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

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Presentation on theme: "Prevention Strategies for Anxiety & Panic in Divers David F. Colvard, MD Psychiatrist & Divemaster DivePsych.com Raleigh, North Carolina, USA."— Presentation transcript:

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. Shermans Lagoon by Jim Toomey Copyright 1999 Reprinted with permission

7 © 2011 David Colvard. All rights reserved. Shermans Lagoon by Jim Toomey Copyright 1999 Reprinted with permission

8 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 © 2011 David Colvard. All rights reserved.

9 So whats 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.

11 © 2011 David Colvard. All rights reserved. Trait Anxiety Predicts Panic Behavior in Beginning Scuba Diving 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 a trait score + 1 stnd dev above mean35 of 42 (83%) accurate predictions using a trait score + 1 stnd dev above mean Predicted 64% of actual panicsPredicted 64% of actual panics Therefore, panic behavior can be predicted in beginning studentsTherefore, panic behavior can be predicted in beginning students Morgan WP, Raglin JS, OConnor PJ, Int J Sports Med 2004: 25

12 © 2011 David Colvard. All rights reserved. Panic Prevention Program* (Primarily for Scuba Diving Students) 1.Information about Panic 2.Calming Response (Breath Control) 3.Mental Rehearsal of Ditch-n-don 4.Systematic Relaxation Training Tom Griffiths, EdD, studied anxiety & panic in dive students and developed this program for high trait anxiety students in 1980s. *Free MP3 files available at www.DivePsych.com

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

14 © 2011 David Colvard. All rights reserved. Trait Anxiety and Panic Behavior in Experienced Scuba Divers in 2001 Year 2001 divers (n= 4,213) in Colvard poll Average STPI Trait Anxiety Average STPI Trait Anxiety Panic in 200110% 16 Almost Panic13% 16 No Panic77% 15 No significant difference in average trait anxiety scores in experienced scuba diversNo significant difference in average trait anxiety scores in experienced scuba divers Colvard – data on file from 2002 survey/poll

15 © 2011 David Colvard. All rights reserved. Trait Anxiety and Panic Behavior in Experienced Scuba Divers 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 96 actual panicsTrait Anxiety only predicted 20 (21% ) of 96 actual panics Failed to predict 76 (79%) of 96 actual panicsFailed to predict 76 (79%) of 96 actual panics 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

16 © 2011 David Colvard. All rights reserved. SAFETY SURVEY OF RECREATIONAL SCUBA DIVERS by Drs. Colvard Anonymous, confidential survey (poll) hosted by Rodales Scuba Diving MagazineAnonymous, confidential survey (poll) hosted by Rodales Scuba Diving Magazine 180 paper surveys collected from August 2000 to January 2, 2001180 paper surveys collected from August 2000 to January 2, 2001 12,722 online surveys collected from September 2000 to January 2, 200112,722 online surveys collected from September 2000 to January 2, 2001 Total of 12,231 complete surveysTotal 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 40-44.

17 © 2011 David Colvard. All rights reserved. Dive Conditions (Colvard – 2000 survey) Poor visibilityPoor visibility Separation from buddy or instructorSeparation from buddy or 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 (cave, wreck, ice)Overhead environment (cave, wreck, ice) SharkShark Other dangerous marine lifeOther dangerous marine life Deep diveDeep dive Cold diveCold dive Solo diveSolo dive Dry suit diveDry suit dive Entrapment or entanglementEntrapment or entanglement Loss of orientationLoss of orientation Long surface swimLong surface swim Other stressful dive conditions not listed aboveOther stressful dive conditions not listed above

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

19 © 2011 David Colvard. All rights reserved. Physical & Psychological (Colvard – 2000 survey) Difficulty equalizing earsDifficulty equalizing ears Fatigue or overexertionFatigue or overexertion Muscle crampsMuscle cramps Chest tightnessChest tightness HyperventilationHyperventilation Decongestant medicationDecongestant medication Other medicationsOther medications Inhaled water instead of airInhaled water instead of air Motion sicknessMotion sickness Fear of the unknownFear of the unknown Fear of scrutiny or embarrassmentFear of scrutiny or embarrassment Task overloadTask overload Other stressful physical or psychological factors not listed aboveOther stressful physical or psychological factors not listed above

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 MalesFemales Hyperventilation4.63.1 Other physical or psychological factor 3.42.4 Other equipment problem 3.42.0 Other dive condition 3.42.6 Chest tightness 2.62.0 Fear of the unknown 2.52.1

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 MalesFemales Cold water 2.11.1 Poor visibility 1.91.1 Inhaled water instead of air 1.81.5 Task overload 1.81.4 Loss of orientation 1.61.3 Fear of scrutiny or embarrassment 1.61.2

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 Awareness Early identification leading to ReferralReferral RefusalRefusal Social and other evaluation issues Lack of recent diving Lack of familiarity with equipment Own discomfort prior to or during a dive Own abilities

25 © 2011 David Colvard. All rights reserved. Medical and/or Psychiatric Re-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 limits carrying tanks)Limitations to diving (e.g. ruptured disc limits carrying tanks) Medications (sedation)Medications (sedation)

26 © 2011 David Colvard. All rights reserved. Fitness 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

27 © 2011 David Colvard. All rights reserved. Observable Indicators of Stress or Anxiety 1.Pre-dive 2.In-water

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

29 Pre-Dive Behavioral Signs Unusually quiet and withdrawn Excessive talking Increased or decreased activity Gallows humor ForgetfulnessStalling Tardiness or dont feel well Mental Errors Extreme Cockiness or bravado Irritability

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

31 © 2011 David Colvard. All rights reserved. Awareness of Physical Factors 1.Overloading 2.Sensory Deprivation 3.Time Pressure 4.Equipment 5.Cold Water 6.Poor Fitness/Swimming Ability 7.Strong Currents, Waves, Obstructions 8.Dangerous Marine Life Tom Griffiths

32 © 2011 David Colvard. All rights reserved. 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)

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 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 (Parker, Sports Diving Medical, 1994)

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

37 © 2011 David Colvard. All rights reserved. Awareness of Social & Psychological Factors 1.Peer Pressure (pushed to dive by friend) 2.Social Evaluation 3.Ego Threat 4.Fear of the Unknown 5.Fear of Evaluation Tom Griffiths

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

39 © 2011 David Colvard. All rights reserved. In-water Signs of Diver Stress Shermans Lagoon by Jim Toomey In-water Signs of Diver Stress Shermans Lagoon by Jim Toomey Copyright 1999 Reprinted with permission

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

41 © 2011 David Colvard. All rights reserved. In-Water Signs Rapid Breathing or Difficulty BreathingRapid Breathing or Difficulty Breathing 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

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

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

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

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


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