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Why do we climb mountains? An exploration of features of behavioural addiction in mountaineering and the association with stress-related psychiatric disorders

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Abstract

Common knowledge implies that individuals engaging in outdoor sports and especially in regular and extreme mountaineering are exceptionally healthy and hardened. Physical activity in outdoor environments has a positive effect on physical and mental health. However, regular and/or extreme mountaineering might share similarities with behavioural addictions and could thus also have a negative impact on health. In this cross-sectional web-based questionnaire study, we collected data on exercise and mountaineering addiction (Exercise Addiction Inventory; original and adapted version for mountaineering; Exercise Dependence Scale adapted version for mountaineering). Further surveyed parameters included mountaineering habits, Risk-Taking Inventory, Sensation-Seeking/Emotion Regulation/Agency Scale (SEAS), resilience, self-perceived stress, physical activity in metabolic units and mental health. Comparisons were performed between individuals with symptoms of addiction to mountaineering (MA) and individuals without symptoms of addiction to mountaineering or sports in general (CO) using non-parametric analyses. We analysed data from 335 participants, n = 88 thereof with addiction to mountaineering (MA) and n = 247 control participants (CO). The MA group scored significantly higher with regards to self-perceived stress ( p < 0.001) and included a significantly higher number of individuals affected by symptoms of depression ( p < 0.001), symptoms of anxiety ( p < 0.001), symptoms of eating disorders ( p < 0.001), alcohol abuse or dependence ( p < 0.001), illicit drug abuse ( p = 0.050), or current and history of psychiatric disorders ( p < 0.001). Individuals with MA showed higher values in all SEAS subscales as well as increased risk-taking ( p < 0.001). Regular and extreme mountaineering can display features of a behavioural addiction and is associated with psychiatric disorders. Behavioural addiction in mountaineering is associated with higher levels of sensation-seeking, emotion regulation, and agency, as well as increased risk-taking.
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European Archives of Psychiatry and Clinical Neuroscience
https://doi.org/10.1007/s00406-022-01476-8
ORIGINAL PAPER
Why dowe climb mountains? Anexploration offeatures
ofbehavioural addiction inmountaineering andtheassociation
withstress‑related psychiatric disorders
LeonieHabelt1,2· GeorgKemmler3· MichaelaDefrancesco3· BiancaSpanier2· PeterHenningsen4· MartinHalle2,5·
BarbaraSperner‑Unterweger1· KatharinaHüfner1
Received: 1 March 2022 / Accepted: 2 August 2022
© The Author(s) 2022
Abstract
Common knowledge implies that individuals engaging in outdoor sports and especially in regular and extreme mountaineer-
ing are exceptionally healthy and hardened. Physical activity in outdoor environments has a positive effect on physical and
mental health. However, regular and/or extreme mountaineering might share similarities with behavioural addictions and
could thus also have a negative impact on health. In this cross-sectional web-based questionnaire study, we collected data
on exercise and mountaineering addiction (Exercise Addiction Inventory; original and adapted version for mountaineering;
Exercise Dependence Scale adapted version for mountaineering). Further surveyed parameters included mountaineering
habits, Risk-Taking Inventory, Sensation-Seeking/Emotion Regulation/Agency Scale (SEAS), resilience, self-perceived stress,
physical activity in metabolic units and mental health. Comparisons were performed between individuals with symptoms of
addiction to mountaineering (MA) and individuals without symptoms of addiction to mountaineering or sports in general
(CO) using non-parametric analyses. We analysed data from 335 participants, n = 88 thereof with addiction to mountaineer-
ing (MA) and n = 247 control participants (CO). The MA group scored significantly higher with regards to self-perceived
stress (p < 0.001) and included a significantly higher number of individuals affected by symptoms of depression (p < 0.001),
symptoms of anxiety (p < 0.001), symptoms of eating disorders (p < 0.001), alcohol abuse or dependence (p < 0.001), illicit
drug abuse (p = 0.050), or current and history of psychiatric disorders (p < 0.001). Individuals with MA showed higher values
in all SEAS subscales as well as increased risk-taking (p < 0.001). Regular and extreme mountaineering can display features
of a behavioural addiction and is associated with psychiatric disorders. Behavioural addiction in mountaineering is associated
with higher levels of sensation-seeking, emotion regulation, and agency, as well as increased risk-taking.
Keywords Exercise addiction· Mental health· Alpine sports· Mountaineering· Behavioral addiction
Introduction
Aphorisms like "The mountains are calling, and I must
go" by the famous mountaineer John Muir encapsulate
how individuals are attracted to outdoor sports. Several
studies have shown that physical activity, especially in out-
door environments, has a positive effect on physical and
mental health [13]. Regular exercise enhances general
physical well-being, mood, and reduces anxiety, whereas
reduced physical activity is affiliated with chronic disease
* Katharina Hüfner
katharina.huefner@tirol-kliniken.at
1 Department ofPsychiatry, Psychotherapy, Psychosomatics,
andMedical Psychology, University Hospital ofPsychiatry
II, Medical University ofInnsbruck, Anichstrasse 35,
Innsbruck, Austria
2 Department ofPrevention, Rehabilitation andSports
Medicine, Klinikum Rechts der Isar, School ofMedicine,
Technical University ofMunich, Munich, Germany
3 Department ofPsychiatry, Psychotherapy, Psychosomatics,
andMedical Psychology, University Hospital ofPsychiatry I,
Medical University ofInnsbruck, Innsbruck, Austria
4 Department ofPsychosomatics, Klinikum Rechts der Isar,
School ofMedicine, Technical University ofMunich,
Munich, Germany
5 DZHK (German Centre forCardiovascular Research),
Partner Site Munich Heart Alliance, Munich, Germany
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European Archives of Psychiatry and Clinical Neuroscience
1 3
[4]. Furthermore, researchers have reported that in healthy
individual taking part in high-risk sports and mountain-
eering could have a positive impact on everyday function-
ing and self-esteem, as well as emotion regulation and
agency [5], despite the high risk of injury or even death
[6]. But there are also aspects of excessive exercise which
go beyond salutogenic effects and might actually share
similarities with psychiatric disorders (e.g. behavioural
addictions, depressive symptoms in overtraining, obses-
sive–compulsive disorder) [4].
The relationship between behavioural addiction and
mountaineering has not been previously addressed in the
literature. Moreover, no clinical criteria are available to
diagnose behavioural addiction in DSM-V or ICD-10/11,
except for gambling disorder. Behavioural addiction implies
a compulsion to engage in a rewarding non-substance-
related behaviour. The ICD-10 codes this form of addic-
tion in F63.—as “abnormal habitude and impulse control
disorder” [7], in ICD-11, there is the category of “Disorders
due to addictive behaviours” which will include “gambling
and gaming”, “impulse control disorder” as well as “other”
[8]. This labelling is highly controversial in the scientific
community and many advocate the inclusion of further
behavioural addictions, such as exercise addiction, into
the classification systems [9]. Nevertheless, there are some
studies evaluating the categorisation of excessive physi-
cal activity as a behavioural addiction. Exercise addiction
involves performing excessive amounts of exercise to the
detriment of physical health, spending too much time exer-
cising resulting in functional impairments in the personal
sphere of life, and exercising regardless of physical injury
[10]. These symptoms also occur as a diagnostic criterion
of anorexia nervosa, a disorder which shows several aspects
of a behavioural addiction [11]. A recent systematic review
summarising studies with individuals at risk for exercise
addiction showed increased rates of a variety of mental dis-
orders, including eating disorders, depression and anxiety
symptoms [12]. Literature indicates that there are individu-
als with mental conditions in consequence of their exercise
habits [13]. The WHO provides no recommendations for
upper limits in terms of intensity, frequency, and duration
of physical activity, which neglects an insufficiently studied
health problem: whilst most people exercise too little, some
exercise too much and even display addiction-like behav-
iour [14]. Excessive physical exercise can lead to so called
“overtraining syndrome” which is patho-physiologically
and symptomatically linked to depression [15] and other
addictive behaviours like Internet addiction, gambling, and
workaholism [16]. There is some evidence of the coexistence
between exercise addiction and nicotine, alcohol, and drug
abuse [17], which was confuted by other studies [18]. This
shows that the literature on this topic is still controversial.
The primary aim of our study was to explore whether
behavioural addiction to mountaineering exists and if there
is an association with stress-related psychiatric disorders
(e.g. co-occurrence with other addictions or depressive and
anxiety symptoms). Its secondary aim was to evaluate resil-
ience levels, sensation-seeking, emotion regulation, agency,
and risk-taking behaviour in alpine sports in individuals with
and without addiction to mountaineering.
Methods
Study design
This is a cross-sectional study. The anonymous web-based
questionnaire was sent out as a link through email distribu-
tors of the Austrian/German Alpine Clubs, Austrian/German
Alpine Mountain Guides Association, posted on the respec-
tive associations websites and promoted via social media in
German-speaking (Austrian, German, Italian, Swiss) Face-
book groups addressing mountaineering topics. Informed
consent and data protection statement were provided on the
first page of the online questionnaire. Study recruitment
was conducted over a 3-month period during fall/winter
2019–2020. The survey contained mainly standardised and
previously validated questionnaires. The study protocol was
authorised and approved by the ethics commission of the
Medical University of Innsbruck (Ethic commission number:
1191/2019).
Participants
The study addressed German-speaking individuals who
self-identified as regular or extreme mountaineers. Moun-
taineering was defined in the participation call as all alpine
activities covering a distance and gaining vertical metres
with the aim to reach a summit or another prominent des-
tination. This included alpine climbing, trekking, high alti-
tude mountaineering, trail running, and ski mountaineer-
ing, whilst excluding sport climbing in the climbing garden
and alpine pasture hikes. We did not define the specifiers
“regular” or “extreme” in the study call since there is no
universally accepted definition. Most mountaineers would
agree that “regular” is equal to one or more mountaineering
activities per week whilst the term “extreme” is used for
mountaineering activities outside of signposted or secured
areas as well as expedition mountaineering involving high
technical demands and high risk. Inclusion criteria were
self-reported participation in regular or extreme mountain-
eering (by the provided definition), fluency in German and
age over 18years. No exclusion criteria were given. Due to
the anonymity of the questionnaire, we did not distinguish
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European Archives of Psychiatry and Clinical Neuroscience
1 3
professional athletes from amateur athletes. Specific aspects
of participants´ mountaineering behaviour were then sur-
veyed in the questionnaire.
Measures
Sociodemographic parameters (e.g. age, sex, BMI, mari-
tal status) and mountaineering-related factors (i.e. vertical
height in m/week, number of peaks climbed per week, age
participants started mountaineering), as well as current or
former somatic or psychiatric disorders with special focus on
addiction, family history of addiction, and injuries related to
mountaineering were surveyed with self-constructed ques-
tions (the full questions are given in the supplemental mate-
rial 1 section).
Exercise addiction was measured with the German Exer-
cise Dependence Scale (EDS, [19]) and the German Exer-
cise Addiction Inventory (EAI, [20]). For the EAI, two ver-
sions were used: the original version and an adapted version
to address mountaineering specifically (EAI-M). The EAI
is a short 6-item instrument to identify exercise addiction
by addressing salience, mood modification, tolerance, with-
drawal symptoms, conflict, and relapse [21]. For the EDS,
an adapted version to address mountaineering specifically
(EDS-M) was used. The EDS and the EAI were adapted to
mountaineering by substituting the words “sport”/“training”
with “mountaineering”. The EDS operationalises exercise
dependence according to the DSM-IV including criteria for
substance dependence like tolerance, withdrawal, intention,
lack of control, time, reductions in other activities or con-
tinuance [22]. EAI and EAI-M scores of 24 were used as
cut-off values [23]. For EDS the cut-off value was 77 [19].
The EAI and the EDS are two established questionnaires
designed to measure addictive characteristics in exercise
behaviour and we decided to use both in the current study to
capture the construct in a more conclusive way, since there
is no “gold standard” to diagnose exercise addiction to date.
Mental health was assessed using subscales of the Ger-
man version of Patient Health Questionnaire (PHQ-4 [24]
screening for depressive symptoms and anxiety) and the sec-
tions focussing on eating disorder and alcohol [25]. Positive
screening for a possible eating disorder was based on PHQ
[26] scorings (module on eating disorders) as well as the
body mass index < 18kg/m2. The BMI criterion was intro-
duced as a surrogate because the PHQ eating disorder mod-
ule does not assess anorexia. Participants were scored as
“current psychiatric disorder positive” if they scored positive
in any of the used PHQ modules or self-reported a psychi-
atric condition not screened for in the PHQ modules used.
Resilience was measured using the German “Resilien-
zskala—RS-13”, which is a short version of the original
RS-25. The minimum score is 13 and maximum score is 91,
with values between 65 and 73 representing moderate resil-
ience, values below low resilience, and values above high
resilience [27]. To assess the willingness to take risks as well
as sensation-seeking during mountaineering, we used the
German version of the Sensation-Seeking/Emotion Regula-
tion/Agency Scale (G-SEAS) and the Risk-Taking Inventory
(G-RTI) [28, 29]. The G-SEAS measures the need for sensa-
tion, difficulty with emotion regulation, and lack of agency.
This is based on a study showing that participants in high-
risk activities have difficulty with a reduced sense of agency
in aspects of their life and emotion regulation, yet improv-
ing these qualities through high-risk sport activities [29].
The RTI measures deliberate risk-taking and precautionary
behaviours in high-risk sports [28]. Self-perceived stress
was measured using the German version of the Perceived
Stress Scale (PSS-4) [30]. Physical activity was assessed
using the standardised Global Physical Activity Question-
naire (GPAQ) provided by the WHO [31]. Physical activity
was calculated using metabolic equivalents (METs) as a unit
for energy use. This questionnaire was adapted with a ver-
sion specifically for physical activity during mountaineering.
The questionnaires were presented in the following order:
sociodemographic, self-constructed questions on physical
and mental health, self-constructed questions on addiction,
self-constructed questions related to mountaineering behav-
iour, RS-13, EAI-M, EAI, EDS-M, SEAS, RTI, PHQ, PSS,
GPAQ.
Statistical methods
A total of 602 German-speaking mountaineers opened the
link, 222 thereof were excluded due to incomplete data
until the EDS-M. Additionally, individuals with addiction
to physical activity only according to the EAI (not specifi-
cally to mountaineering) were excluded from the present
analysis (PA, n = 45). Hence, 335 were included in the final
analysis. The Exercise Addiction Inventory (EAI) and the
specific version adapted for mountaineering (EAI-M) was
used for assigning individuals either to the group of individ-
uals who showed behavioural addiction to mountaineering
(MA, n = 88) or individuals with no behavioural addiction to
mountaineering or physical activity in general (n = 247, CO).
Prior to the analysis, metric variables were checked for
deviations from normality by assessing their skewness, con-
sidering values > 0.5 or < −0.5 as deviations from a sym-
metric distribution requiring non-parametric testing. The
focus of the analysis was placed on a comparison of the
group of individuals who showed behavioural addiction to
mountaineering (MA) and individuals with no behavioural
addiction to mountaineering or physical activity in general
(CO). These comparisons were performed by means of t
Test, Mann–Whitney U Test or Chi-Square Test, depend-
ing on the variable type (normally distributed, non-normally
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European Archives of Psychiatry and Clinical Neuroscience
1 3
distributed metric variables, or categorical variables,
respectively). Apart from comparisons with respect to
socio-demographics and mountaineering-related aspects,
we were mainly interested in investigating group differ-
ences regarding clinical features, addictive disorders, salu-
togenic and pathogenic aspects, as well as physical activity,
using the same tests as above for this purpose. As the two
groups differed significantly in their age, marital status, and
employment status, we also performed group comparisons
with adjustment for these three variables. This was done by
means of analysis of covariance for metric dependent vari-
ables, by logistic regression for binary and by ordinal regres-
sion for ordinal dependent variables (Supplemental Material
2). A correlation analysis between EDS-M and EAI-M was
also conducted to demonstrate the concurrent validity of the
two measures. All statistical analyses were conducted using
SPSS, version 26.
Results
Socio‑demographics andmountaineering‑related
features
Participants with behavioural addiction to mountaineer-
ing (MA (mountaineering addiction), n = 88) as defined by
the Exercise Addiction Inventory (EAI-M, adapted version
for mountaineering) were compared to individuals with no
behavioural addiction to mountaineering or physical activity
in general (CO (controls), n = 247). Scorings on the EAI-M
and the Exercise Dependence Scale adapted for moun-
taineering (EDS-M) correlated with each other over both
groups i.e. MA and CO (Spearman’s rank order correlations,
r = 0.760 p < 0.001). When component scorings of EDS-M
were analysed, the MA group showed significant higher val-
ues in all parameters of behavioural addiction (withdrawal
effects, continuance, tolerance, lack of control, reduction
in other activities, time, intention effect) compared to CO
(Mann–Whitney U Test, all p < 0.001). Table1 shows the
sociodemographic characteristics divided by groups. MA
had a lower mean age (Mann–Whitney U Test, p < 0.001)
and a slightly lower BMI (Mann–Whitney U Test, p = 0.031;
however, significance is lost after adjustment for age, mari-
tal status and employment, general linear model, p = 0.300).
Within the group of MA, there was a higher percentage of
single people (77.3% compared to 62.3% in CO group).
Objective parameters related to mountaineering frequency
and habits differed significantly between MA and CO
(Table1). Individuals in the MA group climbed a higher
number of peaks per week (Chi-Square Test, p < 0.001),
were more likely to go mountaineering during off-season
(Chi-Square Test, p < 0.001), and had fewer ‘mountaineer-
ing-free’ days per weeks (Chi-Square Test, p < 0.001).
Mountaineering addiction isassociated
withpsychiatric disorders
Individuals in the MA group showed higher point prevalence
of psychiatric disorders than CO (Table2). Specifically, MA
had significantly higher values than CO regarding self-per-
ceived stress (Mann–Whitney U Test, p < 0.001), symptoms
of eating disorders (Chi-Square Test, p < 0.001), symptoms
of depression (Chi-Square Test, p < 0.001), symptoms of
anxiety (Chi-Square Test, p < 0.001) and current psychiatric
disorders, whilst there was no significant difference in resil-
ience. Individuals with MA more often self-reported a posi-
tive history of a pre-existing psychiatric disorder (depression
/depressive symptoms (n = 23), anxiety and panic disorders
(n = 4), eating disorder (n = 9) and “other” (n = 6) includ-
ing diagnoses, such as obsessive–compulsive disorder or
attention-deficit hyperactivity disorder Chi-Square Test,
p < 0.001). No difference was found for a history of somatic
conditions (self-report: musculoskeletal disorders (n = 22),
cardiovascular (n = 6), pulmonal (n = 13), neurological
(n = 4) and “other” (n = 25) including diagnoses, such as der-
matitis, hearing loss, allergies), or mountaineering-related
physical injuries. All significances are retained when adjust-
ing for age, marital status, and employment (Supplemental
Material 2, Table2, Chi-Square Test).
Mountaineering addiction isassociated withother
addictive disorders
The MA group showed a higher prevalence of other addic-
tion disorders (Table3). Specifically, individuals in the
MA group more frequently reported a history of addictive
disorders (Chi-Square Test, p < 0.001) as well as currently
active addictive disorders (Chi-Square Test, p < 0.001) more
frequently than CO. Symptoms of alcohol abuse or depend-
ency (Chi-Square Test, p < 0.001) as well as illicit drug use
(Chi-Square Test, p = 0.05) was more frequent in MA. No
difference was found concerning smoking. All significances
except those for illicit drug use and current addiction disor-
der are retained after adjustment for age, marital status, and
employment (Supplemental Material 2, Table3, Chi-Square
Test).
The Mountaineering addiction group shows higher
levels ofintensive physical activity
Individuals with MA scored higher in general physical activ-
ity (Mann–Whitney U Test, p = 0.017) as well as in physi-
cal activity related to mountaineering (Mann–Whitney U
Test, p < 0.001, Table4). Notably, this difference was due
to higher values only for intensive physical activity but not
for moderate values of metabolic equivalents (METS) which
were comparable between the groups. All significances are
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European Archives of Psychiatry and Clinical Neuroscience
1 3
kept when adjusting for age, marital status, and employment
(Supplemental Material 2, Table4, Mann–Whitney U Test).
Mountaineering addiction isassociated
withincreased sensation‑seeking andrisk‑taking
Individuals with MA showed higher values for the use
of on the G-SEAS scale compared to CO in all assessed
Table 1 Sociodemographic data
Results of socio-demographics as well as factors related to mountaineering activity
MA addiction to mountaineering, CO no addiction to mountaineering or general physical activity
a Mean ± standard deviation
b Absolute number (column per cent)
c Mann–Whitney U Test
d Chi-Square Test
Variable MA (n = 88) CO (n = 247) Comparison
test statistics df p value
Age in yearsa31.1 ± 10.0 39.0 ± 13.2 Z = −4.81c < 0.001
BMIa22.3 ± 2.6 23.1 ± 2.6 Z = −2.16c0.031
Genderb1 0.697
Male 55 (62.5%) 152 (61.5%)
Female 33 (37.5%) 93 (38.5%)
Marital statusbχ2 = 8.69d2 0.013
Single 68 (77.3%) 154 (62.3%)
Married/partnership 19 (21.6%) 73 (29.6%)
Divorced/widowed 1 (1.1%) 20 (8.1%)
Employmentbχ2 = 8.39d2 0.015
Full-/part-time employment 53 (60.2%) 185 (74.9%)
Apprenticeship/study/vocational training 30 (34.1%) 47 (19.0%)
Other 5 (5.7%) 15 (6.1%)
Age participants started mountaineeringbχ2 = 3.30d2 0.192
< 10years 33 (37.5%) 69 (28.0%)
10–30years 47 (53.4%) 148 (60.2%)
> 30years 7 (8.0%) 29 (10.6%)
Climbed peaks/weekbχ2 = 31.48d2 < 0.001
0–1 20 (22.7%) 137 (55.5%)
2–3 57 (64.8%) 80 (32.4%)
> 3 11 (12.5%) 30 (12.1%)
Vertical metres/weekbχ2 = 42.84d2 < 0.001
< 1000 6 (6.8%) 112 (45.3%)
1000–3000 66 (75.0%) 103 (41.7%)
> 3000 16 (18.2%) 32 (13.0%)
Mountaineering during off-seasonbχ2 = 13.21d1 < 0.001
Yes 74 (84.1%) 156 (63.2%)
No 14 (15.9%) 91 (36.8%)
Times mountaineering > 5000m sea level χ2 = 5.49d3 0.139
0 49 (55.7%) 168 (68.0%)
1–3 23 (26.1%) 54 (21.9%)
4–10 12 (13.6%) 19 (7.7%)
> 10 4 (4.5%) 6 (2.4%)
Mountaineering free days/weekbχ2 = 22.71d2 < 0.001
5–7 25 (28.4%) 143 (57.9%)
3–4 42 (47.7%) 72 (29.1%)
1–2 21 (23.9%) 32 (13.0%)
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European Archives of Psychiatry and Clinical Neuroscience
1 3
domains which are sensation-seeking (Mann–Whitney
U Test, p < 0.001), emotion regulation (Mann–Whit-
ney U Test, p < 0.001), agency (Mann–Whitney U Test,
p < 0.001). Despite, higher values for risk-taking were found
(Mann–Whitney U Test, p < 0.001; Table4). No difference
between the groups was found for cautiousness (Table4).
Discussion
The key finding of our study is that regular and extreme
mountaineering can show characteristic properties of behav-
ioural addictions. Whilst the majority of individuals who
performed regular and/or extreme mountaineering do not
show behavioural addiction, there is a subgroup of moun-
taineers who are vulnerable to addiction concerning alpine
sports. The problem of addressing behavioural addiction
starts with inconsistencies in terminology and in assessment
tools. The two most accepted assessment tools for assessing
addictive features of physical exercise are the EAI and EDS
which we also used in the current study. Both show similar
results in our study [14].
We found an association of behavioural addiction to
mountaineering with symptoms of depression and anxiety
as well as with a history of psychiatric disorders and with
higher levels of mental stress. This is at first glance sur-
prising since outdoor physical activity is known to promote
mental health [3]. Previous literature has shown a relation-
ship between behavioural addiction in general and depres-
sive and anxiety disorders [32]. It has been shown that exces-
sive training in amateur endurance cyclists is associated with
reduced quality of life, worse sleep and increased levels of
Table 2 Clinical features,
resilience, and self-perceived
stress
Comparison of MA and CO in clinical features, resilience, and self-perceived stress
MA addiction to mountaineering, CO no addiction to mountaineering or general physical activity
a Mean ± standard deviation
b Column per cent(absolute number)
c Mann–Whitney U Test
d Chi-Square Test
MA (n = 88) CO (n = 247) Comparison
test statistics df p value
Depressive symptomsb21.6% (19) 7.7% (19) χ2 = 12.46 d1 < 0.001
Anxiety symptomsb20.5% (18) 8.5% (21) χ2 = 9.01 d1 < 0.003
Self-perceived stressa10.2 ± 2.9 8.8 ± 2.7 Z = −3.95 c1 < 0.001
Resiliencea74.9 ± 10.8 74.1 ± 9.3 Z = −1.09 c1 0.273
Symptoms of eating disorderb22.1% (19) 5.7% (14) χ2 = 18.52 d1 < 0.001
Current psychiatric disorderb52.3% (46) 27.5% (68) χ2 = 17.69 d1 < 0.001
History of psychiatric disorderb19.3% (17) 5.3% (13) χ2 = 15.72 d1 < 0.001
Injuries related to mountaineeringb54.5% (48) 49% (121) χ2 = 0.802 d1 0.371
Current somatic disordersb17.0% (15) 16.6% (41) χ2 = 0.009 d1 0.923
Table 3 Addictive behaviour
and disorders
Comparison of MA and CO regarding addictive behaviour and disorders
Chi-Square Test was used for analysis
Results are given as colum per cent (absolute number)
MA addiction to mountaineering, CO no addiction to mountaineering or general physical activity
MA (n = 88) CO (n = 247) Comparison
test statistics df p value
Symptoms of alcohol abuse or dependence 26.1% (23) 11.7% (29) χ2 = 10.25 1 < 0.001
Nicotine use 9.1% (8) 6.1% (15) χ2 = 0.92 1 0.336
Illicit drug use (mostly marihuana) 10.2% (9) 4.5% (11) χ2 = 3.85 1 0.050
Current addiction disorder (substance or
behavioural addiction)
5.7% (5) 1.2% (3) χ2 = 5.555 1 0.018
History of addiction disorder 10.2% (9) 3.2% (8) χ2 = 6.578 1 0.010
Positive family history of addiction disorder 13.6% (12) 7.7% (19) χ2 = 2.73 1 0.098
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
European Archives of Psychiatry and Clinical Neuroscience
1 3
anxiety [33], which may lead to withdrawal and uncontrolled
behaviour [15]. Addictive disorders in general show a high
comorbidity with anxiety and mood disorders [34]. On the
one side, exercise has anti-depressive and anxiolytic prop-
erties in people with depression and is therefore used as
a coping mechanism and as a therapy for psychiatric dis-
eases [35]. On the other side, there is a subgroup of peo-
ple which loses control over their exercise behaviour and
continues exercising despite negative mental and physical
consequences [12]. With the current data, it is not possible
to determine the direction of the relation between psychiat-
ric symptoms and excessive mountaineering. Psychological
proneness to addiction could lead to excessive mountaineer-
ing, or psychiatric problems could occur as a result of the
burden of exercise addiction [12].
Additionally, individuals with addiction to mountaineer-
ing show higher numbers of further addictive disorders, such
as alcohol, illicit drug use and self-reported diagnosis of cur-
rent or history of addictive disorders. There are common risk
factors between the co-occurrence of behavioural dependen-
cies and substance use disorders in the same individual as
shown in the literature [17]. These findings are, however, not
unequivocal [18]. Some people are more prone to addictive
behaviours, regardless of whether these involve substances
or problematic activities [32]. Multiple studies show a rela-
tion between childhood trauma and addiction, such as drug
addiction [36], gambling disorder [37] and substance use
amongst adolescents [38]. Furthermore, a genetic and epi-
genetic link is possible [39].
Addiction to mountaineering is associated with higher
levels of sensation-seeking, emotion regulation and agency
as well as increased risk-taking. Those individuals with
addictive behaviour related to mountaineering showed
higher levels of sensation-seeking, emotional regulation, and
agency during mountaineering. This might help to explain
the role that excessive mountaineering plays in these indi-
viduals’ lives: problematic exercise has been shown to be
associated with both impulsivity and compulsivity, which
could explain the higher values of the SEAS scale found
in our sample [40]. Exercise dependence negatively corre-
lates with the personal resources trait, state self-control, and
self-concordance [41]. The increased risk-taking behaviour
can also interact with one’s regular life, leading to negative
effects on mental health [29, 42] and could also reflect per-
sonality traits of individuals with addiction to mountaineer-
ing. Sensation seeking and risk-taking have been shown to
be associated with addictive behaviour [43].
In the current study, we also found an association between
addiction to mountaineering and symptoms of eating disor-
ders. This comorbidity might stem from the fact that both
eating disorders and excessive exercise share some patho-
physiological aspects of behavioural addiction [44]. Exces-
sive exercise is frequently associated with eating disorders
and may evolve into exercise addiction [45]. We found an
association also with other addictive disorders which is in
Table 4 Physical activity,
sensation-seeking, emotion
regulation, agency, risk-taking
and cautiousness
Comparison of MA and CO regarding physical activity, sensation-seeking, emotion regulation, agency,
risk-taking and cautiousness
Results of GPAQ (General Physical Activity Questionnaire) the G-SEAS (German Sensation-Seeking
Emotion Regulation and Agency Scale) and G-RTI (German Risk-Taking Inventory)
Physical activity is given in (MET minutes/week)
Mean ± standard deviation is given
Mann–Whitney U Test was used for comparison
MA addiction to mountaineering, CO no addiction to mountaineering or general physical activity, P general
physical activity, M mountaineering, MET metabolic units
a 7 missings
Variable MA CO Comparison test
statistics p value
P totala15,240 ± 8794 14,102 ± 10,429 Z = – 2.392 0.017
P intensivea8716 ± 7512 7215 ± 8116 Z = – 3.423 < 0.001
P moderatea4221 ± 3686 4307 ± 4254 Z = – .639 0.523
M totala5797 ± 5616 3357 ± 4111 Z = – 4.943 < 0.001
M intensivea4670 ± 5266 2455 ± 3445 Z = – 4.966 < 0.001
M moderatea1017 ± 1419 875 ± 1492 Z = – 1.054 0.292
Sensation 22.8 ± 3.6 18.0 ± 4.7 Z = – 8.104 < 0.001
Regulation 23.6 ± 3.8 19.5 ± 5.0 Z = – 6.914 < 0.001
Agency 36.8 ± 4.9 34.1 ± 4.9 Z = – 5.005 < 0.001
Risk-taking 8.2 ± 3.6 5.4 ± 2.4 Z = – 6.639 < 0.001
Cautiousness 17.1 ± 3.0 17.0 ± 2.8 Z = – 0.479 0.632
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
European Archives of Psychiatry and Clinical Neuroscience
1 3
line with research showing that addictions often come in
clusters [46]. Whilst for some addictions (e.g. smoking,
alcohol or drug use), this is easier to understand consid-
ering a common pathophysiology and genetic component
[47], addiction to exercise and mountaineering in particular
is a different story. Since outdoor physical activity such as
mountaineering is generally considered to promote mental
health, its co-occurrence with addictions with a well-known
negative impact on mental and physical health is neverthe-
less to some extent surprising. The similar levels of resil-
ience found in MA and controls could be a hint towards
the health-related aspects of mountaineering even when it
is performed excessively which differentiates it from other
behavioural addictions. Like all other addictions, exercise
addiction may reflect an escape from a hardship along with
an accessible way to overcome negative criticism, because
exercise itself is a positive and socially valued behaviour
[14]. It is also possible that individuals with psychiatric dis-
orders or symptoms use regular and extreme mountaineer-
ing as part of a “self-therapy” to partially overcome their
symptoms.
Limitations
The extent and quality of the evidence are explorative and
bear several limitations. The main limitation is related to
the selection of the current sample: including only Ger-
man-speaking individuals who self-classified as regular
or extreme mountaineers enabled as to include a very high
number of individuals with addiction to mountaineering. On
the other hand, it must be kept in mind that this is of course
a highly selective sample, and results cannot be applied to
the general population, especially since we did not assess
whether individuals were professional athletes. The distinc-
tion between mountaineering addiction and addiction to
general physical activity is partly artificial, since in prac-
tice, both categories range on a spectrum rather than in two
different classes. Furthermore, analysis relies on self-eval-
uated questionnaires and self-assessed ratings and the way
we operationalised eating disorders is not ideal to evaluate
diagnoses. There is also a high number of excluded partici-
pants, due to incomplete data. When interpreting the results,
caution needs to be taken since causal relationships were not
investigated.
Conclusion
We define a group of individuals with addiction specifically
to mountaineering and the co-occurrence with other addic-
tions or depressive and anxiety symptoms. Even though
physical activity outdoors especially in natural environ-
ments are generally considered healthy, it can lead to nega-
tive effects on mental health if taken to a level of addictive
behaviour, involving features, such as mood modification,
tolerance, withdrawal symptoms, conflict, and relapse. Fur-
thermore, addiction to mountaineering is associated with
higher levels of sensation-seeking, emotion regulation, and
agency, as well as increased risk-taking. Future studies are
needed to better understand whether mental disorders are a
succession of excessive mountaineering, or mountaineer-
ing is used as a form of “self- therapy” to reduce mental
symptom burden.
Supplementary Information The online version contains supplemen-
tary material available at https:// doi. org/ 10. 1007/ s00406- 022- 01476-8.
Acknowledgements This manuscript is part of the doctoral thesis of
Leonie Habelt at Medical University Innsbruck and Technical Uni-
versity of Munich. We thank the mountaineers for their participation
in this study and the Alpine Clubs of Austria and Germany as well as
the Austrian/German Alpine Mountain Guides Association forhelp in
recruiting participants.
Funding Open access funding provided by University of Innsbruck and
Medical University of Innsbruck.
Declarations
Conflict of interest On behalf of all authors, the corresponding author
states that there is no conflict of interest.
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
included in the article's Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
the article's Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.
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Objective To determine the accuracy of the Patient Health Questionnaire-9 (PHQ-9) for screening to detect major depression. Design Individual participant data meta-analysis. Data sources Medline, Medline In-Process and Other Non-Indexed Citations, PsycINFO, and Web of Science (January 2000-February 2015). Inclusion criteria Eligible studies compared PHQ-9 scores with major depression diagnoses from validated diagnostic interviews. Primary study data and study level data extracted from primary reports were synthesized. For PHQ-9 cut-off scores 5-15, bivariate random effects meta-analysis was used to estimate pooled sensitivity and specificity, separately, among studies that used semistructured diagnostic interviews, which are designed for administration by clinicians; fully structured interviews, which are designed for lay administration; and the Mini International Neuropsychiatric (MINI) diagnostic interviews, a brief fully structured interview. Sensitivity and specificity were examined among participant subgroups and, separately, using meta-regression, considering all subgroup variables in a single model. Results Data were obtained for 58 of 72 eligible studies (total n=17 357; major depression cases n=2312). Combined sensitivity and specificity was maximized at a cut-off score of 10 or above among studies using a semistructured interview (29 studies, 6725 participants; sensitivity 0.88, 95% confidence interval 0.83 to 0.92; specificity 0.85, 0.82 to 0.88). Across cut-off scores 5-15, sensitivity with semistructured interviews was 5-22% higher than for fully structured interviews (MINI excluded; 14 studies, 7680 participants) and 2-15% higher than for the MINI (15 studies, 2952 participants). Specificity was similar across diagnostic interviews. The PHQ-9 seems to be similarly sensitive but may be less specific for younger patients than for older patients; a cut-off score of 10 or above can be used regardless of age.. Conclusions PHQ-9 sensitivity compared with semistructured diagnostic interviews was greater than in previous conventional meta-analyses that combined reference standards. A cut-off score of 10 or above maximized combined sensitivity and specificity overall and for subgroups. Registration PROSPERO CRD42014010673.
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Purpose of review: To highlight the interdependence between early childhood trauma, substance use and complex concurrent disorders among adolescents and discuss the delayed response and gaps in the healthcare system. Recent findings: High-risk behavior such as suicidality, self-harm and hazardous substance use including overdose and the use of psychotropic substances for self-medication of mental health challenges is a growing concern. These symptoms are often related to early childhood trauma, substance use and complex concurrent disorders. Most countries do not have a youth mental healthcare system, there are no specific guidelines and only few programs addressing high-risk substance use are in place. Summary: In addition to the significance of traumatic experience for high-risk substance use and addiction, most parts of the system of care ignore the trauma aspect in treatment of substance use and focus on abstinence. There are hardly any early intervention programs, broader prevention strategies or evidence-based or target-group-oriented treatment offers.
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Risk-taking Behaviour and Aspects on Adolescents' Participation in High-risk Sports The age of adolescence represents an enhanced reward sensitivity which is often linked to increased risk-taking behaviour. Peers enhance risk-taking behaviour which is shown through delinquency and substance use. Whereas most research on adolescent risk-taking has been directed towards negative risk-taking, this narrative review tries to highlight adventure and high-risk sport participation as a prosocial form of risk-taking and its potential influence on adolescents' behaviour. Adventure/high-risk sports such as mountainbiking, freeride ski and snowboarding and climbing have grown exponentially in the last years with a high popularity among adolescents. Besides the inherent risk of severe injury in case of a mismanaged accident, which should be minimized by preventive steps such as educative risk-management and protective gear, those sports bear the potential for multiple psychological benefits such as enhanced mood, autonomy, resilience and self-efficacy. Adventure/high-risk sports seem to have the possibility to satisfy the need for rewards, prestige and risk-taking in a socially accepted way. Few research projects have already successfully integrated adventure sport interventions in clinical settings in mental health treatment. The idea of testing adventure/high-risk sport interventions as an addition to the treatment in child and adolescent psychiatry and psychotherapy could be promising and an impulse for future research projects.
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OBJECTIVE: To determine the accuracy of the Patient Health Questionnaire-9 (PHQ-9) for screening to detect major depression. DESIGN: Individual participant data meta-analysis. DATA SOURCES: Medline, Medline In-Process and Other Non-Indexed Citations, PsycINFO, and Web of Science (January 2000-February 2015). INCLUSION CRITERIA: Eligible studies compared PHQ-9 scores with major depression diagnoses from validated diagnostic interviews. Primary study data and study level data extracted from primary reports were synthesized. For PHQ-9 cut-off scores 5-15, bivariate random effects meta-analysis was used to estimate pooled sensitivity and specificity, separately, among studies that used semistructured diagnostic interviews, which are designed for administration by clinicians; fully structured interviews, which are designed for lay administration; and the Mini International Neuropsychiatric (MINI) diagnostic interviews, a brief fully structured interview. Sensitivity and specificity were examined among participant subgroups and, separately, using meta-regression, considering all subgroup variables in a single model. RESULTS: Data were obtained for 58 of 72 eligible studies (total n=17 357; major depression cases n=2312). Combined sensitivity and specificity was maximized at a cut-off score of 10 or above among studies using a semistructured interview (29 studies, 6725 participants; sensitivity 0.88, 95% confidence interval 0.83 to 0.92; specificity 0.85, 0.82 to 0.88). Across cut-off scores 5-15, sensitivity with semistructured interviews was 5-22% higher than for fully structured interviews (MINI excluded; 14 studies, 7680 participants) and 2-15% higher than for the MINI (15 studies, 2952 participants). Specificity was similar across diagnostic interviews. The PHQ-9 seems to be similarly sensitive but may be less specific for younger patients than for older patients; a cut-off score of 10 or above can be used regardless of age.. CONCLUSIONS: PHQ-9 sensitivity compared with semistructured diagnostic interviews was greater than in previous conventional meta-analyses that combined reference standards. A cut-off score of 10 or above maximized combined sensitivity and specificity overall and for subgroups. REGISTRATION: PROSPERO CRD42014010673.