The Hidden Risk Among Foreigner Travelers

Many years ago I noticed an emerging trend, one that no one was talking about. So convinced that a lethal concoction of Thailand-holiday associated elements were at play that I even considered making a documentary – with no idea how I would fund it. The point is; it fascinated me that much – especially when it hit so close to home.

I became aware of an increasing number of foreign visitors experiencing acute psychotic episodes. These incidents, often sensationalized in media reports, involve behaviors such as public nudity, incoherent speech, and, tragically, self-harm or suicide. While these episodes may seem sudden and inexplicable, through research I found that a confluence of factors can precipitate such mental health crises.

Rather than focus on specific cases, which I avoid to respect individuals who understandably wish to put such episodes behind them, I’ve included a few screenshots through the article from a simple Google search to illustrate just how common psychosis episodes among tourists in Thailand have become. Indeed, I’m sure you have seen news reports yourself, as every week one or more of these episodes makes the headlines.

A Personal Experience

Consider the case of a close friend of mine back in 2013, a guy in his early thirties with no prior history of mental illness. Upon arriving in Bangkok, he took sleeping pills to combat jet lag. What followed was a descent into psychosis, but it wasn’t sudden.

Over a few days of hanging out, I noticed a difference in him, such as staring at people, looking almost through me when we were talking, seeming distant, but not wanting to be alone. After a few days in town, he left my company to meet his brother – who’d flown in for a holiday. A few days later, I got a call from his brother about him acting strangely, and what followed was increasing bizarre behaviour.

He was found eating from dog bowls on the street, trying to steal women off the arms of their partners, wandering naked, and attempting to drown himself under the delusion that Jesus commanded it. Fortunately, he was helped, repatriated and, with the support of a mental health team, made a full recovery. His experience, while harrowing, is not isolated.

Misguided Media Coverage

One thing I often notice in the reporting of such episodes here in Thailand is an inability, or unwillingness, to point out the obvious. Media coverage of psychotic episodes experienced by tourists, particularly those involving bizarre behavior, arrests, or hospitalizations, frequently lacks nuance and compassion. The same can be said for online gossip in forums and social media. Cases often appear in the news as bizarre, tragic, or violent, but the public rarely hears about the underlying patterns or causes.

Headlines tend to emphasize the sensational or scandalous elements of these incidents, portraying affected individuals as reckless, irresponsible, or even morally deficient. Loaded phrases such as “gone crazy,” “drug-fueled rampage,” or “party gone wrong” reinforce outdated stereotypes that frame mental illness as a personal failing rather than a legitimate medical condition.

This kind of stigmatizing narrative reinforces the “crazy foreigner” stereotype. However, it comes at a significant cost–  to public understanding and, more critically, to the health and safety of the individuals involved. There have been cases where someone experiencing clear signs of mental distress was arrested and then released back into the community without proper evaluation, only to later cause harm to themselves or others.

Furthermore, media bias often overlooks the systemic and environmental factors at play, such as the easy availability of both prescription and non-prescription drugs, the effects of jet lag, extreme heat, and the lack of accessible mental health support in popular tourist areas. While tourists must take personal responsibility for what they consume and for managing their health, much more could be done to raise awareness about the disproportionate number of psychosis cases among tourists – particularly young men – and how these can be prevented or responded to appropriately.

It doesn’t take a genius to observe that the majority of these cases occur in extreme environments, where individuals, often overstimulated by sex, drugs, cannabis, alcohol, sleeping pills, and general sensory overload, find themselves pushed beyond their psychological limits. Yet to date, media narratives have failed to properly highlight the convergence of biological, psychological, and situational stressors that can lead to these breakdowns.

Identifying the Pattern

Reports of similar incidents to that of my friend are alarmingly frequent. Typically involving men in their late twenties to early thirties, these episodes often occur shortly after arrival in Thailand. Common behaviors include:

• Disorientation and incoherence
• Public nudity
• Aggressive or erratic actions
• Attempts at self-harm or suicide

These patterns suggest that certain environmental and physiological stressors associated with travel may act as catalysts for psychosis.

Risk Factors

Underlying Vulnerability: The Diathesis-Stress Model

One of the most widely accepted frameworks for understanding the onset of mental illness – particularly psychosis – is the Diathesis-Stress Model. This model posits that some individuals possess an underlying biological or psychological vulnerability (diathesis) that remains dormant unless triggered by external stressors. These vulnerabilities may be genetic, neurodevelopmental, or related to early life experiences such as trauma or neglect.

For example, a person might inherit a predisposition to mental illness (e.g., due to dopamine dysregulation or altered brain connectivity), but never exhibit symptoms until placed under acute psychological stress, such as travel-related exhaustion, culture shock, substance use, or emotional upheaval. In this sense, stress acts as the match to a latent combustible material.

This model helps explain why psychotic episodes can occur suddenly and without warning, even in people who seemed mentally stable beforehand. It also supports the idea that mental health is not simply a matter of willpower or personality, but the outcome of complex interactions between biology and environment.

In the context of international travel, especially to high-stimulation settings like Thailand, the combination of sleep disruption, climate stress, substance exposure, and social disorientation can serve as a powerful trigger in those who are already vulnerable.

Brief Psychotic Disorder: When Psychosis Strikes Without Warning

One condition particularly relevant to travelers is Brief Psychotic Disorder (BPD), a sudden, short-term episode of psychosis that lasts at least one day but less than one month, followed by full return to previous levels of functioning. It is not uncommon among people with no prior psychiatric history, especially under intense psychological or physiological stress.

Symptoms of brief psychotic disorder include:

• Delusions (false beliefs not grounded in reality)
• Hallucinations (seeing or hearing things that aren’t there)
• Disorganized speech or behavior
• Catatonia or agitation

In tourist hotspots, particularly those associated with intense partying, heat, or culture shock, clinicians and emergency responders occasionally encounter travellers – especially young adults – who exhibit sudden-onset psychosis without a prior diagnosis of schizophrenia, bipolar disorder, or substance addiction.

Although the exact cause is often unclear, acute stress reaction appears to be a key factor. The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) recognizes BPD as distinct from other psychotic disorders, particularly because of its transient nature and full recovery, often within days or weeks, especially when the individual is returned to a safe and familiar environment.

Medical literature notes that BPD can sometimes be confused with substance-induced psychosis, but the two are different in cause and treatment. Accurate diagnosis is crucial because most people who experience BPD never go on to develop chronic psychotic disorders, though close follow-up is recommended to monitor for recurrence.

Potential Triggers

Let’s explore some of these triggers in greater detail:

Sleep Deprivation and Use of Sleeping Pills

Traveling across time zones disrupts the body’s circadian rhythm, leading to sleep disturbances. Sleep deprivation has been linked to the onset of psychotic symptoms, even in individuals without prior mental health issues.

With disrupted sleep patterns due to jet lag, combined with a desire to drink, socialise, and adjust quickly to new time zones, many tourists turn to easily accessible medications such as benzodiazepines and non-benzodiazepine sedatives like zolpidem (Ambien). These drugs are widely used to treat anxiety, insomnia, muscle spasms, and seizures, but their use, especially outside of medical supervision, carries substantial risks.

Benzodiazepines such as diazepam (Valium), alprazolam (Xanax), triazolam (Halcion), lorazepam (Ativan), and clonazepam (Klonopin) act by enhancing the effect of the inhibitory neurotransmitter GABA (gamma-aminobutyric acid) in the brain. While this results in sedation and anxiolysis, it can also cause adverse neuropsychiatric effects, particularly at high doses or when combined with alcohol. Reported side effects include paradoxical agitation, confusion, memory impairment, hallucinations, and even acute psychosis – especially in vulnerable individuals or those with disrupted sleep-wake cycles.

A study published in the Journal of Clinical Psychopharmacology found that benzodiazepines can cause disinhibition and psychotic symptoms, particularly in the elderly and those under acute stress or sleep deprivation. Another report in CNS Drugs highlighted that combining benzodiazepines with alcohol or other depressants dramatically increases the risk of delirium, impaired judgment, and psychotic states.

Additionally, zolpidem (Ambien), a non-benzodiazepine hypnotic often used to treat jet lag-related insomnia, has been associated with rare but serious neuropsychiatric effects. Although structurally distinct, it similarly acts on GABA receptors and can lead to complex sleep behaviors such as sleepwalking, sleep-driving, and in rare cases, hallucinations and transient psychotic reactions.

These reactions are more likely to occur when individuals:

• Take the medication while sleep-deprived or jet-lagged.
• Combine it with alcohol or stimulants.
• Use higher-than-recommended doses.
• Are unfamiliar with the drug’s strength and onset profile.

Given that these medications can be procured relatively easily, tourists may underestimate their potency and the potential for adverse effects. Combined with other risk factors like heat, dehydration, and novelty-induced stress, sedatives can unpredictably tip vulnerable individuals into states of confusion, paranoia, or delusion.

Cannabis Consumption

Thailand’s recent relaxation of cannabis laws has led to the widespread availability of high-potency cannabis strains, particularly in tourist areas. This shift has raised concerns among mental health professionals and researchers, as high-THC cannabis – especially strains with THC levels exceeding 15% – has been linked to a significantly increased risk of psychosis, particularly in adolescents and young adults.

Multiple studies have demonstrated a dose-response relationship between cannabis potency and the likelihood of developing psychotic disorders. A landmark 2015 study published in The Lancet Psychiatry found that daily use of high-potency cannabis (THC > 15%) was associated with a fivefold increase in the risk of psychosis compared to non-users . This risk is further elevated in individuals with a genetic predisposition to schizophrenia or a history of adolescent cannabis use.

High-THC cannabis affects the endocannabinoid system, particularly the CB1 receptors in the brain, which play a key role in regulating mood, cognition, and perception. Excessive activation of these receptors can lead to acute neurochemical disruptions, resulting in paranoia, hallucinations, disorganized thinking, and in some cases, full-blown psychotic episodes.

Young tourists, often unfamiliar with the strength of local strains and potentially combining cannabis with alcohol, heat stress, jet lag, or sleep deprivation, may be especially vulnerable to these adverse mental health effects. Unlike traditional low-THC cannabis used in past decades, modern hybrids can deliver a much more intense psychoactive experience, which unaccustomed users may mistake for recreational intoxication rather than the onset of a psychiatric crisis.

Alcohol and Substance Use

The combination of alcohol with other substances – particularly in unfamiliar or high-stimulation environments like party destinations or foreign countries. – can significantly exacerbate underlying mental health vulnerabilities. Alcohol itself is a central nervous system depressant, and while it may initially produce feelings of euphoria or relaxation, it ultimately slows brain function, impairs cognitive control, and alters emotional regulation.

When consumed in combination with sedatives (like benzodiazepines or zolpidem), stimulants, or cannabis, alcohol’s effects can become unpredictable and dangerous. For example, mixing alcohol with benzodiazepines can lead to excessive sedation, memory blackouts, respiratory depression, and heightened disinhibition. In already sleep-deprived, jet-lagged, or anxious individuals, this mix can quickly lead to confusion, aggression, and in some cases, transient psychosis or dissociation.

From a neurobiological perspective, alcohol disrupts the balance of neurotransmitters – notably GABA, glutamate, dopamine, and serotonin – which are crucial in regulating mood, perception, and decision-making. This disruption can trigger acute psychological distress, especially in people with pre-existing anxiety, depression, or latent psychotic disorders. Even among individuals with no known psychiatric history, alcohol combined with stress, exhaustion, and foreign stimuli can bring on episodes of paranoia, panic, or derealization.

Tourists are especially vulnerable because they’re often navigating novel environments, cultural unfamiliarity, sleep disruption, and social pressure to indulge. These situational stressors can overwhelm the brain’s normal coping mechanisms, and alcohol can lower the threshold for risk-taking and impaired thinking. A 2022 meta-review in Frontiers in Psychiatry noted that alcohol-related psychosis, while rare, is a recognized phenomenon and is more likely to occur in the context of binge drinking, polysubstance use, or in those predisposed to mental health conditions.

Moreover, research has shown that acute alcohol intoxication is a significant factor in emergency room psychiatric presentations abroad, particularly in tourist-heavy areas where high-risk behavior, such as unprotected sex, violent altercations, or reckless drug use, often precedes a mental health crisis. In these cases, psychosis or dissociation is not simply due to one substance, but a synergistic overload on the brain’s stress-response and reward systems.

Heat and Dehydration

Thailand’s tropical climate – characterised by high heat, intense humidity, and prolonged sun exposure – can significantly affect both physical and mental health, particularly for unacclimatised tourists. One of the most overlooked contributors to psychiatric distress in such environments is heat exhaustion and dehydration, both of which are common in Southeast Asia and can negatively impact cognitive function and emotional stability.

Prolonged exposure to high temperatures can impair the body’s ability to regulate its internal environment. Heat exhaustion typically presents with symptoms such as fatigue, dizziness, confusion, and irritability—all of which can mimic or trigger psychological disturbances. More severe heat-related conditions, such as heat stroke, can lead to disorientation, hallucinations, and even delirium. According to research published in The Lancet Planetary Health (2021), extreme heat is correlated with a rise in mental health emergency visits, especially for anxiety, mood disorders, and substance-related conditions.

Dehydration, meanwhile, affects the brain’s ability to maintain normal neurochemical and electrical activity. Even mild dehydration—defined as a fluid loss of 1–2% of body weight—can lead to impaired short-term memory, concentration difficulties, and mood instability. A 2018 review in Nutrients found that dehydration is linked not only to cognitive decline but also to increased reports of confusion and agitation, particularly in hot climates.

For travellers already coping with jet lag, alcohol consumption, or unfamiliar psychoactive substances, the added physiological strain of heat and dehydration may amplify psychiatric symptoms or trigger an acute mental health crisis. This is especially risky for individuals with pre-existing conditions or those unknowingly sensitive to the destabilising effects of heat on the brain and body.

Furthermore, cultural factors may delay recognition and treatment. Tourists might attribute early signs of dehydration or heat exhaustion to jet lag, hangovers, or simply the “shock” of adjusting to a new environment—thus overlooking the need for rehydration, cooling, or medical attention.

Preventative Measures and Recommendations

To mitigate the risk of travel-induced psychosis, travelers should consider the following:

• Gradual acclimatization: Allow time to adjust to new time zones, environments, and routines. Don’t rush into high-stimulation activities immediately after arrival.
• Cautious use of sleep aids: Avoid taking sleeping pills or benzodiazepines unless they are prescribed and you fully understand their effects. Always consult a healthcare professional before using medication abroad.
• Moderation in substance use: Avoid mixing substances—particularly cannabis, alcohol, and prescription or over-the-counter medications—as this significantly increases the risk of adverse psychological reactions. Start slow if using any unfamiliar substance, and understand local laws.
• Stay hydrated: In hot, tropical climates like Thailand, dehydration can come on quickly and contribute to confusion, disorientation, or even psychiatric symptoms. Drink water regularly, especially if consuming alcohol.
• Be mindful of sexual exertion: Overexertion, particularly when tired, intoxicated, or under the influence of drugs, can place extra strain on the body and nervous system. This includes sexual activity. Repeated or intense physical exertion—especially with sex workers in unfamiliar environments—can compound exhaustion and increase the risk of mental health episodes.
• Seek support: If you have a history of mental health conditions, consult a doctor before traveling and consider carrying a brief medical summary with emergency contacts. If you or someone you know experiences confusion, paranoia, hallucinations, or emotional instability, seek help from local medical services, your embassy, or consular support immediately.

In Conclusion

Psychosis can happen to anyone – regardless of background – especially when exposed to extreme or unfamiliar conditions like those often encountered while traveling. From jet lag and sleep deprivation to substance use, overstimulation, and environmental stress, the triggers are varied but very real.

Greater public awareness, safer drug practices, and more compassionate media narratives are essential. By understanding the risks and removing the stigma, we can better support those affected and help prevent future incidents.

It’s my hope that this article serves not only as a cautionary warning but also as a compassionate lens through which to view a complex and often misunderstood issue.

References:

1. FDA Drug Safety Communication. (2013). Risk of next-morning impairment after use of insomnia drugs. U.S. Food & Drug Administration. [Link]
2. Griffin, C. E., Kaye, A. M., Bueno, F. R., & Kaye, A. D. (2013). Benzodiazepine pharmacology and central nervous system–mediated effects. [Link]
3. Di Forti, M., et al. (2015). Proportion of patients in south London with first-episode psychosis attributable to use of high potency cannabis: a case-control study. The Lancet Psychiatry, 2(3), 233–238.  [Link]
4. Sheldon H. Preskorn, MD; Lee J. Denner, MD (1977). Benzodiazepines and Withdrawal PsychosisReport of Three Cases. [Link]
5. Julia Feriato Corvetto, et al (2023) Impact of heat on mental health emergency visits: a time series study from all public emergency centres, in Curitiba, Brazil. [Link]
6. Benton, D., & Young, H. A. (2015). Do small differences in hydration status affect mood and cognitive function? [link]

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Disclaimer:
Some of the links above lead to academic journals or subscription-based content. Where full access is restricted, abstracts are typically available to provide a summary of the findings. The information provided in this article is for educational and awareness purposes only and is not intended as medical advice. If you or someone you know is experiencing mental distress, seek help from a qualified healthcare provider or local emergency services.