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Isolated psychosis during exposure to very high and extreme altitude – characterisation of a new medical entity

  • Katharina Hüfner (a1), Hermann Brugger (a2) (a3), Eva Kuster (a1), Franziska Dünsser (a1), Agnieszka E. Stawinoga (a4), Rachel Turner (a2) (a3), Iztok Tomazin (a5) and Barbara Sperner-Unterweger (a1)...



Psychotic episodes during exposure to very high or extreme altitude have been frequently reported in mountain literature, but not systematically analysed and acknowledged as a distinct clinical entity.


Episodes reported above 3500 m altitude with possible psychosis were collected from the lay literature and provide the basis for this observational study. Dimensional criteria of the Diagnostic and Statistical Manual of Mental Disorders were used for psychosis, and the Lake Louise Scoring criteria for acute mountain sickness and high-altitude cerebral oedema (HACE). Eighty-three of the episodes collected underwent a cluster analysis to identify similar groups. Ratings were done by two independent, trained researchers (κ values 0.6–1).


Cluster 1 included 51% (42/83) episodes without psychosis; cluster 2 22% (18/83) cases with psychosis, plus symptoms of HACE or mental status change from other origins; and cluster 3 28% (23/83) episodes with isolated psychosis. Possible risk factors of psychosis and associated somatic symptoms were analysed between the three clusters and revealed differences regarding the factors ‘starvation’ (χ2 test, p = 0.002), ‘frostbite’ (p = 0.024) and ‘supplemental oxygen’ (p = 0.046). Episodes with psychosis were reversible but associated with near accidents and accidents (p = 0.007, odds ratio 4.44).


Episodes of psychosis during exposure to high altitude are frequently reported, but have not been specifically examined or assigned to medical diagnoses. In addition to the risk of suffering from somatic mountain illnesses, climbers and workers at high altitude should be aware of the potential occurrence of psychotic episodes, the associated risks and respective coping strategies.

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This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (, which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

Corresponding author

Author for correspondence: Katharina Hüfner, E-mail:


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Allardyce, J, Suppes, T and Van Os, J (2007) Dimensions and the psychosis phenotype. International Journal of Methods in Psychiatric Research 16(Suppl. 1), S34S40.
American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders. Arlington, VA: American Psychiatric Publishing.
Barch, DM, Bustillo, J, Gaebel, W, Gur, R, Heckers, S, Malaspina, D, Owen, MJ, Schultz, S, Tandon, R, Tsuang, M, Van Os, J and Carpenter, W (2013) Logic and justification for dimensional assessment of symptoms and related clinical phenomena in psychosis: relevance to DSM-5. Schizophrenia Research 150, 1520.
Basnyat, B (2002) Delirium at high altitude. High Altitude Medicine & Biology 3, 6971.
Basnyat, B, Subedi, D, Sleggs, J, Lemaster, J, Bhasyal, G, Aryal, B and Subedi, N (2000) Disoriented and ataxic pilgrims: an epidemiological study of acute mountain sickness and high-altitude cerebral edema at a sacred lake at 4300 m in the Nepal Himalayas. Wilderness & Environmental Medicine 11, 8993.
Broderick, PA and Gibson, GE (1989) Dopamine and serotonin in rat striatum during in vivo hypoxic-hypoxia. Metabolic Brain Disease 4, 143153.
Brugger, P, Regard, M, Landis, T and Oelz, O (1999) Hallucinatory experiences in extreme-altitude climbers. Neuropsychiatry, Neuropsychology, and Behavioral Neurology 12, 6771.
Daniel, C and Mason, OJ (2015) Predicting psychotic-like experiences during sensory deprivation. BioMed Research International 2015, 439379. doi: 10.1155/2015/439379.
de Aquino Lemos, V, Antunes, HK, dos Santos, RV, Lira, FS, Tufik, S and de Mello, MT (2012) High altitude exposure impairs sleep patterns, mood, and cognitive functions. Psychophysiology 49, 12981306.
Feddersen, B, Ausserer, H, Neupane, P, Thanbichler, F, Depaulis, A, Waanders, R and Noachtar, S (2007) Right temporal cerebral dysfunction heralds symptoms of acute mountain sickness. Journal of Neurology 254, 359363.
Firth, PG and Bolay, H (2004) Transient high altitude neurological dysfunction: an origin in the temporoparietal cortex. High Altitude Medicine & Biology 5, 7185.
Firth, PG, Zheng, H, Windsor, JS, Sutherland, AI, Imray, CH, Moore, GW, Semple, JL, Roach, RC and Salisbury, RA (2008) Mortality on Mount Everest, 1921–2006: descriptive study. BMJ 337, a2654. doi: 10.1136/bmj.a2654.
Geyer, MA and Vollenweider, FX (2008) Serotonin research: contributions to understanding psychoses. Trends in Pharmacological Sciences 29, 445453.
Hackett, PH and Roach, RC (2004) High altitude cerebral edema. High Altitude Medicine & Biology 5, 136146.
Hackett, PH, Yarnell, PR, Hill, R, Reynard, K, Heit, J and McCormick, J (1998) High-altitude cerebral edema evaluated with magnetic resonance imaging: clinical correlation and pathophysiology. JAMA 280, 19201925.
Hall, DP, MacCormick, IJ, Phythian-Adams, AT, Rzechorzek, NM, Hope-Jones, D, Cosens, S, Jackson, S, Bates, MG, Collier, DJ, Hume, DA, Freeman, T, Thompson, AA and Baillie, JK (2014) Network analysis reveals distinct clinical syndromes underlying acute mountain sickness. PLoS ONE 9, e81229 doi: 10.1371/journal.pone.0081229.
Hochstrasser, J, Nanzer, A and Oelz, O (1986) Altitude edema in the Swiss Alps. Observations on the incidence and clinical course in 50 patients 1980–1984. Schweizerische Medizinische Wochenschrift 116, 866873.
Howes, OD and Kapur, S (2009) The dopamine hypothesis of schizophrenia: version III – the final common pathway. Schizophrenia Bulletin 35, 549562.
Landis, JR and Koch, GG (1977) The measurement of observer agreement for categorical data. Biometrics 33, 159174.
Lempert, T, Bauer, M and Schmidt, D (1994) Syncope and near-death experience. The Lancet 344, 829830.
Morrison, AP, Wells, A and Nothard, S (2002) Cognitive and emotional predictors of predisposition to hallucinations in non-patients. British Journal of Clinical Psychology 41, 259270.
Pendlebury, ST, Lovett, NG, Smith, SC, Dutta, N, Bendon, C, Lloyd-Lavery, A, Mehta, Z and Rothwell, PM (2015) Observational, longitudinal study of delirium in consecutive unselected acute medical admissions: age-specific rates and associated factors, mortality and re-admission. BMJ Open 5, e007808. doi: 10.1136/bmjopen-2015-007808.
Roach, R, Bärtsch, P, Oelz, O and Hackett, PH, Lake Louise AMS Scoring Consensus Committee (1993) The Lake Louise Acute Mountain Sickness Scoring System. Burlington, VT: Charles S. Houston.
Rolland, B, Jardri, R, Amad, A, Thomas, P, Cottencin, O and Bordet, R (2014) Pharmacology of hallucinations: several mechanisms for one single symptom? BioMed Research International 2014, 307106. doi: 10.1155/2014/307106.
Ryn, Z (1988) Psychopathology in mountaineering – mental disturbances under high-altitude stress. International Journal of Sports Medicine 9, 163169.
Shukitt-Hale, B, Banderet, LE and Lieberman, HR (1991) Relationships between symptoms, moods, performance, and acute mountain sickness at 4,700 meters. Aviation Space and Environmental Medicine 62, 865869.
Smailes, D, Alderson-Day, B, Fernyhough, C, McCarthy-Jones, S and Dodgson, G (2015) Tailoring cognitive behavioral therapy to subtypes of voice-hearing. Frontiers in Psychology 6, 1933 doi: 10.3389/fpsyg.2015.01933.
SPSS Inc. (2007) SPSS Statistics Base 17.0 User's Guide. Chicago, IL: SPSS Inc.
Subotnik, KL, Nuechterlein, KH, Green, MF, Horan, WP, Nienow, TM, Ventura, J and Nguyen, AT (2006) Neurocognitive and social cognitive correlates of formal thought disorder in schizophrenia patients. Schizophrenia Research 85, 8495.
von Hohenberg, CC, Pasternak, O, Kubicki, M, Ballinger, T, Vu, MA, Swisher, T, Green, K, Giwerc, M, Dahlben, B, Goldstein, JM, Woo, TU, Petryshen, TL, Mesholam-Gately, RI, Woodberry, KA, Thermenos, HW, Mulert, C, McCarley, RW, Seidman, LJ and Shenton, ME (2014) White matter microstructure in individuals at clinical high risk of psychosis: a whole-brain diffusion tensor imaging study. Schizophrenia Bulletin 40, 895903.
West, JB (2011) Con: headache should not be a required symptom for the diagnosis of acute mountain sickness. High Altitude Medicine & Biology 12, 2325; discussion 27.
Willmann, G, Gekeler, F, Schommer, K and Bartsch, P (2014) Update on high altitude cerebral edema including recent work on the eye. High Altitude Medicine & Biology 15, 112122.
Wilson, MH, Newman, S and Imray, CH (2009) The cerebral effects of ascent to high altitudes. The Lancet Neurology 8, 175191.
Windsor, JS (2008) Voices in the air. BMJ 337, a2667. doi: 10.1136/bmj.a2667.
Wu, T, Ding, S, Liu, J, Jia, J, Dai, R, Liang, B, Zhao, J and Qi, D (2006) Ataxia: an early indicator in high altitude cerebral edema. High Altitude Medicine & Biology 7, 275280.
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