Visual height intolerance and fear of heights:
Epidemiology, phenomenology, psychiatry, and neurophysiology

Principle investigators:
PD Dr. Doreen Huppert, MD
Prof. Dr. Thomas Brandt, MD, FRCP, FANA, FEAN



I.   Historical reports about height intolerance and fear of heíghts
II.  Epidemiology, phenomenology, psychiatric comorbidity, quality of life
III. Neurophysiological experiments: Gaze, posture and  gait analysis
IV.  Devising new approaches for prevention and therapy, set-up of a specialized outpatient unit



Analyses of historical texts
Representative, population-based surveys, evaluation of quality of life (MCM-E)   

I. Analyses of historical texts
II. Representative, population-based surveys, evaluation of quality of life (MCM-E)
III.   • Gaze behavior (EyeSeeCam) (MCM-T)
• Visual control of posture (posturography, mobile EMG), analysis of gait
  (GAITRite) (MCM-T)
• Virtual stimulation of heights (MCM-M) in fMRI (MCM-I), stance and gait
IV. Behavioral guidelines for prevention and treatment


Project descriptions:

Ad I.
Search and study of sources in Greek, Roman, and Chinese antiquity and the Middle Ages.


Bauer M., Huppert D., Brandt T. Fear of heights in ancient China J. Neurol. 2012; 259: 2223-2225

Huppert D., Benson J., Krammling B., Brandt T. Fear of heights in Roman antiquity and mythology. J. Neurol. 2013; 260:2430-2432


Ad II.

a) Epidemiological studies in adults and  children
Prevalence and phenomenology of visual height intolerance and fear
of heights; psychiatric comorbidities, associated disorders and life
habits; long-term course over the entire life span; factors causing or
modulating the condition. Four studies: n=1456, n=3517, n=2012, n=455.     
  • Brandt T., Strupp M., Huppert D. Height intolerance: an underrated threat. J. Neurol. 2012; 259: 759-760
  • Huppert D., Grill E., Brandt T. Down on heights? One in three has visual height intolerance.  J. Neurol. 2013; 260: 597-604
  • Huppert D., Grill E., Kapfhammer H.P., Brandt T. Fear of heights and mild visual height intolerance independent of alcohol consumption. Brain Behav. 2013; 3:596-601
  • Huppert D., Crispin A., Brandt T. Height vertigo: epidemiology and phenomenology. Results of a representative study and a survey among members of the German Alpine Association. MMW Fortschr. Med. 2013; 155:104-108
  • Kapfhammer H.P., Huppert D., Grill E., Fitz W., Brandt T. Visual height intolerance and acrophobia: clinical characteristics and comorbidity patterns. Eur Arch Psychiatry Clin. Neurosci. 2015; 265:375-385
 b) Definition of terms:
1) Physiological visual height imbalance, prevalence 100%; 2) Visual height intolerance, prevalence 28%;
3) Fear of heights (acrophobia), prevalence 4 – 6%
  • Brandt T., Benson J., Huppert D. What  to call “non-phobic” fear of heights? Br. J. Psychiatry 2012; 190:81doi:10.1192/bjp.190.1.81a.
  • Brandt T. & Huppert D. Fear of heights and visual height intolerance. Curr. Opin. Neurol. 2014; 27: 111-117
 c) Quantitative and qualitative studies on quality of life
  • Schäffler F., Müller M., Huppert D., Brandt T., Tiffe T., Grill G. Psychosocial factors and consequences of visual height  intolerance: a qualitative study. Qual. Life Res. 2013; 23: 697-705
  • Grill E., Schäffler F., Huppert D., Müller M., Kapfhammer H.P., Brandt T. Self-efficacy beliefs are associated with visual height intolerance: a cross-sectional survey. PLOS ONE 2015; 9(12):e116220. doi:10.137/journal.pone.0116220



Visual exploration of space and control of stance and gait under real and virtual visual height stimuli. Analysis of head-, eye-in-head, and gaze-in-space movements. Measurements and analysis of leg and neck muscle activity, postural sway and gait. Virtual reality will be used to modify and separate the individual visual properties such as different cues, which are coupled in real settings.


a)    Visual exploration during exposure to heights


Gaze in space when standing still                                                                    


  • Kugler G., Huppert D., Schneider E., Brandt T. How fear of heights impairs visual exploration and gait. Nervenarzt 2013; 84: 1233-1237
  • Kugler G., Huppert D., Eckl M., Schneider E., Brandt T. Visual exploration during locomotion limited by fear of heights. PLOS ONE 2014; 9(8): e105906. doi: 10.1371/journal.pone.0105906
  • Kugler G., Huppert D., Schneider E., Brandt T. Fear of heights freezes gaze to the horizon. J. Vest. Res. 2015; 24: 433-441
  • Brandt T., Kugler G., Schniepp R., Wuehr M., Huppert D. Acrophobia impairs visual exploration and balance during standing and walking. Ann. N.Y. Acad. Sci. 2015; 1343:37-48                                                       


b) Balance control, anti-gravity muscle activity, and gait at height

  • Wuehr M., Kugler G., Schniepp R., Eckl M., Pradhan C., Jahn K., Huppert D., Brandt T. Balance control and anti-gravity muscle activity during the experience of fear at heights. Physiol. Rep. 2014; 18;2(2):e00232. doi: 10.1002/phy2.232
  • Schniepp R., Kugler G., Wühr M., Eckl M., Huppert D., Pradhan C., Huth S., Jahn K., Brandt T. Quantification of gait changes in subjects with visual height intolerance when exposed to heights. Front. Hum. Neurosci.  2014; doi: 10.3389/fnhum.2014.00963


Ad IV.  

Functional imaging of anxiety that depends on the direction of gaze during virtual stimulation in the MRI-Scanner. These data are relevant for the development of behavioral guidelines (visual exploration at height, posture, body movements, locomotion). Devising behavioral guidelines as add-ons for behavioral anxiety therapy of severely affected subjects. Set-up of a specialized outpatient unit.


Foto Huppert Juli 2013-klein Brandt
Doreen Huppert Thomas Brandt



  • Eva Grill, PhD, Prof. (W2II-1 Epidemiology); Hans-Peter Kapfhammer, MD, Prof.
  • Siegbert Krafczyk, PhD, Dr., Erich Schneider, PhD, Prof.; Roman Schniepp, MD, Dr.; Max Wühr, PhD, Dr. (YSGII-3, TRFII-5)
  • Birgit Ertl-Wagner, MD, Prof.; Virginia Flanagin, PhD, Dr.; Stefan Glasauer, PhD, Prof.
  • Claas Lahmann, MD, Prof. (CSII-2)



Doreen Huppert

Address: Ludwig-Maximilians University of Munich, Klinikum Großhadern, Marchioninistr. 15,

81377 Munich, Germany
Phone: +49 89 / 4400- 72380/-76969, Fax: -78855, E-mail: