Presentation on theme: "Psychological Issues in Diving"— Presentation transcript:
1Psychological Issues in Diving From Alert Diver in 1999 and 2000.---Psychological Issues in DivingDepressive 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 atErnest S Campbell, MD, FACS Ono Island, AL
2Mental 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 profilepositively 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.
3Hazards of Medications Drugs in combinations can be dangerousFew scientific studiesThe 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)
5Depressive Illnesses Types Causes Symptoms of Depression Sadness, crying, guiltIrritability, anger, anxietyPessimism, indifferenceLoss of energy; achesInability to concentrateSocial withdrawalChanged appetite, sleepRecurring thoughts of death or suicideSymptoms of maniaHigh mood, optimismDelusions of grandeurIrritability, aggression,Increased physical and mental activityRapid speech, ideasPoor judgment, easily distractedReckless behaviorHallucinations, religiosity
6Antidepressives, Tricyclic Tricyclic AgentsAll 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.AMITRIPTYLINECLOMIPRAMINEDESIPRAMINEDOXEPINIMIPRAMINENORTRIPTYLINEPROTRIPTYLINETRIMIPRAMINE (Surmontil, Wyeth-Ayerst)
7Antidepressives, SSRIs 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.
11Advice About Diving: Depression Individualize according to:Drugs requiredResponse to treatmentTime free of symptoms.Consider:decision making abilityresponsibility to other diversrelationship to drug induced side effects.Most texts advise no divingThe 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
12Anxiety, 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”
13Panic Disorders50% + divers experience one or more panic/near panic episodes (Morgan)Panic response:Irrational behavior.Attention narrowsCannot sort out options.Panic producing activitiesmalfunctioning equipmentdangerous marine lifeDisorientation 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): (Dec 1995) .
14AnxiolyticsBENZODIAZEPINES.htmlALPRAZOLAMCHLORDIAZEPOXIDECLONAZEPAMCLORAZEPATEDIAZEPAMLORAZEPAMOXAZEPAMUsed for anxiety disorders; panic disorder, alcohol withdrawal, seizure disorder, muscle spasm and pre op sedation.
15ANXIOLYTICS, OTHERS Drugs other than benzodiazepines .htmlBUSPIRONE (BuSpar, Bristol-Myers Squibb)HYDROXYZINE
17Hypnotics Antihistamines .htmlDIPHENHYDRAMINEDOXYLAMINE (Unisom, Pfizer)Avoid alcohol and other CNS depressants with these agents (except buspirone);drowsiness may impair ability to drive; use caution.
18Hypnotics OMEGA-1 RECEPTOR AGONISTS .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
19Diving 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.
20NarcolepsyNarcolepsy 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.
21Diving 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.
22Schizophrenia Positive symptoms Negative and disorganized symptoms 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 symptomsNegative and disorganized symptomsCausesMedications (block chemical messengers, such as dopamine)
24ANTIPSYCHOTICS:ATYPICAL (Dopamine and serotonin receptor antagonists)CLOZAPINEQUETIAPINE (Seroquel, AstraZeneca)OLANZAPINE (Zyprexa, Zydis, Eli Lilly)RISPERIDONE ( Risperdal, Janssen)
25Advice 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 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.
26Marijuana 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.
27Marijuana 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
28Alcohol 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 timeVisual trackingConcentrated attentionProcessing data in divided attention tasksPerception (Judgment)Alcohol increases nitrogen narcosis (Michalodimitrakis)
29Effects 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.
30Links and References, Alcohol & Diving ‘Alcohol and Aquatic Performance’ by Glen Egstrom, Ph.DAlcohol use and aquatic activities--Massachusetts. (1990). JAMA -(Chicago), 264(1),Alcohol potentiates the effects of inert gas narcosis. Aviat Space Environ Med 1993 Jun; 64(6):493-9N2 narcosis and alcohol –a scuba fatality. J Forensic Sci.1987Jul;32(4):1095Effects of ethanol and amphetamine on IGN in humans. Undersea Biomed Res Sep;13(3):Ethanol and nitrogen may share the same mechanisms of action in the brain Alcohol Jan Feb;13(1):75-
31Attention 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.