Mountaineering: physiological and psychological training

How climbers can prepare effectively for living and exercising at altitude

Exercising at altitude produces a cascade of physiological and psychological responses. Andy Lane and Greg Whyte explain how climbers can prepare effectively for living and exercising at altitude

Living and exercising at altitude has pronounced psychological and physiological effects. With less oxygen available for use, these effects are not surprising. Responses to altitude occurring at altitudes above 1,500 metres above sea level include increased heart rate, ventilation, oxidative stress, dehydration, glycogen depletion, and decreased exercise capacity and immune function.

In the initial stages, exercise simply feels harder than that performed at the same pace at sea level(1). Climbing is a physically demanding activity(2) requiring both strength and endurance, and altitude exacerbates the physiological demands. If climbers perceive that these increased demands outweigh their perceived ability to cope, then climbing at altitude represents a stressful task.

Physiological and psychological effects of altitude
Rapid ascents to heights of more than 3,000m cause many physiological responses triggered by hypobaric hypoxia associated with a reduction in barometric pressure leading to a reduced partial pressure of oxygen. Arterial oxyhaemoglobin saturation decreases and may produce a set of maladaptive physiological and psychological disorders, known as acute mountain sickness (AMS). AMS involves experiencing breathlessness, headaches, insomnia, dizziness and abnormal tiredness, and mood disturbances. Other effects are visual disturbances, adverse changes in cognitive functions, mental reasoning, concentration, working memory, postural stability, sensory motor coordination, eye-hand coordination, and neuromuscular control.

AMS includes two major, life-threatening conditions; high altitude pulmonary oedema (HAPE) and high altitude cerebral oedema (HACE). Treatment for these conditions must be immediate to avoid long-term injury and fatality. The primary treatment for HAPE and HACE is evacuation to lower altitude/sea level as rapidly as possible. Other associated health issues with moderate altitude (up to 3,000m), and in particular high altitude, include cold injury – ranging from non-freezing cold injury and frostbite to hypothermia. Sunburn is also a major issue at altitude, which can have significant negative consequences for the health of the climber.

For a given altitude, AMS symptoms usually show maximal effects during the first or second day of exposure and then recede rapidly in those that adapt (responders). AMS symptoms can reappear if climbing continues too fast, or may persist in those that fail to adapt (non-responders). The number of symptoms, severity and rapidity of the onset and duration of high-altitude symptoms vary between individuals(3). Pronounced changes that occur include alterations in mood states including irritability, hostility, depression and anxiety(4). Figure 1 shows changes in mood states reported in previous research. The message is clear: the higher the altitude, the more pronounced the effects on emotional and cognitive processes(5).

Strategies to manage the effects of altitude
There are a number of strategies that can be used to manage the experience of climbing at altitude. Of the plethora of factors found to influence how people adapt to altitude, possibly the most convincing are the effects of experience. While this might seem an extremely obvious statement, the mechanisms through which experience assists coping efforts are not clear.



It is possible that repeated exposure to altitude leads to physiological changes, which make repeated exposure to altitude much easier. However, evidence indicates the physiological acclimatisation to altitude is relatively transient(1). It could be that individuals expect to experience the acute physiological responses and change their behaviour accordingly. This explanation would suggest that people exercise less intensely or gauge the exercise-rest ratio effectively(6).

Figure 2 shows improvements in mood states from a group of elite biathletes who attended two training camps at an altitude of 2,000m. In the second camp, some four months after the first camp, athletes reported feeling more vigorous and less fatigued.

Whether successful adaptation is driven by physiological or experiential mechanisms is less important in practical terms. Climbers should look to maximise the benefits of experience of altitude and each trip to altitude should be seen as a learning opportunity. The perceptual nature of stress is also an important issue. Climbers need to believe that they can manage the physiological effects of altitude. There are a number of coping strategies that can be considered and developed at sea level and then used when climbing at altitude:

Preparation;
Emotional intelligence;
Social support;
Video;
Positive self-talk;
Visualising success.

Climbers should reflect on their effectiveness and then revise their plans accordingly for subsequent climbs.

Specific strategies
Preparation – When planning a trip involving ascents above 2,000m, it is essential that each individual is aware of the effects of altitude and AMS symptoms in particular. As the symptoms of altitude are similar to symptoms of fatigue, it is important to know when altitude’s effect will begin and it is therefore important to indicate which parts of the climb will feel harder.

This approach can be as simple as noting the various heights of landmarks on the trip. Knowing that an individual is at altitude should impact on how they interpret symptoms of fatigue. At altitude, it is important not to dismiss such feelings or try to ‘work through’ them in a cavalier manner. It is important to accept that cardio-respiratory responses will be elevated more than usual, and to work within these boundaries. The key aspect of preparation is to anticipate how you will feel at altitude. After you have recognised how hard it might feel (and as you gain experience, this exercise become easier), you can begin to develop plans on how to cope.

Emotional intelligence – Identifying emotions that influence performance and how such emotions change over time is key to learning how to manage emotions(7). Accurate assessment of the emotional states that other people are feeling is also important. All climbers in a group expedition will experience the potential stressor associated with altitude simultaneously. Assessment of emotions can be done in a multitude of ways, such as the use of self-report scales or a more user-friendly approach using an open-ended diary-type approach. The diary method is a valid method in research and provides valuable data. This approach is especially valuable when the purpose of data collection is to conduct a needs analysis for a subsequent intervention(8).

Emotional assessment
Assessment of emotions should start by asking the climber to think carefully about a situation when they performed at altitude. If the climber has not performed at altitude, then it is important to describe the likely effects of altitude, and ask the climber to recall such similar experiences. Admittedly, these experiences will not have been performed at altitude, but they represent a starting point. In essence, we are asking the climber to recall a situation that was extremely demanding physically and where they questioned whether they could cope with the challenge. We have provided an example of an open-ended diary in figure 3. It helps if the climber spends some time rehearsing this situation in their mind, and tries to remember how they felt. The climber then writes down (or narrates) all of the emotions they experienced. They should also rate how they performed in the situation to allow comparisons between successful and unsuccessful performance. For example, I could not concentrate because I felt nervous, started thinking negatively and started feeling emotionally drained and fatigued. We should also be aware if our emotions have a positive or negative on others, especially if climbing in a group. We cannot change our emotions immediately, but we can change the dialogue that runs through our mind when we experience emotions.

Social support – This is linked to emotional intelligence and relates to how effective we can be in terms of providing support for others. Interestingly, providing support for others has been found to be an effective strategy for enhancing our own emotions; we improve our own mood by the act of trying to improve the mood states of others.
While aspects of climbing are highly individual, it is also important to recognise that climbing often occurs in a social context for safety reasons. Evidence shows how important the social environment is in terms of maintaining a positive experience. A social environment characterised by boredom (due to the lack of environmental stimulation) and interaction with the same individuals, a lack of privacy, and a reduction in food choice and general control over a situation is counterproductive. For example, a study that investigated climbers at altitudes from 3,810m to 5,000m during a 35-day mountaineering expedition (where these factors were evident) found that climbers became more hostile, constrictive, anxious, obsessive-compulsive, paranoiac and depressed(9).



Collective emotions
The strategy for managing the collective emotions of a group is not straightforward. One approach is for each member of the team to keep a watchful eye on other members. It is unlikely that team members will want to admit that they have the symptoms of altitude sickness for a number of reasons. Acknowledging that you are suffering from altitude sickness might threaten an opportunity to participate in a possibly once-in-a-lifetime opportunity. For example, given the months of preparation and financial investment climbers make to climb Mount Everest, it should not be surprising that individuals will try to tough out the symptoms of mountain sickness, which would clearly threaten their potential participation. Moreover, individuals may not want to show symptoms of ‘weakness’. In one case study, a climber who had AMS noted:
‘In the early stages, all group members struggled with the effects of increased altitude, including breathlessness, dizziness, headaches, and sleeping difficulties. I was bloated and heavy, my clothing was uncomfortable… I avoided using oxygen available in the hotel. I dared not show weakness.

I hoped the others were also experiencing the same, but I didn’t ask. I was disguising my unnatural symptoms, forcing myself to act naturally. I became a confused listener. Unknown to me, colleagues had noticed and were preparing to take action.’(10)

Given conflicting motivational clashes, it is important for group members to develop a sense of team cohesiveness. At baseline, before the climb has started, frank and open discussions should be held on the possible effects of altitude. Trust, honesty and cooperation between all members of a group of climbers are vital, especially due to the dangerous nature of climbing. Regular meetings should be held to foster ‘togetherness’ and acquaint each team member with his or her responsibilities. Creating open communication channels and monitoring the psychological wellbeing of members should be seen as the responsibility of all involved.

Watching success (use of video, DVD, iPod etc) – Watching others who have been successful is a powerful method of raising confidence. Showing models of success generates the message that: ‘If he/she can do that, then so can I’. It is a powerful message and a very effective way to initiate behavioural changes.

Videotaped successful past expeditions can be extremely helpful to develop an awareness of the challenges that may be faced. Through anticipating these challenges, prospective participants can define psychological skills for future expeditions. However, models that reflect the capabilities of the observer are the most powerful; a novice climber watching an elite climber will not identify the difficulties of the task. The elite climber will make difficult skills look simple. A novice who watches someone of a similar skill level to him or herself will be able to identify with the difficulties more accurately. With this in mind, it is important that watching videos of climbers managing the effects of altitude are discussed in detail.

Positive self-talk – A skill that arguably relates to all strategies described above is the use of positive self-talk. Positive self-talk is a technique that can be used to enhance performance and control emotions. It makes use of an athlete’s powerful inner voice. With appropriate repetition, self-talk can positively alter an athlete’s belief system.
The goal is to focus on what the climber should be concentrating on at any specific moment of the climb. This can enhance skilled performance by directing attention to the appropriate cues. By contrast, mood-related self-talk is focused on how the athlete feels. If an individual feels they are failing due to internal reasons, this is likely to impact on mood and motivation.

For example, a climber at 4,000m will feel fatigued the higher she/he climbs. If the climber attributes fatigue to fitness levels saying to themselves ‘I just am not fit enough’ this could be both demotivating and depressing. Alternatively, if the climber attributes his fatigue to the altitude and understands that this response is part of the challenge of performing at altitude, they will be likely to stay more positive. This should lead to developing strategies to incorporate appropriate rests into the climb.

Positive self-talk statements should be developed and reinforced before starting the climb. For example, when fatigue increases, climbers should tell themselves ‘I feel fatigued because of the altitude but I know this is only temporary, and my body is adapting to this. I know it takes a little while for it to adapt but this is the worst it is going to get.’
Visualising success – Another strategy worth implementing alongside positive self-talk, and which is also supported through watching video, is visualising success. Imagery helps athletes cope with difficult situations. Climbers should try to anticipate a difficult situation, and visualise coping with it successfully. An important part of this process is to imagine successfully tackling a number of factors that make the task difficult.

As indicated when discussing the use of video to boost confidence, it is important to develop an accurate assessment of the difficulties of the task. Although it is important to visualise success, it is equally important not to underestimate the difficulty of the task. This can create a false sense of self-confidence. For example, climbers should imagine coping successfully with the toughest part of the climb, the highest altitude, when feeling exhausted, but also having to focus specifically on the next part of the climb.

Summary
Climbing at altitude is about managing physiological and psychological stressors. Climbers should anticipate the potential to experience difficulties with altitude and plan accordingly. Much of the planning can be done at sea level. Climbers should see themselves as active learners and accept that they might not cope with the additional demands altitude imposes. Experiences of climbing at altitude serve as highly valued learning tools for future coping efforts. Strategies such as imagery, self-talk, emotional intelligence training, and providing social support should enhance confidence in being able to manage the demands of climbing at altitude.