Psychological Issues in Diving

 From Alert Diver in 1999 and 2000.

---Psychological Issues in Diving Depressive Disorders, Drugs and References---Psychological Issues in Diving II — Anxiety,

Phobias in Diving--- Psychological Issues in Diving III - Schizophrenia,

Substance AbuseThese articles can be found on DAN’s web site at http://www.diversalertnetwork.org/medical/articles/

index.aspErnest S Campbell, MD, FACS

Ono Island, AL

Mental Problems & Diving

One should not dive if:out of touch with reality;deeply depressed/suicidal;paranoid with delusions and hallucinations.taking drugs that might be dangerous at depth. However, there are many who dive with everyday anxieties, fears and neuroses.

Successful divers profile

positively correlated to intelligence;

characterized by a level of neuroticism that is average or below average;

score well on studies of self-sufficiency and emotional stability.

Hazards of Medications

Drugs in combinations can be dangerousFew scientific studies The condition is more important than the drug. Drugs dangerous to drivers are also dangerous for divers.The interaction between the physiological effects of diving and the pharmacological effects of medications is usually an educated supposition.

Side Effects may include:Seizure level 0.02%Sedation, drowsiness, dizziness, blurred vision, hypotension, tremorHeart irregularitiesReduced exercise capabilityAutonomic nervous system interferenceBruisingBronchial spasm (beta blockers)

Psychotropic Drugs

ANTIDEPRESSANTS: Tricyclics SSRIs MAOIs Others

MOOD STABILIZERS: Anticonvulsants

Anxiolytics BENZODIAZEPINES

OTHERS

Hypnotics BENZODIAZEPINES

ANTIHISTAMINES

OMEGA-1 RECEPTOR AGONISTS

OTHER

Antipsychotics TYPICAL

ATYPICAL

Depressive Illnesses

TypesCausesSymptoms of Depression

Sadness, crying, guilt Irritability, anger, anxiety Pessimism, indifference Loss of energy; aches Inability to concentrate Social withdrawal Changed appetite, sleep Recurring thoughts of death

or suicide

Symptoms of mania High mood, optimism Delusions of grandeur Irritability, aggression, Increased physical and

mental activity Rapid speech, ideas Poor judgment, easily

distracted Reckless behavior Hallucinations, religiosity

Antidepressives, Tricyclic

Tricyclic Agentshttp://www.pharmacypracticenews.com/wworks/CHARTS/psycho/text/anti/tricyc/tricyc2.htmlAll TCAs cause slowed cardiac conduction; all TCAs may lower seizure

threshold; all cause sedation and orthostatic hypotension except protryptyline. Cardiac dysrhythmias. Non-lethal dysrhythmias can become lethal in the diving environment.

AMITRIPTYLINECLOMIPRAMINEDESIPRAMINEDOXEPIN IMIPRAMINENORTRIPTYLINEPROTRIPTYLINETRIMIPRAMINE (Surmontil, Wyeth-Ayerst)

Antidepressives, SSRIs

http://www.pharmacypracticenews.com/wworks/CHARTS/psycho/text/anti/ssris/ssris2.html

SSRI Drugs (Selective Serotonin Reuptake Inhibitors) Most may dive (Parker)CITALOPRAM (Celexa, Forest)FLUOXETINE (Prozac, Sarafem, Eli Lilly)FLUVOXAMINE (Luvox, Solvay)PAROXETINE (Paxil, GlaxoSmithKline)SERTRALINE (Zoloft, Pfizer)All can cause sedation and increased seizure activity.

Antidepressives, MAOIs

MAOIs (Monoamine oxidase inhibitor)http://www.pharmacypracticenews.com/wworks/CHARTS/psycho/text/anti/maois/maois2.html

ISOCARBOXAZID (Marplan, Oxford Pharm Services)PHENELZINE (Nardil, Pfizer) TRANYLCYPROMINE (Parnate, GlaxoSmithKline)Sedation, orthostatic hypotension, anticholinergic effects. Don’t take with SSRIs.

ANTIDEPRESSANTS:OTHERS

Other Drugshttp://www.pharmacypracticenews.com/wworks/CHARTS/psycho/text/anti/others/others2.htmlAMOXAPINEBUPROPION (Wellbutrin, GlaxoSmithKline)MAPROTILINEMIRTAZAPINE (Remeron, Organon)NEFAZODONE (Serzone, Bristol-Myers Squibb)TRAZODONEVENLAFAXINE (Effexor, Wyeth-Ayerst)

MOOD STABILIZERS

http://www.pharmacypracticenews.com/wworks/CHARTS/psycho/text/anti/moodstab/moodsta3.htmlLITHIUM CARBONATE (slurred speech, confusion)

CARBAMAZEPINE (dizziness, sedation, headache)

VALPROIC ACID (Sedation, tremor)

Alternative agents include gabapentin (Neurontin, Pfizer), lamotrigine (Lamictal, GlaxoSmithKline) and topiramate (Topamax, Ortho McNeil)

Advice About Diving: Depression

Individualize according to:• Drugs required• Response to treatment• Time free of symptoms.Consider:• decision making ability• responsibility to other

divers • relationship to drug

induced side effects.Most texts advise no diving

The depressed person should not dive:if there is any possibility of seizures. if there is difficulty in concentrating or following instructions.if suicidal or has mental problems that would deter interaction.Consider additive sedative effect of nitrogen narcosis

Anxiety, Panic & Phobias

Anxiety is normal. An inadvertent mishap =>over reactive anxiety state => irrational behavior and lack of concern for the safety of others.Symptoms are “fight or flight” (Adrenalin)Sudden unexpected surges of anxiety are called panic, and require quick relief of the situation.

Panic occurring at depth can lead to => rapid ascent=>near-drowning and/or DCI.A phobia is an intense fear of particular situations or things that are not normally dangerous. Claustrophobia, may prevent immersion or even entry into a recompression chamberAgoraphobia - "blue orb or dome syndrome”

Panic Disorders

50% + divers experience one or more panic/near panic episodes (Morgan)Panic response:

o Irrational behavior.o Attention narrowso Cannot sort out options.

Panic producing activities o malfunctioning equipmento dangerous marine life o Disorientation during a cave,

ice or wreck dive

“Trait anxiety" is a stable or enduring feature of personality, whereas “state anxiety” is situational or transitory. (Morgan)A diver with trait anxiety is more likely to have increased state anxiety and panic during scuba activities. Morgan WP Anxiety and panic in recreational scuba divers. Sports Med 20 (6): 398-421 (Dec 1995) .

Anxiolytics

BENZODIAZEPINES

http://www.pharmacypracticenews.com/wworks/CHARTS/psycho/text/anxi/benzo/benzo2 .htmlALPRAZOLAM CHLORDIAZEPOXIDE CLONAZEPAM CLORAZEPATEDIAZEPAMLORAZEPAMOXAZEPAM Used for anxiety disorders; panic disorder, alcohol withdrawal, seizure disorder, muscle spasm and pre op sedation.

ANXIOLYTICS, OTHERS

Drugs other than benzodiazepines

http://www.pharmacypracticenews.com/wworks/CHARTS/psycho/text/anxi/others/other2 .html

BUSPIRONE (BuSpar, Bristol-Myers Squibb)

HYDROXYZINE

Hypnotics

BENZODIAZEPINES

http://www.pharmacypracticenews.com/wworks/CHARTS/psycho/text/hypno/benzo/benzo3 .html

ESTAZOLAM (ProSom, Abbott)

FLURAZEPAM

QUAZEPAM (Doral, Wallace)

TEMAZEPAM

TRIAZOLAM

Hypnotics

Antihistamineshttp://www.pharmacypracticenews.com/wworks/CHARTS/psycho/text/hypno/hist/hist3 .htmlDIPHENHYDRAMINE DOXYLAMINE (Unisom, Pfizer)Avoid alcohol and other CNS depressants with these agents (except buspirone); drowsiness may impair ability to drive; use caution.

Hypnotics

OMEGA-1 RECEPTOR AGONISTShttp://www.pharmacypracticenews.com/wworks/CHARTS/psycho/text/hypno/omega/omega3 .htmlZALEPLON (Sonata, Wyeth-Ayerst)ZOLPIDEM (Ambien, Pharmacia)Avoid alcohol and other CNS depressants with these agents (except buspirone); drowsiness may impair ability to drive; use caution

Diving Advice: Anxiety, Phobias & Panic Diving should be decided on the merits of each case, the

type of drugs required, the response to medication, the length of time free of anxiety and phobic problems, decision making ability and responsibility to other divers.

Divers with high trait anxiety are more likely to have increased state anxiety and panic during scuba activities.

Severely affected probably should not dive but if allowed to dive should be carefully monitored and fully informed of their risks.

Most texts advise no diving.

Narcolepsy

Narcolepsy is a chronic hereditary disorder of the sleep regulatory brain center - affecting 1:2000 people. Narcoleptics can fall asleep or lose muscle tone suddenly for periods from 30 seconds to more than 30 minutes, have vivid dreamlike images when drifting off to sleep and wake up unable to move or talk for a period of time.

Driving restrictions fornarcolepsy usually entail anarcolepsy-free period of oneyear after starting treatment;and, no drug-relatedsymptoms.

Treatment includesstimulants, anti-catalepticcompounds and hypnoticcompounds.

Diving Advice:Narcolepsy

Whether or not a person with narcolepsy should be certified as 'fit to dive' should be decided on the merits of each case, the type of drugs required, the response to medication, and the length of time free of narcoleptic problems. Relationship to excitement, emotions and stressful situations should be taken into consideration.These persons probably should not dive except in highly controlled situations and possibly with a full face mask.

Schizophrenia

Schizophrenia is a serious mental illness that affects one person in a hundred. Develops in youth, though it can start later in life.It is treatable, relapses are common, and it may never clear up entirely.  Thoughts, feelings and actions are somewhat disconnected.

Positive symptoms

Negative and disorganized symptoms

Causes

Medications (block chemical messengers, such as dopamine)

Antipsychotics, Typical

Typical (Dopamine receptor antagonists)http://www.pharmacypracticenews.com/wworks/CHARTS/psycho/text/psych/typical/typ2.htmlCHLORPROMAZINEMESORIDAZINE (Serentil, Boehringer Ingelheim)THIORIDAZINEFLUPHENAZINEPERPHENAZINETRIFLUOPERAZINEHALOPERIDOLLOXAPINE (Loxitane, Watson)MOLINDONE (Moban, Endo)THIOTHIXENEHigh incidence of extrapyramidal effects, sedation

ANTIPSYCHOTICS:ATYPICAL

Atypical (Dopamine and serotonin receptor antagonists)http://www.pharmacypracticenews.com/wworks/CHARTS/psycho/text/psych/atypical/atyp2.htmlCLOZAPINEQUETIAPINE (Seroquel, AstraZeneca)OLANZAPINE (Zyprexa, Zydis, Eli Lilly)RISPERIDONE ( Risperdal, Janssen)

Advice About Diving: Schizophrenics Decision-making ability, responsibility to other

divers and relationship to drug induced side effects that would limit ability to gear up and move in the water should be taken into consideration. Most Most probably should not consider diving.probably should not consider diving.Those responsible for divers should be alert to those with inappropriate responses or activity, paranoid behavior or unusual ideation and be quick to ask and find out more about the possibility of schizophrenia.Most texts advise no diving.

Marijuana Effects on Divers

General effects of smoking marijuana: · Tolerance and reducing effect with use. · Psychological and mild physical dependence with regular use. The cannabinoid effect may be additive to nitrogen narcosis. Carbon monoxide leads to hypoxia on ascent.

Withdrawal symptoms : Restlessness, insomnia, nausea, irritability, loss of appetite, sweating. Risk of adverse reactions is greater for persons who have had psychotic disorder, Tar content of marijuana is greater than cigarettes, with more carcinogens.

Marijuana Effects on Divers

Harmful effects: Distorted perception.Impaired recent memory, confusion,Loss of muscle strength and balance. Decreased blood flow in brain, lower exercise tolerance, rapid HRImpaired motor skillsDepression, panic (50%)

Chronic use may cause: Bronchitis, Sinusitis, Pharyngitis, Chronic cough, Emphysema, Lung cancer. Poor immune system functioning; Poor motivation, depressed mental functioning. May predispose to DC.Effects may be potentiated by depth

Alcohol and Diving

Alcohol causes: Diuresis and dehydration,Diminished awareness of cues and reduced inhibitions. (Perrine, Mundt and Weiner) Blood Alcohol Concentration (BAC) 180# man, two beers/1 hour = 0.04%Reduction in information processing, particularly in tasks that require undivided attention.

Decreased behavioral components required for safe diving when alcohol has been on board in past 24 hours:Reaction time Visual trackingConcentrated attention Processing data in divided attention tasks Perception (Judgment) Alcohol increases nitrogen narcosis (Michalodimitrakis)

Effects of Alcohol, Egstrom Review of 150 studies

Ingestion of small amounts of alcohol degrades performance. Variables alter effects of alcohol, but they do not overcome the CNS changes. Alcohol can be cleared from the blood at a predictable rate of .015% BAC per hour. One drink can depress the entire central nervous system.

Alcohol effects are mood elevation, slight dizziness and some impairment of judgment, self control, inhibitions and memory. Increases in reaction time and decreases in coordination follow the dose/response curve quite well. Multitasking is affected by alcohol to a greater degree than single focused jobs.

Links and References, Alcohol & Diving

‘Alcohol and Aquatic Performance’ by Glen Egstrom, Ph.D Alcohol use and aquatic activities--Massachusetts. (1990). JAMA -(Chicago), 264(1), 19-20. Alcohol potentiates the effects of inert gas narcosis. Aviat Space Environ Med 1993 Jun; 64(6):493-9

N2 narcosis and alcohol –a scuba fatality. J Forensic Sci.1987Jul;32(4):1095Effects of ethanol and amphetamine on IGN in humans. Undersea Biomed Res. 1986 Sep;13(3):345-54. Ethanol and nitrogen may share the same mechanisms of action in the brain Alcohol. 1996 Jan Feb;13(1):75-

Attention Deficit Disorder (ADHD, ADD)

ADHD or ADD is a diagnosis applied to children and adults who consistently display certain characteristic behaviors over a period of time. The most common behaviors fall into three categories: inattention, hyperactivity, and impulsivity.Treatment – various forms of methylphenidate (Ritalin), dextroamphetamine (Dexedrine or Dextrostat), and pemoline (Cylert). Nitrox diving contraindicated due to risk of seizures. Advice re diving: Case by case review in treatment responders. Diving with ADD would seem to be somewhat risky, considering the attention to multiple tasking that is required in diving.