ALPINISM is an exceptional sport because of its specific environment and conditions, the personality of alpinists, and motivating factors. The psycliopathological part of this study was therefore preceded by a psychological part intended to answer some basic questions: Why do alpinists climb mountains, and is a special type of personality characteristic of persons who dedicate themselves to this sport? The mental disorders to which alpinists are subject at high altitudes are still insufficiently understood and have not been elaborated monographically.
Physiological and pathophysiological studies at high altitudes were preceded by incidental observations on the behaviour of humans and animals in the mountains. The earliest description, dated 1298, was Marco Polo's account of his experiences in the Tibetan mountains12. Jose d'Acosta6 is usually considered the pioneer observer of mountain disease.
The physiology of high altitudes began to flourish toward the end of the 18th century, when the Alpine peaks were climbed for the first time. Of special interest are the studies and works of de Saussure, who was the first European to describe the symptoms of mountain disease, which he ascribed to the effect of low oxygen pressure in the atmospheric air26. In the 19th century, a lively rivalry arose in studies on altitude between Alpine and South American investigators. Mountain expeditions were better equipped and carried apparatus, and high altitude laboratories were organized which conducted research on adaptation of the human body to high-altitude
Polish authors also took part in studies on physiology of high altitudes. In the years 1925—1939, Kaulbersz carried out studies mainly on the influence of low pressure, temperature and other climatic factors at high altitudes on changes in the blood24, 28.More recently, intensive special studies have been undertaken, the results of which are of interest to alpinists, aviation Medicine and space medicine11'21'22'35.
A survey of the various investigations in this field leads to the conclusion that the reaction of the human body to the specific bioclimatic, ecologic, sociologic and psychological factors in high mountains depends mainly on their duration. At first the body reacts with physiological changes called accommodation ("accommodation a court term") 13, consisting of activation of compensatory cardiorespiratory mechanisms and changes in blood morphology. The period of accommodation may be complicated by functional disorders, called mountain sickness (morbus alti-tudinis, le mal aigu de montagnes), which develops if adaptation to conditions of hypoxia is too rapid. Symptoms of mountain sickness may appear at altitudes of 3—4000 meters above sea level in unaccustomed persons. The onset of sickness may be acute or chronic. Acute mountain sickness is usually of short duration, lasting several hours to several days. Symptoms usually pertain to the internal organs and organs of sense, whereas nervous disorders are rare3' 13> 19»48'53 Complications include bleeding from the oral cavity and reproductive organs48, pulmonary edema, cerebral and pulmonary embolism52, thrombophlebitis, loss of consciousness, and even death17, 45.
After the period of adaptation, whether complicated by acute mountain sickness or not, other more profound changes take place, especially in the neurovegetative and endocrine systems, leading to the next phase of adaptation, in which homeostasis on a higher level is established. In this phase, pathologic complications may take the form of so-called chronic mountain sickness (le mal chronique des montagnes, Monge's disease). This phase is characterized by inability to further acclimatize at altitudes above 3600 meters above sea level as a result of rapid increase in the numbers of red blood cells, pulmonary hypertension and hypertrophy of the right cardiac ventricle with symptoms of cardiorespiratory insufficiency15'18. Monge distinguished several forms, depending on the predominant symptoms: cerebral, neuroplegic, cardiac, digestive, respiratory and mental (c.f 13). The course of the disease is severe and may even be fatal. In spite of many clinical descriptions, the etiology and patho-mechanism of this disease are insufficiently understood38'49,
Prolonged or continuous stay at high altitudes leads to acclimatization, manifested by anatomic and functional adaptative changes without insufficiency and with maintained reproductive ability. For instance, permanent adaption may be observed in inhabitants of high mountains and in alpinists who spend much time in the environment of high altitudes32, 33.
Most authors believe that cerebral hypoxia is the main etiologic factor of mountain sickness. Studies have been carried out on the nervous system, including the cerebrospinal fluid44, elec- troencephalographic changes36, and the endocrine system1.
Compared with the somatic and neurological changes, psycho- pathologic observations are much less numerous 43. Alpinists themselves' were the first to describe mental disorders, sometimes with great accuracy7,9,14,61,34,41,47. Recent alpinistic expeditions have provided very interesting psychological data on psychophysical efficiency under conditions of high altitude stress. For the first time, attention has been called to the possibility of permanent and late intellectual and mental changes after stress at high altitudes10,50. The need of information about the personality of alpinists for proper selection of participants in the great Himalayan expeditions has been pointed out. Important work has been done by Lester30, 31 and Jackson20, who described the personality of members of Himalayan expeditions to Mount Everest. Their results and analysis of the literature indicate that alpinists, irrespective of their nationality and background, are a characteristic and separate group of sportsmen with profound mental and biological peculiarities.
Material and Methods
This study was carried out at the Psychiatrical Clinic of the Medical Academy in Cracow in the years 1965—1969 on a group of Polish alpinists (20 men and 10 women), active mountain climbers, members of the Alpine Club, who participated in alpinistic expeditions at over 4000 meters above sea level in women, and 7000 meters in men.
The basic method of the study consisted in psychiatric and psychological examinations (Cattell's personality questionnaire, Bender, Benton and Graham-Kendall tests), and auxiliary methods such as electroencephalography, radiology, etc. The results were analyzed statistically. In the psychiatric examinations, besides professional, family and social status, special attention was given to childhood diseases and trauma in the past, and illnesses connected with mountain climbing. For purposes of personality evaluation, information was collected about emotional states during climbing. Mental and psychopathologic experiences at high altitudes were specially analyzed. Direct contact with the alpinists provided valuable information their present mental state and an opportunity to assess the influence of personality traits and alpinistic environment on intellectual and emotional contacts.
The psychological examinations were carried out at the P logical Laboratory of the Clinic by an experienced psycho (Mgr. E. UniwersalJ. The electroencephalograms, made I J. Gatarskl, included resting tracings and activation by hyperventilation and the use of a stroboscope, employing a 16 apparatus, product of Alvar Co.
1. General data
The studied group consisted of 30 persons (20 men ail women). The age of the men ranged between 26—49 (mean 33 years), and that of the women 28—45 years (mean35 years). Only one man and one woman came from a rural environment, and the remainder were urban dwellers. Twenty one persons (70%) were from intellectual environments, 8 were physical workers (27%), and one person was of peasant origin (3.3%). Eight persons had no children. Three men were married (15%), 13 were married (65%), and 4 were divorced (20%). Only 3 of the married men had no children. Fore women were married, and 6 were single.
Twenty-six persons (95% of the men and 70% of the won had academic education, and the remainder technical education. Seventeen persons had technical studies, and 8 university studies. Ten persons were employed as scientific worker of academic schools. One person was an assistant professor in medicine, one was a lecturer in physics, and 7 had doctor degrees. The remaining persons had responsible jobs.
2. Past diseases
A large variety and frequency of childhood infectious diseases, often with severe course, were noted (in 6 persons with cerebral complications in the form of delusional-confusional syndromes). Other diseases in childhood included infectious jaundice (3 persons), sinusitis, otitis, Heine-Medin disease (with paralyses and pareses), rickets with bone lesions, and others.
Trauma and diseases connected with mountain climbing can be divided into the following groups: mechanical trauma, thermal trauma, sunstroke and somatic diseases of unclear etiology. Fractures, luxations, torsions, wounds and contusions were frequent. All but two persons had suffered various mechanical injuries during climbing, including simple contusions, wounds, compound bone fractures and craniocerebral injuries with cerebral shock. Ten persons suffered fractures of the lower extremities, and 4 of the upper extremities. Rare complications of climbing injuries included spontaneous pneumothorax with sub- pleural effusion after rib fracture, and in two cases intestinal rupture as a result of injury by climbing rope tied around the chest during a snow avalanche. Six persons had frost injuries, which in two cases necessitated amputation of toes. Three persons had sunstroke.
3. Personality of alpinists
The abundant information about the personality of the alpinists was classified arbitrarily into clinical personality types based on dominant traits. The schizoid-psychasthenic type was observed in 16 persons (11 men, i.e. 53%, and 5 women, 50%). In 4 persons (3 men and 1 woman), schizoidal personality type was noted. In all, 20 persons (68%) exhibited predominance of schizoidal personality. Five persons (4 men 1 woman) presented the asthenic personality type, i.e. 17% of the whole group. The neurotic personality type was noted in 4 persons (13%). One person could not be classified into any group.
In the analysis of the Cattell personality questionnaires, the mean personality profile of the whole group was compared with the mean profiles for men and women). The mean personality profile of the whole group was characterized by schizothymic features and tendency to avoid contact with other persons. Comparison of the mean profiles in the group of men and women showed statistically significant differences in factors C, M, O, Qs and Q4, leading to the following differences between the groups. In women, the level of general adaptation was low, numerous neurotic symptoms were present, control of emotional reactions was poor, sensitivity enhanced, tolerance of frustration was diminished, and a rich phantasy predisposed to neurotic fear of imagined danger. Emotional contact was difficult, with a reserved attitude toward other persons, bashfulness, weak social contacts, strong tendency to fear and hyper compensation. Women tended to be depressive and outwardly aggressive. Men exhibited good adaptation, on the whole, in spite of avoiding contacts with other persons, a strong need of dominating and egoism, marked tolerance for frustration, and well developed self-reliance and independence. The whole group was characterized by weak sexual adjustment, weak social adaptation, un- cooperativeness, and weak professional preoccupation.
In summary, two main personality types were distinguished: schizoidal-psychasthenic and asthenic-neurotic. The first, more frequent, type was characterized by such traits as secretiveness, reserve , emotional sensitivity, and avoiding contacts with people; in spite of lack of self-reliance and feeling of inferiority, and high aspirations. As a rule, these persons were hyperactive, independent, unconventional and excentric. They were emotionally labile, oversensitive, obstinate, excitable and aggressive, and submitted to social and collective discipline with difficulty. The men, especially, showed a need for dominating and expressing their ego, as well as the need for social approval. These persons were inclined to day-dreaming, preferred abstract intellectual work, and had humanistic interests. They were physically fit and tolerated frustration well. In some cases, the schizoidal traits were more pronounced, for instance outward emotional coolness, isolation and a tendency to avoid company. Self-reliant, independent and self-controlled, they tolerated hardships well. Especially pronounced was their need for risk and strong emotions. They were also often distrustful and suspicious of others, and antisocial.
The asthenic and neurotic types, described separately, may be combined into a single asthenic-neurotic personality type. This type was characterized by shyness, fearfulness and inferiority feelings, and presented many neurotic symptoms. Having high aspirations, they felt a strong need to dominate over others, manifested already in childhood. Traumatic factors and childhood diseases led to a feeling of inferior worth and physical efficiency, and to avoidance of playmates, resulting in the need for compensation in other spheres. Moreover, this group was characterized by the need of continual testing of their own worth in difficult and dangerous situations. They displayed distinctly neurotic traits such as excessive sensitivity and emotional imbalance. Neurasthenic, psychosomatic and phobic-depressive symptoms were prominent in this group, and frustration was tolerated poorly. As a result of rich imagination, neurotic fear of imagined danger was felt. The whole group, especially the women, shows poor sexual adjustment and high intelligence.
The motivation of alpinism was based on two main mechanisms: the need for strong emotions and for testing one's own possibilities (11 men, i.e. 55%), and fascination with the alpinistic personality and the desire to be admitted to closed circles (6 women, 60%). A majority of the probands emphasized that the greatest attraction of alpinism is that it provides opportunities for a special kind of emotional experience. Environmental factors included the impression left by the first contact with mountains, alpinistic family traditions, and an influence of alpinistic literature.
The emotions accompanying mountain climbing were of two kinds: 20 persons experienced pleasant emotional tension (positive sign), and in 10 climbing diminished unpleasant emotional states (negative sign) felt in everyday life. Seventeen men (85%) and three women (30%) experienced pleasant emotional tension during climbing, and three men (15%) and 7 women (70%) felt relief from unpleasant tension.
Fear emotions during climbing were of two kinds: biological fear (connected with the situation and hypoxia), and social fear. Emotional processes in alpinists during climbing were characterized by fear leading to personality integration in threatening situations, exerting a favourable effect on personality development, which may be called integrative fear.
4. Mental disorders under conditions of altitude stress. The psychopathological pattern
The mental disorders experienced by the studied group of alpinists during mountain climbing were divided arbitrarily according to the criterion of altitude at which they occurred. The psychopathologic symptoms at low altitudes (1500—2500 metres above sea level), medium (2500—5500 metres) and high altitudes (5500—7500 meters) will be discussed separately.
a. Neurasthenic pattern
At low altitudes (e.g. in the Tatra mountains), two types of psychopathologic reactions were observed: emotional stimulation or depression. During the first day at these altitudes, 20 persons (14 men, i.e. 70%, and 6 women—60%) felt emotionally stimulated; and 6 persons (3 men and 3 women) emotionally depressed. Both types of reaction had neurotic character in all cases. The first type consisted of mental stimulation, slight euphoria, increased motor drive periods of accelerated thinking, scattered attention, impatience, unjustified haste and irritability. In the second type, fatigue predominated, with deterioration of physical fitness, fatiguability, drowsiness, emotional indifference, and sometimes episodic dysphoria. These symptoms lasted from several hours to several days.
b. The cyclophrenic pattern
At moderate altitudes, 22 persons (75%) experienced mental perturbations in the form of apathetic-depressive syndrome, and 6 persons (20%) euphoric-impulsive syndrome. Two persons had alternating apathetic-depressive and euphoric-impulsive symptoms. The intensity of these symptoms was at the neurotic level, respectively moderately psycho-organic, but never attained a psychotic level.
The apathetic-depressive syndrome was characterized by mental and physical fatigue, indifference, narrowing of interests, aversion to physical exertion, muddled thinking, physical lassitude, depressed mood, sorrowfulness, drowsiness and diminished sexual interests. Somatic complaints were also usually present. Several persons exhibited dysphoria.
The euphoric-impulsive syndrome was characterized by elevated, slightly euphoric moods, unmotivated feeling of happiness, bewilderment, increased motor drive and physical activity, motor unrest, unnecessary actions, emotional tension, irritability, ex- plosiveness and a tendency to fall into conflict with other persons. Aggressive and asocial behavior was also observed.
c. The psychoorganic pattern
Only men in the studied group climbed at high altitudes. Mental disorders of the psychoorganic type occurred in 10 men (50%). Three persons (15%) experienced psychotic complications in the form of confusional (2 persons) and schizophrenialike states (1 person).
The most important psychoorganic symptoms consisted of diminished physical activity, clumsiness, disorientation in time and space, diminished criticism, labile moods, disorders of memory (gaps), pathological somnolence, optic-motor discoordination, disorders of equilibrium and perception. In the intellectual sphere, slow and imprecise thinking, dullness, impaired abstract thinking, and tendency to false conclusions were noted.
In persons with psychotic disorders, visual and acoustic illusions, delusions of per section, symptoms of derealization and depersonification, and pronounced confusional disorders of consciousness occurred. These disorders were observed in persons with symptoms of so-called altitude deterioration, with somatic breakdown, and physical emaciation, which in one person resulted in a loss of 25 kg in body weight. These symptoms occurred usually after long stay under conditions of hypoxia, low ambient temperature and insufficient food. At altitudes of up to 7500 meters above sea level these persons did not use oxygen apparatus. For several weeks after the expedition they continued to feel poorly, showing signs by apathy and abulia, and impaired memory.
5. Clinical observations
On the basis of the psychiatric and auxiliary examinations, the following clinical diagnoses were established in the studied group of alpinists: personality disorders in 7 persons (5 men—25%, and 2 women-20%), neurosis in 4 and psychoorganic syndromes in 10 persons (8 men—40%, and 2 women—20%). In the remaining 9 persons, abnormalities justifying a diagnosis of psy- chopathologic syndrome were not observed.
Neurological symptoms of local central nervous system damage were noted in 4 persons.
Electroencephalography, which was performed in the whole group, gave normal tracings in 19 persons, (63%), including so-called flat tracings in 7 persons (23%). This classification was dictated by caution in the interpretation of the electroencephalograms. Pathologic electroencephalograms were found in 11 persons (6 men—30%, and 5 women—50%). The mean number of pathologic electroencephalograms in the whole group was 37%.
The Bender, Benton and Graham-Kendall tests gave the following results: normal in 13 persons, on the boundary between normal and pathologic in 12 persons, and indicating organic pathology in 5 persons. In the whole group, 40% of the results were on the boundary of normal and pathologic, and 17% indicated organic pathology.
Discussion of the results
The specific personality of alpinists must be considered with reference to the cultural and sociological factors peculiar to our nation. Brezezicki5 has described the "Polish character" asskirtothymic, characterized by heroism, altruistic dedication, ability of mobilization in difficult situations, bravado, a tendency to the phantastic, a specific sense of humour, etc. In alpinism, more than in any other sport, heroism is a salient feature, accompanied by the struggle to overcome solitude and the hardships of alpine nature, to master one's own shortcomings and feeling of inferiority4, 51. Alpinists are a group of individuals with high intellect, ambition and creative powers.
Comparison of the results of this study with the descriptions of personality of western alpinists shows many similarities, especially with respect to schizoidal personality, social maladjustment and inferiority complex, besides high aspirations20'31'37'39.
In the analysis of fear in alpinism, the classification proposed by Kepinski29 proved very useful. Kepinski distinguishes four types of fear reaction: connected with direct danger to life, with social endangerment, with the inability to select appropriate action, and disorganization of the existing structure of interaction with the surrounding world. This classification comprises four types of fear: biological, social, moral and disintegrative. Biological fear may occur during dangerous mountain climbing, similar to the fear described under conditions of hypoxia at high altitudes. Fear of a negative judgment by other alpinists, and the fear of orphaning one's family, are of the social type. Fear leading to personality integration in dangerous situations during difficult climbs is peculiar to alpinism. Conscious confrontation with the danger involved in climbing and increased emotional tension mobilize fear and integrate the psychophysical efficiency necessary to overcome difficulties and avoid danger. In contrast to disintegrative fear in the classification of Kepinski, this type of fear is integrative42.
Only an attempt can be made to discover the etiologic factors of mental disorders at high altitudes. The complex altitude stress is connected with biological as well as psychological factors. Depending on their role in the etiology of mental disorders in alpinists at high altitudes, these factors may be arranged in the following order: atmospheric factors, somatic conditions, mechanical injury, psychological and sociological factors.
Hypoxia of the central nervous system as a result of oxygen deficiency in the atmospheric air was unquestionably the main etiologic factor of the mental disorders at high altitudes. This is indicated by the characteristic psychopathological pattern of these disorders, among which disorders of memory, mood, orientation and consciousness predominanate, suggesting disturbed function of the cerebral cortex. A convincing clinical argument is the observation that mental disorders disappear when an oxygen apparatus is used, or if the alpinist descends to a lower altitude. Other important climatic factors include low ambient temperature, high humidity, wind, solar and cosmic radiation. The influence of the latter factors on the human body is insufficiently known.
Among the somatic factors, diseases, or abnormalities which diminish the efficiency of the cardiorespiratory system (cardiac valvular defects, myocardial disease, pulmonary emphysema, bronchopulmonary diseases, excessive smoking and alcohol consumption) are important.
Sociological factors which deserve mention include social isolation during mountaineering expeditions, stay in foreign or exotic countries, altered way of life, confinement to the company of a small group of persons, the language barrier, separation from family, etc. Realization of personal ambitions, and not the success of the whole group, is also an important factor. The complex etiology of mental disorders in alpinists under conditions of altitude stress does not permit differentiation between the various factors. Undoubtedly, the simultaneous effect of many factors, together with individual predisposition (somatic and emotional state), contribute to the resulting disorders. As yet, there is little information available about the therapy of mental disorders occurring at high altitudes. Better known are trials of treating other somatic and mental diseases in high mountain climate40, 46. Empirical observations show that the disorders are favourably affected by proper acclimatization, administration of oxygen and descent to lower altitudes, confirmed also by the author's own experience during an expedition to the Caucasus in 1966.
On the basis of the fragmentary data, the following concept of therapy of these disorders may be proposed: in emergency situations, immediate administration of oxygen (if possible) , or descent to a lower altitude, and complete repose in recumbent position. Theoretically, administration of neuroleptic drugs is indicated in disorders of the euphoric-impulsive type and psychoorganic syndromes with psychotic symptoms. Small or moderate doses of these drugs should not only alleviate the symptoms, but by diminishing cerebral metabolism should decrease the effect of oxygen deficiency. The action of psychoanaleptic drugs in apathetic-depressive syndrome (e.g. oxazolidine or centohenoxine derivatives) deserves trial under altitude conditions. Prophylaxis consists in careful selection of members of high mountaineering expeditions with respect to cardiorespiratory function, planned acclimatization to altitude, restriction of activity to the necessary minimum under conditions with a possible detrimental effect on health, and early administration of oxygen.
Positive and negative effects of alpinism
The positive, or beneficial, effects of alpinism consist mainly in satisfying the psychological needs of the individual connected with his personality structure. In addition, physical fitness and motor efficiency are improved, resistance to climatic factors increases, and rehabilitation of the effects of injuries may be attained.
The negative effects of mountain climbing include the possibility of injuries, including fatal accidents, and the possibility of remote and permanent psychiatric sequels of long exposure to altitude stress. In the studied group, changes of this type were found in 4 men who stayed at altitudes between 6500—7500 meters above sea level for periods of seven to nine days. The psychopathologic symptoms in these persons were of the asthenic- apathetic type, and auxiliary examinations indicated pathologic lesions of the cerebral cortex. Assumption of a causative relation of these symptoms to attiutude stress and the effect of hypoxia, low temperatures and somatic disorders (deterioration) seems justified. In view of the specific etiopathogenesis of this type of psychoorganic syndrome, it may be called altitude cerebrasthenia.
The mental disorders occurring under high altitude conditions and later changes in the central nervous system do not require psychiatric therapy. Appropriate prophylaxis should suffice to prevent these minor psychiatric complications.