediate interventions following trauma (usually within 3 days) that seek to relieve stress with the intent of mitigating or preventing long-term pathology. In the first days after the death of a colleague, expeditioners are advised to:

People are most likely to recover after a traumatic event if they experience positive and supportive responses from those around them. Blaming and negative thoughts about the event are unhelpful. Ensure basic needs are met and facilitate an open environment where the survivor can talk if needed. Forcing people to talk when they are not ready can be detrimental.

The most extreme psychological threats of an expedition relate to death, serious accident or illness, RTCs, mugging/assault/carjacking, or kidnapping/hostage-taking.

Unfortunately, kidnapping and hostage-taking remain prevalent in many areas of the world. They probably represent the most extreme and sustained form of psychological (and sometimes physical) abuse.

It is important to be aware of any such risks in the locations to be explored (see  https://www.gov.uk/foreign-travel-advice). Clear contingency plans are advisable. A reputable ‘survival in hostile region’ course may help in learning how to avoid becoming captured (  http://www.akegroup.com). The course should include training in how to cope if kidnapping does occur.

All kidnappings are undertaken for gain, usually after careful surveillance. Captors are criminal and/or political; whilst of perceived value, captives of criminals are relatively safe. The fate of political hostages is less certain. Kidnappers’ previous behaviour is the best predictor of outcome. Kidnapping is not personal; most victims are a pawn in another’s game. The aim of those kidnapped is to survive.

Kidnapping may be conceptualized in three phases:

Kidnappers obtain compliance through extreme violence, dominance, and uncertainty. Capture and release are the most dangerous times of kidnapping. If escape is unlikely, heroics should be avoided. Weapons should not be used, unless the captive is skilled in their use. Sensory deprivation may be used to isolate the captive and is disorientating, by design. After the initial shock of abduction, there may be a short-lived euphoria at having survived, followed by a pattern of enforced sensory deprivation, threats, abuse, and hardships.

On abduction:

Immediately establish a routine that focuses on maintaining physical and mental hygiene, health, and fitness. Physical health requires eating the food and drink offered. Physical fitness improves resistance to infection, raises mood, and may allow for a successful escape attempt. Mental fitness requires awareness of uncontrollable (external) and controllable (internal, self-induced) stressors. A positive frame of mind is important. Release is the most likely outcome; someone will be working for release of hostages.

A primitive existence will develop, centred upon bodily functions, sleeping, and eating in an atmosphere of intimidation and ruthlessness. Self-questioning and blame are destructive to self-esteem and self-worth, and lead to inertia, depression, and despair. Emotional lability is common. Any pre-existing psychological or psychiatric predispositions may be triggered. Physical activity is the best counter to this.

Compassion is required for those who are not coping well. Captors’ attempts to ‘split’ the group will severely worsen the situation for all captives. Maintaining clear lines of communication and interest in each other’s welfare is protective. The intimacy engendered by enforced proximity and shared adversity may lead to deep personal attachments/ antipathies. A group leader should be appointed if taken as a group.

Captors vary in their abilities to mistreat their charges. Dehumanization promotes maltreatment. Trying to understand captors and developing rapport by active listening and drawing attention to your human needs, e.g. hunger, thirst, and bodily functions may be beneficial.

To prevent dehumanization:

Maintain belief in rescue, and be patient. Peaceful resolution is the default option, as violent conclusion may involve killings. Deadlines are dangerous for all parties. Any escalation of violence by kidnappers will increase the likelihood of an armed solution. Thus always assume there are plans for a forceful solution. Think ahead; obtain as much information as possible about deadlines. Armed forces are most likely to enter through windows or doors, thus stay away from portals, locate a safe place, and wait.

On hearing gunfire or explosion:

There is a natural euphoria on release. This may be tempered if locally employed individuals remain behind or were killed. Relationships formed during captivity may influence the healing process. Problems present before capture will remain unresolved. Depending on the event, consideration should be given to the competing physical, psychological, and social variables, and the variety of interested parties involved, e.g. family, friends, colleagues, employers, pressure groups, politicians, doctors, and media.¹

Worldwide, levels of drug abuse are rising, with evidence suggesting illegal drug use in up to 1/3 of some groups of travellers. Drug use on expeditions is rare, although do not assume that expedition members are immune to inquisitive behaviour, especially if the expedition finds itself located amongst bushes of wild plants such as marihuana.

The consequences of drug misuse on expedition are considerable, ranging from life-threatening illness to life-threatening judicial sentencing. In addition, the consequences might not be confined to the individuals participating, but also to other non-participants on the expedition. Have policies on drug use and make them known before the expedition.

When managing drug abuse on expedition, consider the implications of involving local authorities, especially the police. Advice should be sought carefully and involve the expedition leadership team. However, decisions such as these should not prevent the patient from receiving life-saving hospital treatment.

The average expedition medical kit is unlikely to contain the appropriate medicines for managing an individual who is under the influence of drugs.

For the majority, expeditions are positive experiences that enhance self-esteem and, in young people, contribute to maturity. Expeditions will change all those involved; the individual and those they interact with at work, socially, and at home. It takes time for the ‘system’ to readjust to the returnee and vice versa. Readjustment requires acceptance, adjustment, and accommodation. Prepare people that a period of ‘reverse culture shock’ is normal and this may include a period of mourning. Reconnection with enjoyable activities at home and contact with other expedition members is helpful. Accept that change is irrevocable and inevitable but not necessarily negative.

Severe problems persisting for >3 months or those interfering with day to day function merit the following: