Paradise Lost: The Hidden Risk of Psychosis Among Foreigners in Thailand

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. It fascinated me that much, and even more so when it hit closer to home.

I became aware of an increasing number of foreign visitors experiencing acute psychotic episodes. These incidents followed a trend, usually including subtle obscure behaviors that progressively became worse over a number of days and ended up with displays of public nudity, shouting incoherently in the street, and, tragically, self-harm or suicide. Often labelled as simply drunken or drug-induced behavior, through a little reading it was obvious to me that these were episodes of psychosis caused by a confluence of factors.

Rather than focus on specific news cases in this article (though I will discuss my friend's case), which I avoid to respect individuals who understandably wish to put such episodes behind them, I’ve included a few screenshots in 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

Back in 2014, I had a deeply unsettling experience involving a friend of mine – we’ll call him Tom –who was living in Bangkok at the time, working as an international school teacher. He had no previous history of mental health issues. He’d been teaching abroad for a few years but less than 3 months in Thailand at the time.

The first signs were subtle. When we met up, he seemed unusually distracted, often zoning out mid-conversation or speaking in riddles that didn’t quite make sense. At first, I thought he was just tired or stressed from work. But the strangeness escalated quickly. He began making cryptic spiritual remarks, deeply fascinated with Buddhism, but in a way that felt unbalanced. He would mumble about enlightenment and claim to have some kind of divine insight, hinting that he was a higher being on some spiritual mission.

Things got more concerning when he started giving away his belongings. I found out he’d handed his smartphone to a stranger in a park and given away most of the cash in his wallet to random passersby.

The turning point came one evening near the Chao Phraya River. Tom had stripped off his clothes in public and climbed the railing of a bridge, preparing to jump. Thankfully, someone intervened and managed to talk him down before he could hurt himself. The authorities were called, but even then, it took a while for them to take decisive action. Only when there was a clear threat to his life, and potentially others, was he finally sectioned and brought to a psychiatric facility.

It was a slow build-up to a full-blown psychotic episode. Mental health support, especially for expats abroad, can be fragmented and hard to access, and Tom’s case was a stark reminder of how quickly things can deteriorate when someone isn’t grounded by familiar support systems.

He did eventually receive help and began the slow process of recovery. What transpired post the episode was that he had been taking sleeping pills for some time, initially to overcome the jet-lag upon arriving in Bangkok so that he could get into a routine for his new teaching job. Coupled with other factors we'll discuss below, this was likely the trigger.

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 lack nuance and critical thinking. 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” or “drug-fueled rampage” serve to reinforce 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.

The media and society at large, including the expat community, often overlook 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

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, and readily available stimulants, emergency responders occasionally encounter travellers 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, 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.

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 (references included at the end of the article).

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 purchased over the counter in many pharmacies around Thailand  – just take a trip down to lower Sukhumvit in Bangkok and you can pretty much get what you want – tourists may underestimate their potency and the potential for adverse effects. Combined with other risk factors like dehydration, lack of sleep, cannabis, alcohol and novelty-induced stress, sedatives can unpredictably tip a person into a state 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, 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 Pattaya, Bangkok, Phuket, or Koh Samui – 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. Alcohol-related psychosis, while rare, is a recognized phenomenon and is more likely to occur in the context of binge drinking, substance 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 means that tourists are instantly exposed to high heat, intense humidity, and potentially prolonged sun exposure. This can significantly affect both physical and mental health, particularly for unacclimatised tourists from cooler counties. 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. Research shows that 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.

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

This article is intended as a scare piece, but rather as a way of creating some awareness around an issue that I have observed over a long period of time. If you have a friend, partner, son, or daughter visiting Thailand, it is hugely important to be aware of the aforementioned risks to mental health.

To mitigate the risk of travel-induced psychosis, consider the following preventative measures:

• 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.

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.

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.

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