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Psychological Issues in Diving

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					   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 Abuse
These articles can be found on DAN’s web site at
http://www.diversalertnetwork.org/medical/articles/i
   ndex.asp
Ernest S Campbell, MD, FACS
       Ono Island, AL
Mental Problems & Diving
One should not dive if:      Successful divers profile
out of touch with reality;   positively correlated to
deeply depressed/suicidal;   intelligence;
paranoid with delusions      characterized by a level of
and hallucinations.          neuroticism that is average
taking drugs that might be   or below average;
dangerous at depth.
                             score well on studies of
However, there are many      self-sufficiency and
who dive with everyday
anxieties, fears and         emotional stability.
neuroses.
Hazards of Medications
Drugs in combinations can     Side Effects may include:
be dangerous                 Seizure level 0.02%
Few scientific studies       Sedation, drowsiness,
The condition is more        dizziness, blurred vision,
important than the drug.     hypotension, tremor
Drugs dangerous to           Heart irregularities
drivers are also dangerous   Reduced exercise
for divers.                  capability
The interaction between      Autonomic nervous
the physiological effects    system interference
of diving and the            Bruising
pharmacological effects of
medications is usually an    Bronchial spasm (beta
educated supposition.        blockers)
  Psychotropic Drugs
ANTIDEPRESSANTS:       Hypnotics
     Tricyclics            BENZODIAZEPINES
     SSRIs
                            ANTIHISTAMINES
     MAOIs
                            OMEGA-1
     Others
                         RECEPTOR AGONISTS
MOOD STABILIZERS:
                            OTHER
     Anticonvulsants
Anxiolytics            Antipsychotics
   BENZODIAZEPINES           TYPICAL
     OTHERS                  ATYPICAL
    Depressive Illnesses
    Types                              Symptoms of mania
    Causes                            High mood, optimism
    Symptoms of Depression            Delusions of grandeur
   Sadness, crying, guilt            Irritability, aggression,
   Irritability, anger, anxiety      Increased physical and
   Pessimism, indifference            mental activity
   Loss of energy; aches             Rapid speech, ideas
   Inability to concentrate          Poor judgment, easily
   Social withdrawal                  distracted
                                      Reckless behavior
   Changed appetite, sleep
                                      Hallucinations, religiosity
   Recurring thoughts of
    death or suicide
   Antidepressives, Tricyclic
   Tricyclic Agents
http://www.pharmacypracticenews.com/wworks/CHARTS/psycho/tex
   t/anti/tricyc/tricyc2.html
All 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.
AMITRIPTYLINE
CLOMIPRAMINE
DESIPRAMINE
DOXEPIN
IMIPRAMINE
NORTRIPTYLINE
PROTRIPTYLINE
TRIMIPRAMINE (Surmontil, Wyeth-Ayerst)
        Antidepressives, SSRIs
http://www.pharmacypracticenews.com/wworks/CH
   ARTS/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/CH
   ARTS/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 Drugs
http://www.pharmacypracticenews.com/wworks/C
HARTS/psycho/text/anti/others/others2.html
AMOXAPINE
BUPROPION (Wellbutrin, GlaxoSmithKline)
MAPROTILINE
MIRTAZAPINE (Remeron, Organon)
NEFAZODONE (Serzone, Bristol-Myers Squibb)
TRAZODONE
VENLAFAXINE (Effexor, Wyeth-Ayerst)
      MOOD STABILIZERS
http://www.pharmacypracticenews.com/wworks/C
HARTS/psycho/text/anti/moodstab/moodsta3.html
LITHIUM 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:   The depressed person should
• Drugs required                not dive:
• Response to treatment         if there is any possibility
• Time free of symptoms.
                                of seizures.
Consider:                       if there is difficulty in
                                concentrating or following
• decision making ability       instructions.
• responsibility to other       if suicidal or has mental
   divers                       problems that would deter
• relationship to drug          interaction.
   induced side effects.        Consider additive sedative
Most texts advise no diving     effect of nitrogen narcosis
Anxiety, Panic & Phobias
Anxiety is normal.          Panic occurring at depth
An inadvertent mishap       can lead to => rapid
=>over reactive anxiety     ascent=>near-drowning
state => irrational         and/or DCI.
behavior and lack of        A phobia is an intense fear
concern for the safety of   of particular situations or
others.                     things that are not
Symptoms are “fight or      normally dangerous.
flight” (Adrenalin)         Claustrophobia, may
Sudden unexpected surges    prevent immersion or even
of anxiety are called       entry into a recompression
panic, and require quick    chamber
relief of the situation.    Agoraphobia - "blue orb
                            or dome syndrome”
    Panic Disorders
    50% + divers experience      “Trait anxiety" is a stable
    one or more panic/near       or enduring feature of
    panic episodes (Morgan)      personality, whereas “state
    Panic response:              anxiety” is situational or
o   Irrational behavior.         transitory. (Morgan)
o   Attention narrows            A diver with trait anxiety
                                 is more likely to have
o   Cannot sort out options.     increased state anxiety and
    Panic producing activities   panic during scuba
o   malfunctioning equipment     activities.
o   dangerous marine life        Morgan WP Anxiety and
o   Disorientation during a      panic in recreational scuba
    cave, ice or wreck dive      divers. Sports Med 20 (6):
                                 398-421 (Dec 1995) .
Anxiolytics
BENZODIAZEPINES
http://www.pharmacypracticenews.com/wworks/C
HARTS/psycho/text/anxi/benzo/benzo2 .html
ALPRAZOLAM
CHLORDIAZEPOXIDE
CLONAZEPAM
CLORAZEPATE
DIAZEPAM
LORAZEPAM
OXAZEPAM
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/ww
orks/CHARTS/psycho/text/anxi/others/othe
r2 .html
BUSPIRONE (BuSpar, Bristol-Myers
Squibb)
HYDROXYZINE
              Hypnotics
BENZODIAZEPINES
http://www.pharmacypracticenews.com/wworks/C
HARTS/psycho/text/hypno/benzo/benzo3 .html
ESTAZOLAM (ProSom, Abbott)
FLURAZEPAM
QUAZEPAM (Doral, Wallace)
TEMAZEPAM
TRIAZOLAM
              Hypnotics
Antihistamines
http://www.pharmacypracticenews.com/wworks/C
HARTS/psycho/text/hypno/hist/hist3 .html
DIPHENHYDRAMINE
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 AGONISTS
http://www.pharmacypracticenews.com/wworks/C
HARTS/psycho/text/hypno/omega/omega3 .html
ZALEPLON (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      Driving restrictions for
hereditary disorder of the   narcolepsy usually entail a
sleep regulatory brain       narcolepsy-free period of one
center - affecting 1:2000
people.                      year after starting treatment;
Narcoleptics can fall        and, no drug-related
asleep or lose muscle tone   symptoms.
suddenly for periods from       Treatment includes
30 seconds to more than      stimulants, anti-cataleptic
30 minutes, have vivid
dreamlike images when        compounds and hypnotic
drifting off to sleep and    compounds.
wake up unable to move
or talk for a period of
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      Positive symptoms
mental illness that affects
one person in a hundred.        Negative and
Develops in youth, though       disorganized
it can start later in life.     symptoms
It is treatable, relapses are
common, and it may never
                                Causes
clear up entirely.              Medications (block
Thoughts, feelings and          chemical messengers,
actions are somewhat            such as dopamine)
disconnected.
Antipsychotics, Typical
Typical (Dopamine receptor antagonists)
http://www.pharmacypracticenews.com/wworks/CHARTS/psycho
/text/psych/typical/typ2.html
CHLORPROMAZINE
MESORIDAZINE (Serentil, Boehringer Ingelheim)
THIORIDAZINE
FLUPHENAZINE
PERPHENAZINE
TRIFLUOPERAZINE
HALOPERIDOL
LOXAPINE (Loxitane, Watson)
MOLINDONE (Moban, Endo)
THIOTHIXENE
High incidence of extrapyramidal effects, sedation
ANTIPSYCHOTICS:ATYPICAL
Atypical
(Dopamine and serotonin receptor antagonists)
http://www.pharmacypracticenews.com/wwork
s/CHARTS/psycho/text/psych/atypical/atyp2.ht
ml
CLOZAPINE
QUETIAPINE (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 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         Withdrawal symptoms :
smoking marijuana:         Restlessness,
· Tolerance and            insomnia, nausea,
reducing effect with       irritability, loss of
use.                       appetite, sweating.
· Psychological and mild   Risk of adverse
physical dependence        reactions is greater for
with regular use.          persons who have had
The cannabinoid effect     psychotic disorder,
may be additive to          Tar content of
nitrogen narcosis.         marijuana is greater
Carbon monoxide leads      than cigarettes, with
to hypoxia on ascent.      more carcinogens.
Marijuana Effects on Divers
Harmful effects:          Chronic use may cause:
Distorted perception.     Bronchitis, Sinusitis,
Impaired recent           Pharyngitis, Chronic
memory, confusion,        cough, Emphysema,
Loss of muscle strength   Lung cancer.
and balance.              Poor immune system
Decreased blood flow in   functioning;
brain, lower exercise     Poor motivation,
tolerance, rapid HR       depressed mental
Impaired motor skills     functioning.
Depression, panic         May predispose to DC.
(50%)                     Effects may be potentiated
                          by depth
Alcohol and Diving
Alcohol causes:          Decreased behavioral
Diuresis and               components required
dehydration,               for safe diving when
Diminished awareness       alcohol has been on
of cues and reduced        board in past 24
inhibitions. (Perrine,     hours:
Mundt and Weiner)          Reaction time
Blood Alcohol              Visual tracking
Concentration (BAC)        Concentrated
180# man, two              attention
beers/1 hour = 0.04%       Processing data in
Reduction in               divided attention
information                tasks
processing,
  Effects of Alcohol, Egstrom
       Review of 150 studies
 Ingestion of small        Alcohol effects are
  amounts of alcohol        mood elevation, slight
  degrades                  dizziness and some
  performance.              impairment of
  Variables alter effects   judgment, self control,
  of alcohol, but they do   inhibitions and
  not overcome the          memory.
  CNS changes.              Increases in reaction
  Alcohol can be            time and decreases in
  cleared from the          coordination follow
  blood at a predictable    the dose/response
  rate of .015% BAC         curve quite well.
  per hour.                 Multitasking is
  One drink can             affected by alcohol to
Links and References,
Alcohol & Diving
 ‘Alcohol and Aquatic     N2 narcosis and
Performance’ by Glen       alcohol –a scuba
Egstrom, Ph.D              fatality. J Forensic
Alcohol use and            Sci.1987Jul;32(4):1095
aquatic activities--       Effects of ethanol and
Massachusetts.             amphetamine on IGN
(1990). JAMA -             in humans. Undersea
(Chicago), 264(1), 19-     Biomed Res. 1986
20.                        Sep;13(3):345-54.
Alcohol potentiates        Ethanol and nitrogen
the effects of inert       may share the same
gas narcosis. Aviat        mechanisms of action
Space Environ Med          in the brain Alcohol.
1993 Jun; 64(6):493-9      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.