Prevention Strategies for Anxiety & Panic in Divers David F. Colvard, MD Psychiatrist & Divemaster DivePsych.com Raleigh, North Carolina, USA

Prevention Strategies for Prevention Strategies for Anxiety & Panic in DiversAnxiety & Panic in Divers

David F. Colvard, MDPsychiatrist & Divemaster

DivePsych.com Raleigh, North Carolina, USA

Realistic Fear? Paralyzing Anxiety?

© 2011 David Colvard. All rights reserved.

Realistic Fear? Paralyzing Anxiety?


Flora Fisk Quiz for Recreational Divers:

Question: Is recreational diving supposed to be fun?

Answer: YES

Flora Fisk Quiz for Recreational Divers:

Question: Are you having fun?

Answer: If “Yes", continue diving.

If “NO" — STOP DIVING.


Sherman’s Lagoon by Jim ToomeyCopyright 1999 Reprinted with permission


Sherman’s Lagoon by Jim ToomeyCopyright 1999 Reprinted with permission

Healthy Fear vs. Anxiety

Healthy Fear

•Valid perception of danger•Fight or Flight•May keep you alive

Anxiety

•Not related to any real threat•No useful function•Fortune-telling•Catastrophizing•Affects breathing•Can lead to PANIC


So what’s wrong with panic?

• Psychological stress reaction of extreme anxiety.

• Frenzied and irrational behavior.

• It is unhelpful

• Reduces the chance of survival



According to various studies,39% - 60% of diver deaths are

associated with panic,

but panic is usually NOT the primary factor.


Trait Anxiety Predicts Panic Trait Anxiety Predicts Panic Behavior in Beginning Scuba Behavior in Beginning Scuba

Diving StudentsDiving Students

• 42 students in 4 month course42 students in 4 month course• Pre-instruction STAI Trait AnxietyPre-instruction STAI Trait Anxiety• 35 of 42 (83%) accurate predictions using 35 of 42 (83%) accurate predictions using

a trait score + 1 stnd dev above meana trait score + 1 stnd dev above mean• Predicted 64% of actual panicsPredicted 64% of actual panics• Therefore, panic behavior can be Therefore, panic behavior can be

predicted in beginning studentspredicted in beginning studentsMorgan WP, Raglin JS, O’Connor PJ , Int J Sports Med 2004: 25


Panic Prevention Program* Panic Prevention Program* (Primarily for Scuba Diving Students)(Primarily for Scuba Diving Students)

1.1. Information about PanicInformation about Panic

2.2. Calming Response (Breath Control)Calming Response (Breath Control)

3.3. Mental Rehearsal of Ditch-n-donMental Rehearsal of Ditch-n-don

4.4. Systematic Relaxation TrainingSystematic Relaxation Training

Tom Griffiths, EdD, studied anxiety & panic in dive students and developed this program for high trait anxiety students in 1980’s.

*Free MP3 files available at www.DivePsych.com


Face Fears in TrainingFace Fears in Training

Stress inoculationStress inoculation

Systematic desensitization Systematic desensitization to overcome fears to overcome fears

Prolonged exposure and response Prolonged exposure and response prevention to overcome phobiasprevention to overcome phobias


Trait Anxiety and Panic Trait Anxiety and Panic Behavior in Experienced Scuba Behavior in Experienced Scuba

Divers in 2001Divers in 2001

Year 2001 divers (n= 4,213) in Colvard pollYear 2001 divers (n= 4,213) in Colvard poll

Average STPI Trait AnxietyAverage STPI Trait Anxiety

Panic Panic in 2001in 2001 10%10% 1616Almost PanicAlmost Panic 13%13% 1616No PanicNo Panic 77%77% 1515

• No significant difference in average trait anxiety scores in No significant difference in average trait anxiety scores in experienced scuba diversexperienced scuba divers

Colvard – data on file from 2002 survey/poll


Trait Anxiety and Panic Trait Anxiety and Panic Behavior in Experienced Scuba Behavior in Experienced Scuba

Divers in 2003Divers in 2003

• Year 2003 male experienced divers (n= 1,415)Year 2003 male experienced divers (n= 1,415)

• STPI Trait Anxiety (10 items) used to predictSTPI Trait Anxiety (10 items) used to predict

• Reported panic rate in 2003 was 7% (96 of 1,415)Reported panic rate in 2003 was 7% (96 of 1,415)

• Trait Anxiety only predicted 20 (21% ) of Trait Anxiety only predicted 20 (21% ) of 96 actual panics96 actual panics

• Failed to predict 76 (79%) of 96 actual Failed to predict 76 (79%) of 96 actual panicspanics

• 1,149 of 1,415 (81%) accurate predictions using average trait score + 1 standard deviation to predict panic

• Colvard – data on file from 2004 survey/poll


SAFETY SURVEY OF SAFETY SURVEY OF RECREATIONAL SCUBA DIVERSRECREATIONAL SCUBA DIVERS

by Drs. Colvardby Drs. Colvard

• Anonymous, confidential survey (poll) hosted Anonymous, confidential survey (poll) hosted by Rodale’s by Rodale’s Scuba Diving MagazineScuba Diving Magazine

• 180 paper surveys collected from August 180 paper surveys collected from August 2000 to January 2, 20012000 to January 2, 2001

• 12,722 online surveys collected from 12,722 online surveys collected from September 2000 to January 2, 2001September 2000 to January 2, 2001

• Total of 12,231 Total of 12,231 completecomplete surveys surveysColvard, D.F. and Colvard, L.Y: A Study of Panic in Recreational Divers, The Undersea Journal, First Quarter 2003, pp 40-44.


Dive ConditionsDive Conditions(Colvard – 2000 survey)(Colvard – 2000 survey)

• Poor visibilityPoor visibility• Separation from buddy Separation from buddy

or instructoror instructor• Low on air or out of airLow on air or out of air• Sharing airSharing air• Rough seas or surfRough seas or surf• Strong current or surgeStrong current or surge• Nighttime or darknessNighttime or darkness• Overhead environment Overhead environment

(cave, wreck, ice)(cave, wreck, ice)• SharkShark

• Other dangerous marine Other dangerous marine life life

• Deep diveDeep dive• Cold diveCold dive• Solo diveSolo dive• Dry suit diveDry suit dive• Entrapment or Entrapment or

entanglemententanglement• Loss of orientationLoss of orientation• Long surface swimLong surface swim• Other stressful dive Other stressful dive

conditions not listed conditions not listed aboveabove


EquipmentEquipment(Colvard – 2000 survey)(Colvard – 2000 survey)

• Mask leakMask leak• Loss of maskLoss of mask• Loss of weight beltLoss of weight belt• Tank slippageTank slippage• Regulator leak or Regulator leak or

free flowfree flow• Broken or loose fin Broken or loose fin

strapstrap• Uncontrolled ascentUncontrolled ascent

• Loss of computer or Loss of computer or gauge functionsgauge functions

• Dive light failureDive light failure• Poorly fitting Poorly fitting

equipmentequipment• Difficulty operating Difficulty operating

BCBC• Over-weighted or Over-weighted or

under-weightedunder-weighted• Other stressful Other stressful

equipment problems equipment problems not listed abovenot listed above


Physical & PsychologicalPhysical & Psychological(Colvard – 2000 survey)(Colvard – 2000 survey)

• Difficulty equalizing Difficulty equalizing earsears

• Fatigue or Fatigue or overexertionoverexertion

• Muscle crampsMuscle cramps• Chest tightnessChest tightness• HyperventilationHyperventilation• Decongestant Decongestant

medicationmedication• Other medicationsOther medications

• Inhaled water instead Inhaled water instead of airof air

• Motion sicknessMotion sickness• Fear of the unknownFear of the unknown• Fear of scrutiny or Fear of scrutiny or

embarrassmentembarrassment• Task overloadTask overload• Other stressful Other stressful

physical or physical or psychological factors psychological factors not listed abovenot listed above


Relative Risk of First Panic During Dive Relative Risk of First Panic During Dive in the Presence of the Followingin the Presence of the Following

(Colvard – 2000 survey data on file)(Colvard – 2000 survey data on file)

Top 6 Relative RisksTop 6 Relative Risks MalesMales FemalesFemales

Hyperventilation Hyperventilation 4.64.6 3.13.1

Other physical or Other physical or psychological factorpsychological factor

3.43.4 2.42.4

Other equipment problemOther equipment problem 3.43.4 2.02.0

Other dive conditionOther dive condition 3.43.4 2.62.6

Chest tightnessChest tightness 2.62.6 2.02.0

Fear of the unknown Fear of the unknown 2.52.5 2.12.1


Relative Risk of First Panic During Dive Relative Risk of First Panic During Dive in the Presence of the Followingin the Presence of the Following

(Colvard – 2000 survey data on file)(Colvard – 2000 survey data on file)

Next 6 Relative RisksNext 6 Relative Risks MalesMales FemalesFemales

Cold water Cold water 2.12.1 1.11.1

Poor visibility Poor visibility 1.91.9 1.11.1

Inhaled water instead of airInhaled water instead of air 1.81.8 1.51.5

Task overload Task overload 1.81.8 1.41.4

Loss of orientation Loss of orientation 1.61.6 1.31.3

Fear of scrutiny or Fear of scrutiny or embarrassment embarrassment

1.61.6 1.21.2

Panic in the diving environment


Panic in the diving environment



AwarenessAwareness

Early identification leading toEarly identification leading to• ReferralReferral• RefusalRefusalSocial and other evaluation issuesSocial and other evaluation issuesLack of recent divingLack of recent divingLack of familiarity with equipmentLack of familiarity with equipmentOwn discomfort prior to or during a diveOwn discomfort prior to or during a diveOwn abilitiesOwn abilities


Medical and/or Psychiatric Medical and/or Psychiatric Re-evaluationRe-evaluation

• Changes in health since last evaluationChanges in health since last evaluation

• Contra-indications to divingContra-indications to diving

• Limitations to diving (e.g. ruptured disc Limitations to diving (e.g. ruptured disc limits carrying tanks)limits carrying tanks)

• Medications (sedation)Medications (sedation)


Fitness to DiveFitness to Dive

• Lack of physical fitnessLack of physical fitness

• Health condition on day of diveHealth condition on day of dive

• FatigueFatigue

• Lack of sleepLack of sleep

• Hang-overHang-over

• Intoxicated from alcohol or cannabisIntoxicated from alcohol or cannabis

• OtherOther


Observable Indicators of Observable Indicators of Stress or AnxietyStress or Anxiety

1.1. Pre-divePre-dive

2.2. In-waterIn-water

Observable Physiological Signs

Beidel D. J Clin Psychiatry 1998;59(Suppl 17):27-31.

Blushing

Sweating

Trembling Shaking

StutteringStuttering



Pre-Dive Behavioral SignsPre-Dive Behavioral Signs

Unusually quiet and withdrawnUnusually quiet and withdrawnExcessive talkingExcessive talkingIncreased or decreased activityIncreased or decreased activityGallows humorGallows humorForgetfulnessForgetfulnessStallingStallingTardiness or don’t feel wellTardiness or don’t feel wellMental ErrorsMental ErrorsExtreme Cockiness or bravadoExtreme Cockiness or bravadoIrritabilityIrritability


Pre-divePre-dive

• Planning & mental rehearsal Planning & mental rehearsal • Humor to reduce tensionHumor to reduce tension• Social support - buddy systemSocial support - buddy system• Task loadingTask loading

A Bachrach, G Egstrom. A Bachrach, G Egstrom. STRESS and Performance in Diving,STRESS and Performance in Diving, 1987 1987


Awareness of Physical FactorsAwareness of Physical Factors

1.1. OverloadingOverloading2.2. Sensory DeprivationSensory Deprivation3.3. Time PressureTime Pressure4.4. EquipmentEquipment5.5. Cold WaterCold Water6.6. Poor Fitness/Swimming AbilityPoor Fitness/Swimming Ability7.7. Strong Currents, Waves, ObstructionsStrong Currents, Waves, Obstructions8.8. Dangerous Marine LifeDangerous Marine Life

Tom Griffiths


Agoraphobia:Agoraphobia:Fear of wide open spacesFear of wide open spaces

Blue Orb Syndrome• Lone diver suspended in deep water• Unable to see the surface or bottom• No visual references• Alone in the vastness of the ocean• Could be aggravated by nitrogen narcosis

*Advise to keep close to dive buddy*Advise to keep close to dive buddy(Parker, Sports Diving Medical, 1994)

Agoraphobia:Agoraphobia:Fear of wide open spacesFear of wide open spaces

PREVENTION:• Dive with a buddy who provides reassuring

company and a visual reference.• Avoid deep water where there are no visual

references.Diving Medicine for Scuba Divers, Dr Carl Edmonds, 2010 edition


AgoraphobiaAgoraphobia::Fear of wide open spacesFear of wide open spaces

CORRECTIVE ACTION:• Establish visual contact with concrete

objects such as the sea bed, a dive boat or even another diver

• Concentrate on diving instruments,

such as a watch or depth gauge.

Diving Medicine for Scuba Divers, Dr Carl Edmonds, 2010 edition



Claustrophobia: Claustrophobia: Fear of enclosed spacesFear of enclosed spaces• Underwater can feel enclosedUnderwater can feel enclosed• NightNight• Darker with depthDarker with depth• Poor visibilityPoor visibility• Hemmed in by maskHemmed in by mask• Overhead environmentsOverhead environments

*Usual reaction is to escape to surface*Usual reaction is to escape to surface

*Complicate treatment in hyperbaric chamber *Complicate treatment in hyperbaric chamber (Parker, Sports Diving Medical, 1994)


Herpetophobia:Herpetophobia:

Fear of snakesFear of snakes

**Advise not to dive in areas frequented Advise not to dive in areas frequented by sea snakes or eels.by sea snakes or eels.


Awareness of Social & Awareness of Social & Psychological FactorsPsychological Factors

1.1. Peer Pressure (pushed to dive by friend)Peer Pressure (pushed to dive by friend)

2.2. Social EvaluationSocial Evaluation

3.3. Ego ThreatEgo Threat

4.4. Fear of the UnknownFear of the Unknown

5.5. Fear of EvaluationFear of Evaluation

Tom Griffiths


There are no stupid questions or ideas.


In-water Signs of Diver StressIn-water Signs of Diver StressSherman’s LagoonSherman’s Lagoon by Jim Toomey by Jim Toomey

Copyright 1999 Reprinted with permission


In-water Signs of Diver StressIn-water Signs of Diver Stress


In-Water SignsIn-Water Signs • Rapid BreathingRapid Breathing or Difficulty or Difficulty

BreathingBreathing• The “Wide-Eyed” LookThe “Wide-Eyed” Look• Inefficient SwimmingInefficient Swimming• Clinging and ClamberingClinging and Clambering• Fixation and Perceptual NarrowingFixation and Perceptual Narrowing• Sudden SurfacingSudden Surfacing• High Treading/Trashing/AgitationHigh Treading/Trashing/Agitation• Equipment RejectionEquipment Rejection


STOP

BREATHE

THINK

ACT


In-Water HelpIn-Water Help

• Social support – being thereSocial support – being there• CommunicationCommunication• Eye contactEye contact• Physical contactPhysical contact• Providing assistanceProviding assistance

A Bachrach, G Egstrom. A Bachrach, G Egstrom. STRESS and Performance in Diving,STRESS and Performance in Diving, 1987 1987


Train. Train. Train.Train. Train. Train.

Re-train to unlearn bad habitsRe-train to unlearn bad habits

Be over-prepared Be over-prepared

Expect the unexpectedExpect the unexpected


STOP

BREATHE

THINK

ACT

Documents

Prevention Strategies for Anxiety & Panic in Divers David F. Colvard, MD Psychiatrist & Divemaster DivePsych.com Raleigh, North Carolina, USA