Mental Health in Nepal

Psychological Problems in Travelers and Expatriates

Adventure travel can be emotionally loaded for many people. This psychological burden takes place on several levels. Part of the attraction of adventure travel is this very potential for being placed in a crucible and purified into somebody that you were not before. But there is also a potential for risk, leading to disappointment in one`s own performance at best, and psychological decompensation at worst. When people ask me what is the hardest aspect of working at the CIWEC Clinic, I always think of the psychotic travelers we have had to deal with. The third world environment is both capable of helping to induce psychosis, and fraught with obstacles that prevent the stabilization of a psychotic person. The possibility of encountering or even traveling with someone who could become psychotic during a journey should at least be a part of one`s overall travel awareness. Even when psychosis is not a concern, psychological adjustments are often necessary due to stress on the traveler, prior expectations of one`s performance in a new environment, and a feeling of lack of control over one`s surroundings.Travel is StressEven at the best of times, travel involves a level of stress that is higher than we usually deal with at home. Depending on the destination, one has to deal with jet lag, loss of contact with familiar support systems, bombardment of sights and sounds, beggars, touts and people who won`t get out of your face. Even trying to absorb a particularly beautiful or moving event can be a form of stress. Trying to accomplish simple tasks, such as finding a decent room, buying a bus ticket, or obtaining a visa can lead to hours of frustration and uncertainty. If you are headed to remote areas, you can have a sense of being too far removed from familiar surroundings. You may suddenly realize that you are two week`s walk from a strange and terrifying capital city, which is still 36 hours of flying time away from your home environment.We all like to think that we can cope with our surroundings. The heroes that we admire in movies and television all have in common that they are not flustered by unexpected obstacles. They just deal with their changing environment as it unfolds, whether it be a volcano, primitive headhunters, or sleazy bandits. Most of us try hard to avoid the unexpected, to exert control over our surroundings, to expect things to go a certain way. When things don`t go as we think they should, we expect someone to be able to account for it, to take responsibility. We extend this concept of control to most aspects of our existence: we exercise to prolong our lives and prevent illness, we work hard in the expectation that we will be rewarded, we avoid areas of cities where we are likely to encounter trouble, we wear our seat belts. We have learned the rules, and as long as we follow them, we think we can stay out of trouble.When one shifts to an environment and culture half way around the world, these rules can change as well. Michael Palin, while trying to travel around the world in 80 days without flying, summed it up nicely: “What in Europe had been problems to solve, in Asia became limitations to accept.” One of the most difficult things for travelers to adjust to is the loss of their sense of control. They may fall quite ill despite all their efforts to avoid it. They may find that they bought the wrong ticket; or they bought the right ticket, but the bus didn`t come at all, or they are on the correct train, but someone else has their seats. Their trip of a lifetime might be scrubbed by three days in a row of bad weather, preventing the flight in. Since we are used to being in control, not having to handle situations beyond our control, our stress levels can reach astronomic proportions. Further pressure arises from the concept in the west that we must assert ourselves when things are not going our way. We are taught that we should not passively accept events as being beyond our control. However, in adventure travel, events may truly be beyond anyone`s control. The successful travelers are the ones who can learn to accept the limitations, work within the new systems as they are encountered. What they ultimately learn is that what we had at home was the illusion of control. We assumed that we were in control because things were going our way for a period of time. But we can`t truly prevent illness, accident, or loss of friends and relatives. If we think about it, travel just becomes an accelerated learning course for accepting things beyond our control. The result of these lessons can be to become much stronger in dealing with our daily lives at home.

Personal Physical Goals

Adventure travelers often add an artificial stress to their journeys: the question of whether they will “make it” or not. Adventure travel is often very goal oriented: the viewpoint of Kala Pattar near Mt. Everest, the confluence of glaciers at the base of K2, a complete traverse of Dolpo in Nepal. Setting out to do something that you are not sure you can do is part of the adventure. But linking the attainment of this goal with a psychological sense of worth can be dangerous. I have seen so many neurotically anxious people heading out for routine adventures, heedless of the needs of their traveling companions, oblivious of the local culture, compulsively monitoring their own health, all with the goal of standing on some patch of ground that they have read about.

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

Spiritual Concerns

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

The danger arises when people are traveling in order to undergo major changes. People who are unhappy at home, or misfits in various ways, may set out to travel in order to “get it together.” The stresses of a new culture, the sudden exposure to severe poverty, the pantheon of new deities, and the freedom from normal constraints, may lead to risky behavior, drug-taking, and psychological dislocation. The potential for psychological turmoil, even acute psychosis, is substantial. People with any significant psychotic history should probably not travel in developing Asian countries.

The use of hallucinogenic drugs in the pursuit of religious practice in South Asia fueled the beliefs of many Western travelers that a type of nirvana could be inhaled or swallowed. Although most people can handle these experiences, we have seen drug use be the final lever into the abyss of psychosis in a number of travelers.


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

A gentle approach can be helpful. You can point out that they don`t have to feel responsible for the unpleasant things that they are seeing. You can try to get them to question whether the people they are seeing, who are quite poor, are actually suffering or unhappy. You can point out that they chose to travel to see and experience new things, including food and accommodation. If they can`t recover their composure within a few days, they should either go home, or–less defeating–travel to a less intense part of Asia (for example, Thailand).

Panic Attacks

One non-psychotic manifestation of stress may be the panic attack. This is fairly common among travelers these days, which is perhaps a factor of increased recognition. It also may be that a more marginal group of travelers are starting to head to adventurous destinations. The result is that healthy people of all ages may present with severe symptoms, occasionally requiring helicopter evacuation. The symptoms are familiar to most physicians: some combination of dyspnea, chest pain, weakness, dizziness, hyperventilation, and cramps of the hands and feet. The point to remember is that an overwhelming sense of dread is part of this syndrome, and the patients are often certain that they are dying. In this particular population, reassurance has worked well; many patients do not wish to use anti-anxiety medications such as Alprazolam. However, the medications can help in severe or recurrent cases.

Most of the patients experiencing panic attacks cannot pinpoint a cause. They genuinely feel that things had been going well up to that point. Some confess to a vague feeling of being out of their element. It is important to remember that a specific cause for the attack is usually not found. Panic attacks are sometimes like unexplained skin rashes. They come, they are annoying or frightening, and their cause often cannot be determined. With panic attacks, it is most important to realize that nothing life-threatening is happening, and then to treat the symptoms, if necessary. A reassuring discussion with a doctor can be curative in many cases of panic attacks related to travel.


When I`m working in Nepal I live in dread of the phone call that tells me that someone has lost their mind. The delusional, aggressive psychotic patient is often first encountered in jail, due to their disruptiveness in public (trying to kill a pig in a temple, to give an actual example). The police are only too happy to get rid of someone who is not in their right mind, unless they killed someone. But now what do you do with them?

Finding a stable, safe environment, with plenty of people to take turns watching the patient, and using generous amounts of anti-psychotic medication are the two goals in immediate therapy. Embassies cannot take forceful control of people in other countries, so asking the U.S. Marines to gather up a psychotic 21 year old American man and ship him home on a cargo plane is not an option. The goal is to stabilize the patient as quickly as possible, and to repatriate them accompanied by reliable people. The value of anti-psychotic medication cannot be overemphasized in this situation. A bottle of Haldol injectable should find a niche in the adventure travel doctor`s first aid kit. Hopefully you will never need to use it.

The exact diagnoses in these cases have not been systematically studied by psychiatrists. The majority of episodes occur in people with no prior history of mental illness. Acute situational psychosis is probably the most common diagnosis. Other cases may be the first manifestations of schizophrenia in a susceptible younger adult. Another category may be manifestations of manic-depressive disease, with manic symptoms sliding over into psychosis. These people will feel that everything has come together in their lives, and every event is loaded with huge meaning. Fortunately, the treatment is the same for all of these diagnoses.


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

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

If you feel that you are having emotional problems, and don`t know how to handle it, please come in and talk to one of the psychiatric or regular practitioners at the CIWEC Clinic. We can offer completely confidential professional advice and use medication if needed.

Written by
David R. Shlim, M.D.
Former Medical Director,
CIWEC Clinic