Viewing an alpine environment positively affects emotional analytics in patients with somatoform, depressive and anxiety disorders as well as in healthy controls

Abstract

Background: Patients with somatoform, depressive or anxiety 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 psychiatric disorders (mostly somatoform, depressive and anxiety 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. Further parameters related to mental health and physical activity were recorded.
Results: 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 somatoform, depressive and anxiety disorders should consider taking the benefits of natural outdoor such as alpine 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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Viewing an alpine environment positively affects emotional analytics in
patients with somatoform, depressive and anxiety disorders as well as
in healthy controls
Katharina Hüfner (  katharina.huefner@tirol-kliniken.at )
Medizinische Universitat Innsbruck 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
Research article
Keywords: alpine environment, resilience, self-perceived stress, self-assessment manikin, emotional analytics, psychosomatic disorders
DOI: https://doi.org/10.21203/rs.3.rs-15834/v3
License:   This work is licensed under a Creative Commons Attribution 4.0 International License.  Read Full License

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Abstract
Background: Patients with somatoform, depressive or anxiety disorders often don´t respond well to medical treatment and experience many side
effects. It is thus of clinical relevance to identify alternative, scientically 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 benecial 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
psychiatric disorders (mostly somatoform, depressive and anxiety 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. Further
parameters related to mental health and physical activity were recorded.
Results: 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 signicant 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 somatoform, depressive and anxiety disorders should consider taking the
benets of natural outdoor such as alpine environments, into account. Organizational barriers which are preventing the implementation of such
programs in clinical practice need to be identied and addressed.
Background
The natural environment is known to improve physical and mental health: A meta-analysis reported an 8% reduction in all-cause mortality for
residents with the highest nature outdoor exposure compared with the lowest exposure group (Gascon et al. 2016). Discovering blue (de Bell et
al. 2017) and green (van den Berg et al. 2016) spaces is associated with psychological benets. 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
marker of stress (Twohig-Bennett and Jones 2018). Stress as important marker of mental health is signicantly reduced by the exposure to
nature 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, Bangasser and Valentin 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 dened 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 signicantly 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 signicantly greater
positive effects on affective valence and activation compared to indoor physical activity (Niedermeier et al. 2017a). It is unknown whether the
mechanisms linking different natural environments (green space, blues space, alpine) to mental health are due to similar or differential effects
(Gascon et al. 2015, Liu et al. 2020).
Although studies report an improvement on various psychological measures, as a result of exposure to alpine environments they do not refer to
a possible therapeutic effect in mental health. There are only few studies investigating therapeutic alpine interventions as treatment for patients
in mental health care. In a mountain hiking program for suicidal patients, participants reported signicant reduction in depression, hopelessness
and suicidal ideation (Sturm et al. 2012). In another study adults and youth with mental illness experienced signicant improvements in self-
esteem, mastery and resilience following activities like mountain biking and raft building (Bowen et al. 2016).
The primary aim of the present study was to investigate whether stimuli depicting alpine environments would elicit differential or similar
emotional analytics in patients with somatoform, depressive and anxiety disorders and healthy controls in order to judge the potential

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usefulness for a therapeutic intervention program. This aim was approached by the following study setting:
1. We assessed emotional analytics upon viewing neutral and alpine stimuli in patients with somatoform, depressive and anxiety disorders
and healthy controls. The alpine stimuli depicted individuals while engaged in physical activity in an alpine environment
2. We investigated whether there was a correlation of emotional analytics with resilience or perceived stress in patients and healthy controls.
3. We measured the amount of self-performed physical activity in an alpine environment as a marker of previous exposure to the depicted
stimuli in a natural environment.
Methods
2.1 Study design
This is a cross-sectional observational study including a quasi-experimental part (gure 1). The whole study was performed online. The rst part
of the study contained questionnaires, while the second part recorded emotional reaction to visual stimuli. It was not possible to skip one
question or a questionnaire. The current data is part of a larger study examining the effect of physical activity in an alpine environment on
mental health, part of which has been published (Ower et al. 2018). Innsbruck is one of few urban spaces located directly within the Alps and
thus allows for easy access to the alpine environment. The 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 consent prior to study
participation. Study recruitment was conducted over a four-month period in 2016.
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 individuals participated in an open online-only survey. They were recruited via
email (mailing lists), social media and classied websites or whilst treated at the Department of Psychiatry, Psychotherapy and Psychosomatics
(Division of Psychiatry II/Psychosomatic Medicine) at Innsbruck Medical University at the inpatient or outpatient clinic. We included mainly
patients with the diagnosis of somatoform, depressive and anxiety disorders. For the present analysis participants who terminated the
questionnaire early i.e. prior to the Self-Assessment Manikin (SAM) ratings (missing data n = 436, Figure 2) were excluded from the study. This
high drop-out rate was mainly due to the fact that SAM ratings of emotional analytics were performed as the nal phase of the questionnaire
and it was not possible to skip questions. Comparison of participants terminating early with those included in the data analysis showed that the
former were signicantly older (mean age ± standard deviation, 33.5 ± 12.1 years vs 29.7 ± 10.1 years, p<0.001, Mann-Whitney U-Test) and that
a larger proportion of them was female (68.4 % vs 61.2%, p=0.017, Chi-square test). Despite statistical signicance, the differences in age (effect
size d= 0.34) and sex distribution (odds ratio = 1.37) were comparatively small. Furthermore participants that reported implausible values (n =8),
screened positively for alcohol abuse only (n =54) or for an eating disorder only (Anorexia nervosa and Bulimia nervosa; n=33) were excluded
from the present analysis (Figure 2). In Anorexia nervosa or Bulimia nervosa it is known that high levels of PA are used as tool for losing weight
and therefore are an expression of disease. Therefore, these patients were excluded (Bezzina et al. 2019). There were 4% to 13% missing values
for individual SAM ratings. The 498 participants included in the present analysis consisted of two groups. Patients screened positively for
mental health disorder on the Patient Health Questionnaire (PHQ, n =183). Participants without positive PHQ screening (n =315) formed the
control group (=HC).
2.2 Stimuli
Stimuli were alternating 5 neutral pictures (re-staged to ocial International Affective Picture System (IAPS) pictures (slide no. 6150, 7009, 5661,
5500, 7150)) and 5 alpine stimuli (Figure 3). Neutral pictures displayed gural subjects of daily life (e.g. mug, wall, umbrella). Alpine stimuli
displayed alpine environments with individuals performing some sort of physical activity therein (e.g. hiking, biking, skiing). The pictures were
presented to all participants in the same order. Two picture stimuli had to be excluded due considerations related to the displayed content
(canyon wall in the neutral stimuli and paraglider in the mountains in the alpine stimuli) and their mean ratings for at least one of the analyzed
dimensions ranging two standard deviations outside the mean of the other stimuli in the group. Pictures were displayed for 5 seconds before the
page with the emotional analytic ratings appeared. Each stimulus could only be observed once (Figure 1).
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 elds 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 (PA) using the Global Physical Activity Questionnaire (GPAQ-2) (Bull et al. 2009). PA is calculated using
metabolic equivalents of task (METs) as a unit for energy expense. As determined of the World Health Organization we classied PA in
moderate and vigorous intensity. We adapted the standard questionnaire to measure PA performed in the alpine environment.

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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, unsatised, melancholic, despaired, bored; lower values) to a smiling, happy gure (happy, pleased,
satised, contented, hopeful). The arousal scale displays the lowest value with a calm, eyes-closed gure (relaxed, calm, sluggish, dull, sleepy,
unaroused), whilst the highest value is represented by an excited gure (stimulated, excited, frenzied, jittery, wide-awake, aroused). The lowest
values in the dominance scale are symbolized by a controlled small gure (controlled, inuenced, cared-for, awed, submissive, guided.) whilst
highest values are represented by a dominant and oversized gure (controlling, inuential, in control, important, dominant, autonomous). After
presenting a picture for ve 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 and their kurtosis,
considering skewness values > 0.5 or < -0.5 (Lehman 1991) and kurtosis values > 1 or <-1 (https://brownmath.com/stat/shape.htm) as
deviations from a normal 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 scores 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. As the two groups differed signicantly in their age; education, marital status, and work situation, we also
performed analyses of covariance with adjustment for these potential confounders. As the emotional analytic ratings displayed missing values
(4% to 13%), we performed an additional analysis where missing ratings were replaced by imputed values. The SPSS Missing Value Analysis
procedure with Little’s test for missingness completely at random (MCAR) and imputation by expectation-maximization (EM) was used for this
purpose (IBM SPSS manual). 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 coecients were used as most the variables involved showed
deviations from a normal distribution.
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 prevalent combination was somatoform disorder and major depressive syndrome (n=42, 23.0%).
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 signicantly lower in patients than in HC (Mann-Whitney U Test-Test, p<0.001; Table 2).
Furthermore the total score of the PSS was signicantly 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 signicantly 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 signicantly higher (p<0.001) for patients indicating that they felt more aroused or
jittery than the HC at baseline. In alpine pictures the difference in arousal was not signicant 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 signicantly lower in patients as in HC (p< 0.001
table 2) although both groups showed a high attraction to the alpine stimuli. All statistically signicant differences in Table 2 remained
signicant when adjusting for age, education, marital status, and work situation by analysis of covariance. Missing value analysis for emotional
analytics revealed that SAM ratings were not missing completely at random (Little’s test, c² = 3607.5, d.f.= 3314, p < 0.001). Replacement of
missing emotional analytics ratings by the EM imputation method led to comparable results as the analysis without replacement. Mean ratings
changed by less than 0.1 in both groups. Moreover, all signicant group differences were retained.
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 signicantly 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
signicantly between patients and HC (Table 2). For arousal the difference was signicantly smaller in patients than in HC due to higher
baseline arousal values in patients (p<0.001; Table 2).

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3.3 Correlation between resilience, self-perceived stress, physical activity in an alpine environment and emotional analytics
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 neutral and alpine stimuli (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 signicant
correlation with neutral stimuli (Table 3).
Discussion
In the present study we evaluated the effect of viewing alpine stimuli on emotional analytics in patients with somatoform, depressive and
anxiety disorders and healthy controls. The major ndings were: 1) the emotional analytics valence and dominance were signicantly lower in
patients compared to HC for both alpine and neutral stimuli. Baseline arousal when viewing neutral stimuli was signicantly higher in patients,
2) the emotional analytic scores were signicantly higher for alpine compared to neutral pictures for patients as well as for HC, 3) 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 somatoform, depressive and anxiety disorders we observed lower levels of resilience and higher levels of perceived stress
compared to HC. These ndings are in line with previous studies showing 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 somatoform, depressive and anxiety 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) reect the fact that our largest subgroup in our patient group was „depressive disorders” (55,2%). This conrms 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 nding previously described in individuals with depressive symptoms (Gilbert et
al. 2019). This led to a signicantly 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 somatoform, depressive and
anxiety disorders but also in healthy controls. This underlines the theory that there is a continuum of health and disease also for somatoform,
depressive and anxiety 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). The inverse correlation of arousal while viewing
neutral pictures (negatively with resilience and positively with perceived stress) were mostly due to patients´ values: They are more jittery or
aroused at baseline which ts well with their predominant diagnoses of somatoform, depressive and anxiety disorders (Jung et al. 2016).
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 signicant increase in valence,
arousal and dominance compared to neutral stimuli. This nding of a positive impact on emotional analytics is in line with previous studies
evaluating psychological and physical reactions to visual natural stimuli. Comparing reactions to urban with those to natural scenery a
signicant 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

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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 nding 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). People living in perceived safe, lively and beautiful neighborhoods were more likely to engage in PA, and people living in perceived boring
and depressing neighborhoods were less likely to engage in PA (Wang et al
.
2019). Multilevel modeling results showed that after controlling for
depressive symptoms at baseline, symptoms decreased in neighborhoods where physical environment and social environment were better
(Wang et al. 2018).
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 conrm 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 nding 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). Though importantly the latter studies
as well as the present one showed a positive correlation of outdoor physical activity on parameters of mental well-being.
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 present study does not allow the differentiation which components of viewing alpine environment lead to the observed
positive effects on the emotional analytics. This was a cross sectional study which cannot give any evidence about the long term effects on
emotional analytics. Due to the spread of the study invitation via social media, yers, classied websites and mailing list, we cannot report the
response rate.

Conclusion And Consequences For Clinical Practice
4.7 Conclusion and consequences for clinical practice Therapeutic programs for patients with somatoform, depressive and anxiety disorders
should contain physical activity and according to our results, also consider taking the effect of nature into account. The results from the current
study indicate that patients with somatoform, depressive and anxiety 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 nancial 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 nanced by public healthcare. To further elucidate the effect of physical
activity in an alpine environment on mental health longitudinal intervention studies are needed. The current study indicates that such studies
could be promising.
Declarations

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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 rst author upon request.
Competing interests
The authors report no conict of interest.
Funding
This research did not receive any specic grant from funding agencies in the public, commercial, or not-for-prot sectors.
Authors' contributions
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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Tables

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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=2.42c 0.016
Female genderb117 (63.9) 187 (58.4) c=1.02d1 0.313
Educationb- - c=30.989d3 <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- - c=13.699d2 0.001
Single 105 (57.4) 194 (61.6)  - -
Married 56 (30.6) 110 (34.9)  - -
Separated/divorced/widowed 22 (12.0) 11 (3.5)  - -
Employmentb- - c=66.81d2 <0.001
Full-/part-timeemployment 75 (41.0) 177 (56.2)   
In education/study/vocational training 49 (26.8) 122 (38.7)   
Unemployed 59 (32.2) 16 (5.1)   
amean±standard deviation
babsolute number (percent)
ctest statistic for Mann Whitney U test
dtest statistics for Chi-Square test
Table 1: Sociodemographic characteristics of patients and healthy controls (adapted with participant numbers for the current
analysis from Ower et al. 2018)
Table 2: Resilience, self-perceived stress and emotional analytics (SAM ratings) in patients and controls

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Variable Group  Comparison
Patients (N=183)
Mean ± SD
Controls (N=315)
Mean ± SD
Test statistics Effect size, d p-valuea
Resilience (BRS mean score) 2.78 ±0.85 ¯ 3.76 ± 0.66 Z=-11.84 -1.33 <0.001
     
Stress (PSS score) 9.53 ± 3.61 4.73 ± 2.50 Z=-13.47 1.62 <0.001
     
SAM Rating     
Neutral pictures     
Valence 5.09 ± 1.06 ¯ 5.65 ± 1.21 Z=-4.696 -0.48 <0.001
Arousal 4.13 ± 1.31 3.38 ± 1.23 Z= 5.848 0.60 <0.001
Dominance 4.78 ± 1.08 ¯ 5.13 ± 1.35 Z=-2.312 -0.15 0.021
     
Alpine pictures     
Valence 6.99 ± 1.68 ¯ 7.85 ± 1.12 Z=-5.661 -0.64 <0.001
Arousal 5.01 ± 1.76 5.17 ± 1.94 Z=-1.218 -0.09 0.223
Dominance 5.85 ± 1.52 ¯ 6.42 ± 1.58 Z=-3.655 -0.37 <0.001
Attraction 6.62 ± 2.10 ¯ 7.52 ± 1.48 Z=-4.106 -0.52 <0.001
     
Comparison (Alpine>Neutral)     
Valence 1.91 ± 1.80 *** 2.19 ± 1.42 *** Z=-1.466 -0.18 0.143
Arousal 0.87 ± 2.11 ¯** 1.79 ± 1.91 *** Z=-4.741 -0.46 <0.001
Dominance 1.09 ± 1.61 *** 1.29 ±1.67 *** Z=-1.465 -0.12 0.143
 ap-values were calculated using Mann Whitney U Test
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, SD: standard
deviation
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

Figures

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Figure 1
Flow chart of the overall study design including details of the quasi experimental part with presentation of alpine stimuli and emotional analytic
ratings (boxed section shaded in grey). Specic questionnaires are indicated BRS = Brief resilience scale, PHQ = Patient health questionnaire,
PSS = Perceived stress scale, GPAQ = General Physical Activity Questionnaire. (…) indicates that there were questionnaires at the indicated point
in the study design not analyzed in the current study but in Ower et al. 2018.

Page 14/15
Figure 2
Flowchart of patient and healthy control recruitment (adapted with participant numbers for the current analysis from Ower et al. 2018). Excluded
cases terminated early, reported implausible values or had a single diagnose of alcohol abuse or eating disorder. Abbreviations: BRS = Brief
resilience scale, GPAQ = General Physical Activity Questionnaire, PHQ = Patient health questionnaire, PSS = Perceived stress scale, SAM ratings
= Self-Assessment Manikin for emotional analytic ratings. (…) indicates that there were questionnaires at the indicated point in the study design
not analyzed in the current study but in Ower et al. 2018.

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Figure 3
Examples of alpine stimuli depicting individuals performing physical activity in an alpine environment. Neutral stimuli are not depicted since this
is not considered good scientic practice for the IAPS picture collection (J Lang et al. 2008).