Viewing an alpine environment positively affects emotional analytics in patients with stress-related psychiatric disorders

Abstract

Background: Patients with stress-related psychiatric (psychosomatic) disorders often don´t respond well to medical treatment and experience many side effects. It is thus of clinical relevance to identify alternative, scientifically based, treatments. Our approach is based on the recent evidence that urbanicity has been shown to be associated with an increased risk for mental disorders. Conversely green and blue environments show a dose-dependent beneficial impact on mental health.
Methods: Here we evaluate the effect of viewing stimuli of individuals in an alpine environment on emotional analytics in 183 patients with stress-related psychiatric disorders and 315 healthy controls (HC). Emotional analytics (valence: unhappy vs happy, arousal: calm vs excited, dominance: controlled vs in control) were assessed using the Self-Assessment Manikin.
Results: Patients showed significantly lower levels of resilience and significantly higher scores of self-perceived stress. Emotional analytics of patients indicated that they feel less happy, less in control and had higher levels of arousal than HC when viewing neutral stimuli. The comparison alpine>neutral stimuli showed a significant a positive effect of alpine stimuli on emotional analytics in both groups. Patients and HC both felt attracted to the scenes displayed in the alpine stimuli. Emotional analytics correlated positively with resilience and inversely with perceived stress.
Conclusions: Preventive and therapeutic programs for patients with stress-related psychiatric disorders should take benefits of outdoor natural environments into account. Organizational barriers which are preventing the implementation of such programs in clinical practice need to be identified and addressed.

Full text

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Preprint:Pleasenotethatthisarticlehasnotcompletedpeerreview.
Viewinganalpineenvironmentpositivelyaffects
emotionalanalyticsinpatientswithstress-related
psychiatricdisorders
CURRENTSTATUS:UND ERREVIEW
KatharinaHüfner
MedizinischeUniversitatInnsbruck
katharina.huefner@tirol-kliniken.atCorrespondingAuthor
ORCiD:https://orcid.org/0000-0002-5453-8792
CorneliaOwer
MedizinischeUniversitatInnsbruck
GeorgKemmler
MedizinischeUniversitatInnsbruck
TheresaVill
MedizinischeUniversitatInnsbruck
CarolineMartini
MedizinischeUniversitatInnsbruck
AndreaSchmitt
Ludwig-Maximilians-UniversitatMunchen
BarbaraSperner-Unterweger
MedizinischeUniversitatInnsbruck
DOI:
10.21203/rs.3.rs-15834/v1
SUBJECTAREAS
Psychiatry
KEYWORDS
alpineenvironment,resilience,self-perceivedstress,self-assessmentmanikin,
emotionalanalytics,psychosomaticdisorders

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Abstract
Background:Patientswithstress-relatedpsychiatric(psychosomatic)disordersoftendon´trespond
welltomedicaltreatmentandexperiencemanysideeffects.Itisthusofclinicalrelevancetoidentify
alternative,scientificallybased,treatments.Ourapproachisbasedontherecentevidencethat
urbanicityhasbeenshowntobeassociatedwithanincreasedriskformentaldisorders.Conversely
greenandblueenvironmentsshowadose-dependentbeneficialimpactonmentalhealth.
Methods:Hereweevaluatetheeffectofviewingstimuliofindividualsinanalpineenvironmenton
emotionalanalyticsin183patientswithstress-relatedpsychiatricdisordersand315healthycontrols
(HC).Emotionalanalytics(valence:unhappyvshappy,arousal:calmvsexcited,dominance:
controlledvsincontrol)wereassessedusingtheSelf-AssessmentManikin.
Results:Patientsshowedsignificantlylowerlevelsofresilienceandsignificantlyhigherscoresofself-
perceivedstress.Emotionalanalyticsofpatientsindicatedthattheyfeellesshappy,lessincontrol
andhadhigherlevelsofarousalthanHCwhenviewingneutralstimuli.Thecomparison
alpine>neutralstimulishowedasignificantapositiveeffectofalpinestimulionemotionalanalyticsin
bothgroups.PatientsandHCbothfeltattractedtothescenesdisplayedinthealpinestimuli.
Emotionalanalyticscorrelatedpositivelywithresilienceandinverselywithperceivedstress.
Conclusions:Preventiveandtherapeuticprogramsforpatientswithstress-relatedpsychiatric
disordersshouldtakebenefitsofoutdoornaturalenvironmentsintoaccount.Organizationalbarriers
whicharepreventingtheimplementationofsuchprogramsinclinicalpracticeneedtobeidentified
andaddressed.
1.Background
Naturalenvironmentshavebeenshowntoimprovephysicalandmentalhealth:Ameta-analysis
reporteda8%reductioninall-causemortalityforresidentswiththehighestnatureoutdoorexposure
comparedwiththelowestexposuregroup(Gasconetal.2016).Visittoblue(deBelletal.2017)and
green(vandenBergetal.2016)spacesisassociatedwithpsychologicalbenefitslinkedtothenature
experience.Stressisanimportantmediatoroftheeffectofnaturaloutdoorenvironmentsandmental
well-being(Triguero-Masetal.2017).Greenspaceshavebeenshowntoreducecortisollevelsasa

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markerofstress(Twohig-BennettandJones2018).Stressasimportantmarkerofmentalhealthis
significantlyreducedbytheexposuretonatureandevenbyonlythevisualstimulationwithnature
withoutphysicalexposureinadose-responserelationship(Hazeretal.2018).Visualorauditory
naturestimulicanfacilitaterecoveryfrompsychologicalstressfulevents(Brownetal.2013;
Alvarssonetal.2010)andfromphysicaldisease(Ulrich1984).Inmentalhealth,chronicstressis
amongthestrongestriskfactorsfordepressionbutisalsoanimportantpathogeneticfactorin
anxietydisorders,post-traumaticstressdisordersorsomatoformdisorders(SlavichandIrwin2014).
Anotherfactorthroughwhichexposuretonaturaloutdoorenvironmentsexertsitspositiveeffecton
mentalhealthmightbethroughthestrengtheningofresilience(Ritchieetal.2014;Pannoetal.
2017).Resiliencecanbedefinedasone’sabilitytocopewithandrecoverfromadverselifeevents.
Resilienceisimprovedbyphysicalactivityperformedinanaturaloutdoorenvironmentbutisnot
associatedwithphysicalactivityperformedindoors(Oweretal.2018).Whenthenaturalenvironment
isusedtoperformphysicalactivitythepositiveeffectsofphysicalactivityandnaturalenvironments
canbecombined:thereisevidencethatexercisingoutdoorsresultsingreaterimprovementsof
mentalwell-beingthanexercisingindoorswithgreaterfeelingsofdelight,energyandrevitalization,
aswellasdecreasesinfrustration,tirednessandanger(ThompsonCoonetal.2011).
Thepositiveeffectsofthealpinenaturalenvironmenthaverarelybeenexamined.Oneofthefew
availablestudiessuggeststhatwatchinggrandmountainscenestriggersagreatermood
improvementthanmundanenature.Furthermoreparticipantswerefeelingsignificantlymore
connectedtoothers,morecaring,andmorespiritualafterwatchingawe-inspiringnaturecondition
(JoyeandBolderdijk2015).Hikersofalpinewildernesstrailsreportedsubstantialstressreductionand
mentalrejuvenationfollowingadayorovernighthike(ColeandHall2010).Furthermoreina
crossovertrialfocusingondifferencesbetweenindoorandalpineactivity,mountainhikingshowed
significantlygreaterpositiveeffectsonaffectivevalenceandactivationcomparedtoindoorphysical
activity(Niedermeieretal.2017a).
Althoughthesestudiesreportanimprovementonvariouspsychologicalmeasures,theydonotrefer
toapossibletherapeuticeffectinmentalhealth.Thereareonlyfewstudiesinvestigatingtherapeutic

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alpineinterventionsastreatmentforpatientsinmentalhealthcare.Inamountainhikingprogramfor
suicidalpatients,participantsreportedsignificantreductionindepression,hopelessnessandsuicidal
ideation(Sturmetal.2012).Inanotherstudyadultsandyouthwithmentalillnessexperienced
significantimprovementsinself-esteem,masteryandresiliencefollowingactivitieslikemountain
bikingandraftbuilding(Bowenetal.2016).
Inthepresentstudy,weassessedemotionalanalyticsuponviewingneutralandalpinestimuliin
patientswithstress-relatedpsychiatricdisordersandcontrols.Thealpinestimulidepictedoneor
severalindividualswhileengagedinphysicalactivityinanalpineenvironment.Furthermorewe
evaluatedself-perceivedstress,resilienceandtheamountofself-performedphysicalactivityinan
alpineenvironment.Ourmainaimwastoexploreifemotionalreactionstopicturesofindividualsin
analpineenvironmentwoulddifferbetweenpatientswithstress-relatedpsychiatricdisorderand
controls.
2.Methods
2.1.Studydesign
Thecurrentdataispartofalargercross-sectionalobservationalstudyinvestigatingtheeffectof
physicalactivityinanalpineenvironmentonmentalhealthin2016overa4monthperiod.Partsof
thisstudyhavebeenpublished(Oweretal.2018).Theinstitutionalreviewboard(ethicscommission
oftheMedicalUniversityofInnsbruck)reviewedandapprovedthestudyprotocol.Afterbeing
informedindetailaboutthestudyaimsandprocedures,participantsprovidedinformedwritten
consentonlinebyclickingontheconsentstatementandmanuallyaddingthedateofconsent,priorto
studyparticipation.ThismethodofconsentwasapprovedbytheethicscommissionoftheMedical
UniversityofInnsbruck.
Participants
ParticipantsandrecruitingaredescribedinOweretal.2018,participantnumbersvaryslightly
comparedtothepreviouspublicationduetomissingdatainindividualparticipants.Inbrief,atotalof
1029participantswererecruitedtoparticipateinanopenonlinesurvey.Thisincludedhealthy
participantsaswellaspatientstreatedattheDepartmentforPsychosomaticMedicineatInnsbruck

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MedicalUniversity.Participantswhoterminatedthequestionnaireearly(missingdatan = 436)who
reportedimplausiblevalues,whoscreenedpositivelyforalcoholabuseonlyorforaneatingdisorder
only(usingphysicalactivityforlosingweight)wereexcludedfromthepresentanalysis(Fig.1).There
were4–13%missingvaluesforindividualSAMratings.The498participantsincludedinthepresent
analysisconsistedofagroupofpatients(definedbypositivescreenonthePatientHealth
Questionnaire(PHQ,n = 183))andagroupofhealthyparticipants(HC,negativePHQscreening;n =
315).
2.2.Stimuli
Stimuliwerealternatingneutralpictures(re-stagedtoofficialInternationalAffectivePictureSystem
(IAPS)pictures(slideno.6150,7009,5661,5500,7150))andalpinestimuli(Fig.2).Alpinestimuli
displayedalpineenvironmentswithindividualsperformingsomesortofphysicalactivitytherein(e.g.
hiking,biking,skiing).Twopicturestimulihadtobeexcludedduetostatisticaloutliersintheratings.
Picturesweredisplayedfor5secondsbeforethepagewiththeemotionalanalyticratingsappeared.
Eachstimuluscouldonlybeobservedonce.
2.3.Measures
Socio-demographicparametersincludedinformationonage,sex,educationandmaritalstatus.
MentalhealthwasassessedusingtheGermanversionofPatientHealthQuestionnaire(Gräfeetal.
2004).Additionally,opentextfieldswereprovidedforenteringpsychiatricdiagnoses.Resiliencewas
measuredusingtheBriefResilienceScore(BRS)(Smithetal.2008),self-perceivedstressusingthe
PerceivedStressScale(PSS)(Cohenetal.1983)andPhysicalactivityusingtheGlobalPhysical
ActivityQuestionnaire(GPAQ-2)(Bulletal.2009).
TomeasureemotionalresponseweusedtheSelf-AssessmentManikin(SAM)9-pointLikert-scale.This
scalemeasuresemotionalanalyticsinthethreedimensionsvalence,arousalanddominance(JLang
etal.2008).Thevalencescalerangesfromafrowning,unhappy(adjectivesusedintheSAMmanual:
unhappy,annoyed,unsatisfied,melancholic,despaired,bored;lowervalues)toasmiling,happy
figure(happy,pleased,satisfied,contented,hopeful).Thearousalscaledisplaysthelowestvaluewith
acalm,eyes-closedfigure(relaxed,calm,sluggish,dull,sleepy,unaroused),whilstthehighestvalue

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isrepresentedbyanexcitedfigure(stimulated,excited,frenzied,jittery,wide-awake,aroused).The
lowestvaluesinthedominancescalearesymbolizedbyacontrolledsmallfigure(controlled,
influenced,cared-for,awed,submissive,guided.)whilsthighestvaluesarerepresentedbyadominant
andoversizedfigure(controlling,influential,incontrol,important,dominant,autonomous).After
presentingapictureforfivesecondsparticipantswereaskedtoratetheiremotionalreactioninthe
threedimensions.Foralpinestimuli,weaddedafourthdimensionaskingaboutonesattractiontothe
situation,labelledmotivationaldirection.The9pointLikert-scalerangedfrom“Idon’twanttobein
thissituation”to“Iwanttobeinthesituation”.
2.4.Statisticalmethods
Metricvariableswereanalyzedfornormaldistributionpriortoapplyingfurtherstatisticaltestsby
assessingtheirskewness,consideringvalues > 0.5or<-0.5asdeviationsfromasymmetric
distributionrequiringnon-parametrictesting.Tocompareemotionalreactionsbetweenoverallneutral
andalpinepictureswecreatedameanscoreforeachcategory.Ineachcategoryonepicturewas
excludedduetostatisticaloutliers(paraglideinalpinepictures;redwallinneutralpictures).Mean
scorewerecalculatedforeachemotionaldimensionperpersonifatleastthreescoreswere
completed.Groupcomparisons(patientsvs.HC)wereperformedusingt-test,Mann-WhitneyU-test
andChi-squaretest,dependingonthevariabletypeanddistribution.Therelationshipbetween
resilience,self-perceivedstress,PAandemotionalanalyticswasinvestigatedonadescriptivelevelby
meansofcorrelationanalysis.Spearmanrankcorrelationcoefficientswereusedasmostthevariables
involvedshoweddeviationsfromanormaldistribution.
3.Results
3.1.Sociodemographiccharacteristicsandclinicalfeatures
ThesociodemographiccharacteristicsofpatientsandHCaredisplayedinTable1.Patients´diagnoses
accordingtoPHQwereindecreasingfrequency:somatoformdisorder(n = 101,55.2%),major
depressivesyndrome(n = 67,36.6%),otheranxietysyndrome(n = 45,24.6%),panicsyndrome(n =
36,19.7%),otherdepressivesyndrome(n = 34,18.6%),alcoholabuse(n = 31,16.9%),bingeeating
disorder(n = 23,12.6%),bulimianervosa(n = 10,5.5%)andothers(n = 2,1.1%).Morethanhalfof
thepatients(n = 100,51.9%)werediagnosedwithmorethanonementalhealthdisorder,themost

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prevalentcombinationwassomatoformdisorderandmajordepressivesyndrome(n = 42,23.0%).
Table1
Sociodemographiccharacteristicsofpatientsandhealthycontrols(adaptedwithparticipantnumbers
forthecurrentanalysisfromOweretal.2018)
 
Variable Groups Comparison
Patients
(n = 183) Controls
(n = 315) Test
statistics D.f. p-value
Agein
yearsa, 36.0 ± 12.8 32.8 ± 11.7 Z = 2.42 0.016
Female
genderb117(63.9) 187(58.4) χ²=1.02 1 0.313
Educationb- - χ²=30.989 3 < 0.001
University 41(22.4) 111(35.2) - -
Secondary
school 62(33.9) 133(42.2) - -
Vocational
training 53(29.0) 34(10.8) - -
Compulsory
schooland
other
27(14.8) 37(11.7) - -
Marital
statusb- - χ²=13.699 2 0.001
Single 105(57.4) 194(61.6) - -
Married 56(30.6) 110(34.9) - -
Separated/d
ivorced/wido
wed
22(12.0) 11(3.5) - -
Employment
b- - χ²=66.81 2 < 0.001
Full-/part-
time
employment
75(41.0) 177(56.2) 
In
education/st
udy/vocatio
naltraining
49(26.8) 122(38.7) 
Unemployed 59(32.2) 16(5.1) 
amean±standarddeviation
babsolutenumber(percent)
3.2.Comparisonofresilience,self-perceivedstressandemotionalanalyticsin
patientsandHC
ThemeanscoreoftheBriefResilienceScale(BRS)wassignificantlylowerinpatientsthaninHC
(Mann-WhitneyUTest-Test,p < 0.001;Table2).FurthermorethetotalscoreofthePSSwas
significantlyhigherinpatientsthaninHC(MannWhitneyUTest,p < 0.001;Table2).
Comparingthemeanemotionalanalyticsscoreinneutralandalpinestimuli,patientsreported
significantlylowervaluesforvalence(bothps < 0.001)indicatingthattheyfeltlesshappythanHC,
anddominance(neutral:p = 0.021,alpine:p < 0.001;Table2)indicatingthattheyfeltlessincontrol
thanHC.Arousalwhenviewingneutralstimuliwassignificantlyhigher(p < 0.001)forpatients
indicatingthattheyfeltmorearousedorjitterythantheHCatbaseline.Inalpinepicturesthe

8
differenceinarousalwasnotsignificantbetweenpatientsandHC(p = 0.223;Table2).Inthefourth
dimensionaskingaboutattractiontothedisplayedalpinesituation,themeanscorewassignificantly
lowerinpatientsasinHC(p < 0.001Table2)althoughbothgroupsshowedahighattractiontothe
alpinestimuli..
Tomeasuretheeffectofthealpinestimulinormalizedtotheneutralbaseline,weevaluatedthe
differenceofeachemotionaldimensionbetweenalpineandneutralpictures.Thecomparisonalpine
> neutralstimuliwassignificantlygreaterthan0forbothpatientsandHCindicatingapositiveeffect
ofalpinestimulionemotionalanalytics.Forvalenceanddominancethiscomparisonofalpine >
neutralstimulididnotdiffersignificantlybetweenpatientsandHC(Table2).Forarousalthe
differencewassignificantlysmallerinpatientsthaninHCduetohigherbaselinearousalvaluesin
patients(p < 0.001;Table2).
Table2
Resilience,self-perceivedstressandemotionalanalytics(SAMratings)inpatientsandcontrols
Variable Group Comparison
Patients(N = 183)
Mean ± SD
Controls(N = 315)
Mean ± SD
Teststatistics p-valueb
Resilience(BRSmean
score)
2.78 ± 0.85↓ 3.76 ± 0.66 Z=-11.84 < 0.001
    
Stress(PSSscore) 9.53 ± 3.61↑ 4.73 ± 2.50 Z=-13.47 < 0.001
    
SAMRating    
Neutralpictures    
Valence 5.09 ± 1.06↓ 5.65 ± 1.21 Z=-4.696 < 0.001
Arousal 4.13 ± 1.31↑ 3.38 ± 1.23 Z = 5.848 < 0.001
Dominance 4.78 ± 1.08↓ 5.13 ± 1.35 Z=-2.312 0.021
    
Alpinepictures    
Valence 6.99 ± 1.68↓ 7.85 ± 1.12 Z=-5.661 < 0.001
Arousal 5.01 ± 1.76 5.17 ± 1.94 Z=-1.218 0.223
Dominance 5.85 ± 1.52↓ 6.42 ± 1.58 Z=-3.655 < 0.001
Attraction 6.62 ± 2.10↓ 7.52 ± 1.48 Z=-4.106 < 0.001
    
Comparison(Alpine >
Neutral)
   
Valence 1.91 ± 1.80*** 2.19 ± 1.42*** Z=-1.466 0.143
Arousal 0.87 ± 2.11↓** 1.79 ± 1.91*** Z=-4.741 < 0.001
Dominance 1.09 ± 1.61*** 1.29 ± 1.67*** Z=-1.465 0.143
bp-valueswerecalculatedwithChiSquareTestforcategoricalvariablesandMannWhitneyUTestfor
continuousvariables
↑Significantlyhigherscoresinpatientsthaninhealthycontrols
↓Significantlylowerscoresinpatientsthaninhealthycontrols
**Difference“alpine–neutral”significantlygreaterthan0,Z = 3.25,p < 0.01
***Difference“alpine–neutral”significantlygreaterthan0,alwaysZ ≥ 4.5,p < 0.001
Abbreviations:BRS:BriefResilienceScale13,PSS:PerceivedStressScale
3.3Correlationbetweenresilience,self-perceivedstress,physicalactivityinan
alpineenvironmentandemotionalanalytics

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Forthecorrelationanalysisbetweenresilience,self-perceivedstressandemotionalresponse,we
combinedthepatientandHCgrouptoonetotalsample.Resiliencecorrelatedpositivelyinboth
neutralandalpinestimuliwiththeemotionalanalyticsforvalence,dominanceandattraction(allps <
0.001,Table3)indicatingthatgreaterresiliencewasassociatedwithhigheremotionalratings.Self-
perceivedstresscorrelatednegativelywithvalence,dominanceandattractioninbothcategories(all
ps < 0.05;Table3)demonstratingthathigherstresslevelswereassociatedwithloweremotional
ratings(Table3).
Arousalwhileviewingneutralpicturescorrelatedinaninverseway:negativelywithresilienceand
positivelywithperceivedstress.Subanalysesdemonstratedthatthiswasmostlyduetopatients´
values(notshown).Thisdemonstratesthatindividualswithlowresilienceandhighlevelsofstress
feelmorearousedorjitteryatbaselinecomparedtoresilientindividualswhofeelcalmerwhen
viewingneutralstimuli.Physicalactivityinanalpineenvironmentcorrelatedpositivelywithallfour
emotionalanalyticsinalpinestimuli(allp < 0.001),whilsttherewasnosignificantcorrelationwith
neutralstimuli(Table3).
Table3
Correlationofemotionalanalytics(SAM)withresilience,self-perceivedstressandPAinalpine
environment

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Totalsample(n = 498)
BRS PSS PAinalpine
environment(MET)
Neutralpictures    
Valence rs0.188** -0.249** 0.081
p 0.000 0.000 0.078
Arousal rs-0.183** 0.187** -0.091
p 0.000 0.000 0.051
Dominance rs0.227** -0.150** -0.021
p 0.000 0.002 0.656
Alpinepictures 
Valence rs0.303** -0.276** 0.440**
p 0.000 0.000 0.000
Arousal rs0.073 -0.096* 0.225**
p 0.121 0.040 0.000
Dominance rs0.209** -0.172** 0.277**
p 0.000 0.000 0.000
Attraction rs0.222** -0.172** 0.413**
p 0.000 0.000 0.000
Comparison(Alpine
> Neutral)
   
Valence rs0.125** -0.043 0.316**
p 0.007 0.358 0.000
Arousal rs0.175** -0.188** 0.266**
p 0.000 0.000 0.000
Dominance rs0.043 -0.025 0.278**
p 0.368 0.604 0.000
AbbreviationsMET:metabolicequivalents,BRS:briefresiliencescale,PSS:perceivedstressscale
rs:Spearmanrankcorrelationcoefficient,p:p-value,*p < 0.05,**p < 0.01.***p < 0.001
4.Discussion
Inthepresentstudyweevaluatedtherelationshipofemotionalanalytics,resilienceandperceived
stresswhenviewingalpineandneutralstimuliinpatientswithstress-relatedpsychiatricdisordersand
healthycontrols.Majorfindingswere:1)Patientswithstress-relatedpsychiatricdisordershadlower
valuesinresilienceandhigherlevelsofperceivedstressthanHC,2)theemotionalanalyticsvalence
anddominanceweresignificantlylowerinpatientscomparedtoHCforbothalpineandneutral
stimuli.Baselinearousalwhenviewingneutralstimuliwassignificantlyhigherinpatients,3)the
emotionalanalyticscoresweresignificantlyhigherforalpinecomparedtoneutralpicturesfor
patientsaswellasforHC,4)Emotionalanalyticsofalpinepicturescorrelatedpositivelywith
resilienceandphysicalactivityinanalpineenvironmentandinverselywithperceivedstress.
4.1.Resilienceandpsychosomaticstressinpatientswithpsychosomatic
disorders
Inpatientswithstress-relatedpsychiatricdisordersweobservedlowerlevelsofresilienceandhigher
levelsofperceivedstresscomparedtoHC.Thesefindingsareinlinewithpreviousstudiesshowing

11
thatpatientswithmentaldisordersoftenlackstrategiesofaresilientmindset,whichcanimproved
duringrecovery(Leeetal.2017).Likewiseperceivedstresshasbeenshowntobeelevatedinstates
ofemotional-illbeing(Kadzikowska-Wrzosek2012).Impairedresilienceandhigherperceivedstress,
arepartofthecurrentvulnerability-stress-modelofpsychosomaticdisorders(Favaetal.2017).
4.2Emotionalanalyticsinresponsetoneutralandalpinestimuliinpatients
withstress-relatedpsychiatricdisorders
WefoundlowerlevelsofvalenceanddominanceinpatientsthaninHCoverall(neutralandalpine)
stimuli.Thelowerlevelsofvalence(i.e.moreunhappy)reflectthefactthatourlargestsubgroupin
ourpatientgroupwas„depressivedisorders”(55,2%).Thisconfirmspreviousstudiesshowingthat
patientssufferingfromdepressiontendtoshowlowerlevelsofvalenceastheydescribeafeelingof
numbnessundjoylessnessintheirlives(Daietal.2016).Adysfunctioninemotionalprocessingmight
betheunderlyingpathophysiologicalconcept(Kemmisetal.2017).Viewingalpinestimulileadtoa
comparableincreaseinvalence(feelinghappier)anddominance(feelingmoreincontrol)inpatients
andcontrols.BaselinearousalwashigherinthepatientsthanHCafindingpreviouslydescribedin
individualswithdepressivesymptoms(Gilbertetal.2019).Thisledtoasignificantlysmallerincrease
inarousalbetweenneutralandalpinestimuliforpatientsthancontrols.
4.3.Associationofresilience,perceivedstressandemotionalanalytics
Theassociationofresilienceandperceivedstresswithemotionalanalyticswasfoundnotonlyin
patientswithstress-relatedpsychiatricdisordersbutalsoinhealthycontrols.Thisunderlinesthe
theorythatthereisacontinuumofhealthanddiseasealsoforstress-relatedpsychiatricdisorders,
andthatmechanismsofovertlyillpatientsarealsopresentinindividualswithsub-syndromalformsof
psychosomaticdisorderspointingtowardsgeneralmechanismsofmentalhealth(Keyes2007).
4.4.Theeffectofalpinestimulionemotionalanalytics
Theeffectthealpineenvironmentonmentalhealthhasrarelybeenresearchedtodate,moststudies
whereperformedonothernaturalenvironments.Inthepresentstudywefoundthatbothpatients
andHCreactedtoalpinestimuliinformofasignificantincreaseinvalence,arousalanddominance
comparedtoneutralstimuli.Thisfindingofapositiveimpactonemotionalanalyticsisinlinewith
previousstudiesevaluatingpsychologicalandphysicalreactionstovisualnaturalstimuli.Comparing

12
reactionstourbanwiththosetonaturalsceneryasignificantincreasedpositiveaffectinemotional
responsecouldbefoundinnatureconditiononlyusingvirtualrealitystimuli(Valtchanovetal.2010).
Therestorativeeffectofthenaturalenvironment,evenifonlypresentwithinvisualstimuli,mightbe
explainedbyareductioninstresslevelsinducedbyexposuretoviewsofnature(Valtchanovetal.
2010).PatientsandHCshowedhigheremotionalanalyticsforvalenceanddominance,butwealso
detectedanincreaseinarousalinresponsetothealpinestimuli.Thisisincontrastwithseveral
studiespointingtowardsrelaxationandtranquilityfeltwhileviewingnaturalenvironment(Davis
2004).Onepossibleexplanationofourdivergingfindingisthatmostofthealpinepicturesshownin
thisstudydisplayedphysicallyactivepersons(e.g.downhillskiing).Comparabledatawerepublished
byIAPSshowinghigharousalratingsintheSAMscalewhenviewingstimuliofphysicallyactive
personsinalpinesurroundings(JLangetal.2008).
4.5.Theeffectofphysicalactivityinanalpineenvironmentonmentalhealth
Physicalactivitybyitselfandespeciallywhenperformedinanoutdoor/green/alpineenvironmentis
knowntoimprovementalhealth.Fewpilotstudiescouldconfirmthepositiveeffectofthealpine
environmentwhenperformingphysicalactivity(Sturmetal.2012;Niedermeieretal.2017a;Oweret
al.2018).Thisisinlinewithourfindingthatself-performedphysicalactivity(METs)correlateswith
highervalenceanddominancefeltbyparticipantsafterviewingalpinebutnotneutralstimuli.
Converselysomestudiesdidnotdetectanydifferencesinaffectiveresponsewhencomparingalpine
toindoorphysicalexercise(Niedermeieretal.2017b).Furthermorenoeffectofanthropogenic
elementsinthealpineenvironmentonacutestress-relatedphysiologicalresponseswasfound
(Niedermeieretal.2019).Importantlythelatterstudiesaswellasthepresentoneshoweda
beneficialeffectofoutdoorphysicalactivityonparametersofmentalwell-being.Inmostprevious
studieshealthycontrolsandnotpatientswithpsychosomaticdisorderswereinvestigated.
4.6.Limitations
Themainlimitationofthestudyisthatinasurveystudynocausalrelationshipbetweenthe
emotionalanalyticsandmentalhealthcanbeobtained.Furthermoretheexposureinourstudywas
appliedinformofvisualstimuliinsteadofactuallyspendingtimeinanalpineenvironment.The

13
presentstudydoesnotallowthedifferentiationwhichcomponentsofviewingalpineenvironment
leadtotheobservedpositiveeffectsontheemotionalanalytics.
4.7.Conclusionandconsequencesforclinicalpractice
Therapeuticprogramsforpatientswithstress-relatedpsychiatricdisordersshouldcontainphysical
activityandaccordingtoourresults,alsotaketheeffectofnatureintoaccount.Theresultsfromthe
currentstudyindicatethatpatientswithstress-relatedpsychiatricdisordershaveapositiveattitude
towardsphysicalactivityinanalpineenvironmentandthatemotionalanalyticssuchasvalenceand
dominanceincreaseinpatientsandHCinacomparablemanner.Practicalstrategiestoimplement
suchprogramsshouldbediscussed.Obviouspracticalbarrierstotheimplementationofsuch
programsareprimarilyofafinancialorigin,sinceinourmedicalsystemmoneyformedicationsand
inpatienthospitalstaysisreadilyavailablewhiletherapeuticprogramsincludingphysicalactivityin
analpineenvironmentarenotfinancedbypublichealthcare.
Declarations
Ethicsapprovalandconsenttoparticipate
ThestudywasappovedbytheethicscommitteeofInnsbruckMedicalUniversity(AN2014-0243).After
beinginformedindetailaboutthestudyaimsandprocedures,participantsprovidedinformedconsent
priortostudyparticipation.
Consentforpublication
Notapplicable.
Availabilityofdataandmaterials
Dataareavailablefromthefirstauthoruponrequest.
Competinginterests
Theauthorsreportnoconflictofinterest.
Funding
Thisresearchdidnotreceiveanyspecificgrantfromfundingagenciesinthepublic,commercial,or
not-for-profitsectors.
Authors'contributions

14
Studydesign:K.H.,C.O.,C.M.,G.K.,B.S-U.
DataCollection:K.H,C.O.,C.M.
Dataanalysis:K.H.,C.O.,G.K.,T.V.,
Datainterpretation:allauthors
Writingandreviewofmanuscript:allauthors
Acknowledgements
WethankDr.ThomasPost,Dr.UlrikeWeber-Lau,Dr.BarbaraMangweth-Matzek,forhelpwithpatient
recruitmentandDr.ChristianWidschwendterforhelpfuldiscussion.Thisstudyispartofthedoctoral
thesisofCorneliaOwer.
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Figures

19
Figure1
Flowchartofpatientandhealthycontrolrecruitment.

20
Figure2
Examplesofalpinestimulidepictingindividualsperformingphysicalactivityinanalpine
environment.Neutralstimuliarenotdepictedsincethisisnotconsideredgoodscientific
practicefortheIAPSpicturecollection(JLangetal.2008).