I was in Paris the first time it happened: I woke up in bed and couldn't move. Shit, I thought. Am I dead? Blinking out of existence would have been bad, but spending eternity staring at the lid of a coffin seemed much, much worse. Panicked, I tried to will my consciousness into leaving my body or dissolving into the ether. But my mind, like my body, wouldn't budge.
What I experienced that morning wasn't death, but something much weirder: sleep paralysis, a condition where the extreme loss of strength (called muscle atonia) you experience during REM sleep doesn't stop immediately when you wake. It's mostly harmless, though some sufferers experience terrifying hallucinations. I never did. And even though I woke up paralyzed a few more times during the rest of my time in Paris, when I came back to the US, the episodes stopped completely.
The idea that moving across borders might affect the brain in odd ways isn't new. A study published in BMJ this March, for instance, found that refugees in Sweden were 3.6 times more likely to experience symptoms of schizophrenia than the native-born population. Non-refugee immigrants, both first- and second-generation, have been shown to have an elevated risk for the disorder, too.
But many refugees and immigrants deal with all sorts of issues that your average American expat doesn't, from discrimination in their new country to traumatic memories of events in their old one. Is it possible that the simple act of moving abroad, without these other complications, could make a brain go haywire, too?
No one is quite sure what causes sleep paralysis, but some studies have it chalked up to garden-variety mental health issues like depression and anxiety. I definitely showed some symptoms of the former during the long, cold Parisian winter of that year, when I would eschew sightseeing or group activities in favor of locking myself in my room. There is evidence that living abroad makes most people more vulnerable to both these types of issues. A 2011 study published in the International Journal of Mental Health found that expatriates on corporate assignments were at risk for problems like depression and anxiety at a rate 2.5 times that of their US-based counterparts.
Social isolation may be part of the reason, said one of the study's co-authors, Sean Truman, a psychologist and director of clinical services at the Truman Group, a St. Paul, Minnesota–based therapy practice that provides counseling services via live video chat for English speakers abroad. "Expat communities tend to be very accepting, and people make friends easily," he told VICE. "But it's not the same when you've only known someone eight to ten months, and you get depressed and need someone to lean on."
It can also be extremely difficult for expats to find medications or qualified professional help, Truman said. "All of these communities are incredibly underserved."
Lack of access to therapy was the problem for Sarah*, who lives abroad about half the year for her work with refugees. She told me over email that while medication and therapy control her anxiety at home, "travel has totally fucked me up."
While posted in Turkey, Sarah ran out of the anti-anxiety drug gabapentin, which she needs a high dose of just to sleep. Even with a good English interpreter, Sarah had difficulty describing her dosage to Turkish doctors. "They were talking about 'packets'—like foil packets, which is what prescription medications come in there—and I didn't know what that meant," she said. She later discovered the doctor had prescribed her four times the quantity of pills she'd asked for.
Finding help abroad is hard enough when you're an adult used to navigating medical bureaucracy. But student-aged travelers might be at a particular risk. "A few years back, I noticed that among our scholastic clients, there were a really large number of mental health repatriations [people who return to their home countries]," Robert L. Quigley, senior vice president of medical assistance at International SOS, a company that provides medical and emergency services for organizations with operations overseas, told VICE. "That disturbed me as a parent, and it disturbed me as a member of this industry."
A 2015 study published by Quigley and some collaborators in The Journal of Global Mobility found that study-abroad students were 23 times more likely to require repatriation for a mental health condition than business expatriates. Quigley pointed to high rates of pre-existing mental health conditions in millennials as a potential cause: More than one-third of US college students said that they had felt so depressed in the past 12 months it was difficult to function.
It's not just a lack of access to medication and therapy that can be triggering for people living in a country other than their own. Simply being in a foreign place—in which you have to speak a different language, eat unfamiliar foods, and navigate unexpected circumstances—can be dislocating in itself. Anna* left her own Paris-based study-abroad program after only a week when she experienced a sudden flare-up of her pre-existing OCD. "The change in scenery fucked with my sense of stability more than I thought it would," she said over email. "[I] just pretty quickly realized that I couldn't do it."
Experts agree that in countries with greater cultural difference from the United States, the impact can be even more pronounced. "All these trends may have been enhanced by the fact that students no longer go on study abroad to Germany, France, and the UK; they're going to emerging markets in Africa or Asia," Quigley said. A trip abroad may be the first time they've seen a child beggar or someone who has lost a limb to a land mine. For someone who grew up in a privileged environment, this kind of suffering is not easy to process—not to mention that, as three of the experts I talked to for this piece pointed out, expats can undergo trauma themselves, from kidnapping to sexual assault.
Given all this, it's possible that businesspeople experience similar rates of psychological trouble but simply underreport it compared to study-abroad students. If you've left the US to advance your career, there's a lot more incentive to stay put even when things go south. There's also a lot more incentive not to report mental health issues at all. Take Dave*, who was in Guam for his military job when he started to experience what he termed "paranoid social anxiety." If a friend ordered a different beer than him at a bar, it would feel like "the worst thing that had happened... all week," he told me over email. He'd chug his beer "out of terror" and order the same one his friend had ordered, feeling a rush of "euphoria" now that he was finally fitting in. This roller coaster of emotions continued for weeks.
Dave didn't dare ask for help, as mental health issues were an "immediate disqualification" from his military job—and at that point, his job was "the only thing in the whole entire world that [made] a shred of sense." A professional told him later that his symptoms were typical of borderline personality disorder, a condition characterized by difficulties regulating emotion and severe mood swings. They subsided when he left Guam three years ago and so far haven't returned.
Should mental health risks like these keep curious Americans from trying out the expat lifestyle? Probably not—but taking a few simple precautions makes sense. For instance, travelers who take medications should call the US embassy in their area to find out which local doctors can prescribe them more if needed. They should also think about who in their support network they can reach out to if they're feeling anxious, depressed, or otherwise unwell.
Beyond that, basic self-care is vitally important. Christopher Willard, a psychologist and author of the forthcoming book Growing Up Mindful, worked with study abroad students as a therapist at Tufts University. "The old saying HALT—don't get too hungry, angry, lonely, or tired—really helps you... stave off stress that can trigger mental health issues," he told me over email. He suggests that expats establish a daily routine for consistency and make sure they have a private space of their own to get away from the chaos of the street.
It sounds way too easy. But the truth is, it is easy to forget this kind of obvious stuff when living abroad. Several of these hazards were familiar to me from my time in France: I often skipped meals to save cash, and I didn't know a soul in my study-abroad program, while it seemed like everyone else had come with their best friends. If I'd eaten three square meals a day and dragged friends with me to Paris, maybe I'd never have experienced sleep paralysis at all.
It seems less likely that HALT alone would have staved off more severe problems like Anna's OCD or Dave's BPD. It could be that some part of mental health risk is an inevitable part of expat life—the flip side of all the things that make it interesting. Americans go abroad to study and to work, but also to discover who we are when wrenched from our usual context. It's just up to each of us to decide if it's worth the risk of increasing our vulnerability.
*Names have been changed.