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

2. Realistic Fear? Paralyzing Anxiety?
© 2011 David Colvard. All rights reserved.

3. Realistic Fear? Paralyzing Anxiety?
© 2011 David Colvard. All rights reserved.

4. Flora Fisk Quiz for Recreational Divers:
Question: Is recreational diving supposed to be fun?
Answer: YES

5. Flora Fisk Quiz for Recreational Divers:
Question: Are you having fun?
Answer: If “Yes", continue diving.
If “NO" — STOP DIVING.

6. © 2011 David Colvard. All rights reserved.
Sherman’s Lagoon by Jim Toomey Copyright Reprinted with permission
© 2011 David Colvard. All rights reserved.
© 2007 David F Colvard MD. All rights reserved.

7. © 2011 David Colvard. All rights reserved.
Sherman’s Lagoon by Jim Toomey Copyright Reprinted with permission
© 2011 David Colvard. All rights reserved.
© 2007 David F Colvard MD. All rights reserved.

8. Healthy Fear vs. Anxiety
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
© 2011 David Colvard. All rights reserved.

9. So what’s wrong with panic?
Psychological stress reaction of extreme anxiety.
Frenzied and irrational behavior.
It is unhelpful
Reduces the chance of survival
© 2011 David Colvard. All rights reserved.

10. According to various studies,
39% - 60% of diver deaths are associated with panic,
but panic is usually
NOT the primary factor.
© 2011 David Colvard. All rights reserved.

11. © 2011 David Colvard. All rights reserved.
Trait Anxiety Predicts Panic Behavior in Beginning Scuba Diving Students
42 students in 4 month course
Pre-instruction STAI Trait Anxiety
35 of 42 (83%) accurate predictions using a trait score + 1 stnd dev above mean
Predicted 64% of actual panics
Therefore, panic behavior can be predicted in beginning students
Morgan WP, Raglin JS, O’Connor PJ , Int J Sports Med 2004: 25
© 2011 David Colvard. All rights reserved.
© 2007 David F Colvard MD. All rights reserved.

12. Panic Prevention Program* (Primarily for Scuba Diving Students)
Information about Panic
Calming Response (Breath Control)
Mental Rehearsal of Ditch-n-don
Systematic 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
© 2011 David Colvard. All rights reserved.
© 2007 David F Colvard MD. All rights reserved.

13. © 2011 David Colvard. All rights reserved.
Face Fears in Training Stress inoculation Systematic desensitization to overcome fears Prolonged exposure and response prevention to overcome phobias
© 2011 David Colvard. All rights reserved.

14. Trait Anxiety and Panic Behavior in Experienced Scuba Divers in 2001
Year 2001 divers (n= 4,213) in Colvard poll
Average STPI Trait Anxiety
Panic in % 16
Almost Panic 13% 16
No Panic 77% 15
No significant difference in average trait anxiety scores in experienced scuba divers
Colvard – data on file from 2002 survey/poll
© 2011 David Colvard. All rights reserved.
© 2007 David F Colvard MD. All rights reserved.

15. Trait Anxiety and Panic Behavior in Experienced Scuba Divers in 2003
Year 2003 male experienced divers (n= 1,415)
STPI Trait Anxiety (10 items) used to predict
Reported panic rate in 2003 was 7% (96 of 1,415)
Trait Anxiety only predicted 20 (21% ) of 96 actual panics
Failed to predict 76 (79%) of 96 actual panics
1,149 of 1,415 (81%) accurate predictions using average trait score standard deviation to predict panic
Colvard – data on file from 2004 survey/poll
© 2011 David Colvard. All rights reserved.
© 2007 David F Colvard MD. All rights reserved.

16. SAFETY SURVEY OF RECREATIONAL SCUBA DIVERS by Drs. Colvard
Anonymous, confidential survey (poll) hosted by Rodale’s Scuba Diving Magazine
180 paper surveys collected from August 2000 to January 2, 2001
12,722 online surveys collected from September 2000 to January 2, 2001
Total of 12,231 complete surveys
Colvard, D.F. and Colvard, L.Y: A Study of Panic in Recreational Divers, The Undersea Journal, First Quarter 2003, pp
© 2011 David Colvard. All rights reserved.
© 2007 David F Colvard MD. All rights reserved.

17. Dive Conditions (Colvard – 2000 survey)
Poor visibility
Separation from buddy or instructor
Low on air or out of air
Sharing air
Rough seas or surf
Strong current or surge
Nighttime or darkness
Overhead environment (cave, wreck, ice)
Shark
Other dangerous marine life
Deep dive
Cold dive
Solo dive
Dry suit dive
Entrapment or entanglement
Loss of orientation
Long surface swim
Other stressful dive conditions not listed above
© 2011 David Colvard. All rights reserved.

18. Equipment (Colvard – 2000 survey)
Loss of computer or gauge functions
Dive light failure
Poorly fitting equipment
Difficulty operating BC
Over-weighted or under-weighted
Other stressful equipment problems not listed above
Mask leak
Loss of mask
Loss of weight belt
Tank slippage
Regulator leak or free flow
Broken or loose fin strap
Uncontrolled ascent
© 2011 David Colvard. All rights reserved.

19. Physical & Psychological (Colvard – 2000 survey)
Difficulty equalizing ears
Fatigue or overexertion
Muscle cramps
Chest tightness
Hyperventilation
Decongestant medication
Other medications
Inhaled water instead of air
Motion sickness
Fear of the unknown
Fear of scrutiny or embarrassment
Task overload
Other stressful physical or psychological factors not listed above
© 2011 David Colvard. All rights reserved.

20. © 2011 David Colvard. All rights reserved.
Relative Risk of First Panic During Dive in the Presence of the Following (Colvard – 2000 survey data on file)
Top 6 Relative Risks
Males
Females
Hyperventilation
4.6
3.1
Other physical or psychological factor
3.4
2.4
Other equipment problem
2.0
Other dive condition
2.6
Chest tightness
Fear of the unknown
2.5
2.1
© 2011 David Colvard. All rights reserved.

21. © 2011 David Colvard. All rights reserved.
Relative Risk of First Panic During Dive in the Presence of the Following (Colvard – 2000 survey data on file)
Next 6 Relative Risks
Males
Females
Cold water
2.1
1.1
Poor visibility
1.9
Inhaled water instead of air
1.8
1.5
Task overload
1.4
Loss of orientation
1.6
1.3
Fear of scrutiny or embarrassment
1.2
© 2011 David Colvard. All rights reserved.

22. Panic in the diving environment
© 2011 David Colvard. All rights reserved.

23. Panic in the diving environment
© 2011 David Colvard. All rights reserved.

24. © 2011 David Colvard. All rights reserved.
Awareness
Early identification leading to
Referral
Refusal
Social and other evaluation issues
Lack of recent diving
Lack of familiarity with equipment
Own discomfort prior to or during a dive
Own abilities
© 2011 David Colvard. All rights reserved.

25. Medical and/or Psychiatric Re-evaluation
Changes in health since last evaluation
Contra-indications to diving
Limitations to diving (e.g. ruptured disc limits carrying tanks)
Medications (sedation)
© 2011 David Colvard. All rights reserved.

26. © 2011 David Colvard. All rights reserved.
Fitness to Dive
Lack of physical fitness
Health condition on day of dive
Fatigue
Lack of sleep
Hang-over
Intoxicated from alcohol or cannabis
Other
© 2011 David Colvard. All rights reserved.

27. Observable Indicators of Stress or Anxiety
Pre-dive
In-water
© 2011 David Colvard. All rights reserved.

28. Observable Physiological Signs
Stuttering
Blushing
Sweating
Trembling
Shaking
© 2011 David Colvard. All rights reserved.
Beidel D. J Clin Psychiatry 1998;59(Suppl 17):27-31.
© 2007 David F Colvard MD. All rights reserved.

29. Pre-Dive Behavioral Signs
Unusually quiet and withdrawn
Excessive talking
Increased or decreased activity
Gallows humor
Forgetfulness
Stalling
Tardiness or don’t feel well
Mental Errors
Extreme Cockiness or bravado
Irritability
© 2011 David Colvard. All rights reserved.

30. © 2011 David Colvard. All rights reserved.
Pre-dive
Planning & mental rehearsal
Humor to reduce tension
Social support - buddy system
Task loading
A Bachrach, G Egstrom. STRESS and Performance in Diving, 1987
© 2011 David Colvard. All rights reserved.

31. Awareness of Physical Factors
Overloading
Sensory Deprivation
Time Pressure
Equipment
Cold Water
Poor Fitness/Swimming Ability
Strong Currents, Waves, Obstructions
Dangerous Marine Life
Tom Griffiths
© 2011 David Colvard. All rights reserved.

32. Agoraphobia: Fear 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
(Parker, Sports Diving Medical, 1994)
© 2011 David Colvard. All rights reserved.

33. Agoraphobia: Fear 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
© 2011 David Colvard. All rights reserved.

34. Agoraphobia: Fear 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
© 2011 David Colvard. All rights reserved.

35. Claustrophobia: Fear of enclosed spaces
Underwater can feel enclosed
Night
Darker with depth
Poor visibility
Hemmed in by mask
Overhead environments
*Usual reaction is to escape to surface
*Complicate treatment in hyperbaric chamber
(Parker, Sports Diving Medical, 1994)
© 2011 David Colvard. All rights reserved.

36. © 2011 David Colvard. All rights reserved.
Herpetophobia:
Fear of snakes
*Advise not to dive in areas frequented by sea snakes or eels.
© 2011 David Colvard. All rights reserved.

37. Awareness of Social & Psychological Factors
Peer Pressure (pushed to dive by friend)
Social Evaluation
Ego Threat
Fear of the Unknown
Fear of Evaluation
Tom Griffiths
© 2011 David Colvard. All rights reserved.

38. There are no stupid questions or ideas.
© 2011 David Colvard. All rights reserved.

39. © 2011 David Colvard. All rights reserved.
In-water Signs of Diver Stress Sherman’s Lagoon by Jim Toomey Copyright Reprinted with permission
© 2011 David Colvard. All rights reserved.
© 2007 David F Colvard MD. All rights reserved.

40. In-water Signs of Diver Stress
© 2011 David Colvard. All rights reserved.

41. © 2011 David Colvard. All rights reserved.
In-Water Signs
Rapid Breathing or Difficulty Breathing
The “Wide-Eyed” Look
Inefficient Swimming
Clinging and Clambering
Fixation and Perceptual Narrowing
Sudden Surfacing
High Treading/Trashing/Agitation
Equipment Rejection
© 2011 David Colvard. All rights reserved.

42. © 2011 David Colvard. All rights reserved.
STOP
BREATHE
THINK
ACT
© 2011 David Colvard. All rights reserved.

43. © 2011 David Colvard. All rights reserved.
In-Water Help
Social support – being there
Communication
Eye contact
Physical contact
Providing assistance
A Bachrach, G Egstrom. STRESS and Performance in Diving, 1987
© 2011 David Colvard. All rights reserved.

44. © 2011 David Colvard. All rights reserved.
Train. Train. Train. Re-train to unlearn bad habits Be over-prepared Expect the unexpected
© 2011 David Colvard. All rights reserved.

45. © 2011 David Colvard. All rights reserved.
STOP
BREATHE
THINK
ACT
© 2011 David Colvard. All rights reserved.