2002 Divers Alert Network Psychological Issues in Diving From Alert Diver in 1999 and 2000....

2002 Divers Alert Network

Psychological Issues in DivingPsychological 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/

index.asp

Ernest S Campbell, MD, FACS


Mental Problems & DivingMental 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 MedicationsHazards of Medications• Drugs in combinations

can be dangerous.• Few 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 0.02-0.04% sedation, drowsiness,

dizziness, blurred vision, hypotension, tremor;

heart irregularities; reduced exercise

capability; autonomic nervous

system interference bruising; bronchial spasm (beta

blockers).


Psychotropic DrugsPsychotropic DrugsList of Brand and Generic Names List of Brand and Generic Names

http://scuba-doc.com/http://scuba-doc.com/drugpagedrugpage.html.html

ANTIDEPRESSANTS: • TRICYCLICS• SSRIs• MAOIs• OTHERS

MOOD STABILIZERS:

• ANTICONVULSANTS

ANXIOLYTICS:• BENZODIAZEPINES• OTHERS

HYPNOTICS:• BENZODIAZEPINESBENZODIAZEPINES

• ANTIHISTAMINES

• OMEGA-1 RECEPTOR AGONISTS

• OTHERS

ANTIPSYCHOTICS:• TYPICAL

• ATYPICAL


Depressive IllnessesDepressive Illnesses• Types• Causes• Symptoms 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, TricyclicAntidepressives, TricyclicTricyclic Agents

http://www.pharmacypracticenews.com/wworks/http://www.pharmacypracticenews.com/wworks/

CHARTS/psycho/text/anti/tricyc/tricyc2.htmlCHARTS/psycho/text/anti/tricyc/tricyc2.html

All cause slowed cardiac conduction; may lower seizure threshold; sedation and orthostatic hypotension except protriptyline.• AMITRIPTYLINE• CLOMIPRAMINE• DESIPRAMINE• DOXEPIN• IMIPRAMINE• NORTRIPTYLINE• PROTRIPTYLINE• TRIMIPRAMINE (Surmontil, Wyeth-Ayerst)


Antidepressives, SSRIsAntidepressives, SSRIs

SSRI Drugs (Selective Serotonin Reuptake Inhibitors)

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

• 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, MAOIsAntidepressives, MAOIs

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

• ISOCARBOXAZID (Marplan, Oxford Pharm

Services)• PHENELZINE (Nardil, Pfizer)• TRANYLCYPROMINE (Parnate,

GlaxoSmithKline)• Sedation, orthostatic hypotension,

anticholinergic effects


Antidepressants: OtherAntidepressants: OtherOther Drugs

http://www.pharmacypracticenews.com/wworks/http://www.pharmacypracticenews.com/wworks/CHARTS/psycho/text/anti/others/others2.htmlCHARTS/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 STABILIZERSMOOD STABILIZERS

http://www.pharmacypracticenews.com/wworks/http://www.pharmacypracticenews.com/wworks/CHARTS/psycho/text/anti/moodstab/moodsta3.htmlCHARTS/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: Advice About Diving: DepressionDepression

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 & PhobiasAnxiety, 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 chamber

• Agoraphobia - "blue orb or dome syndrome”


Panic DisordersPanic Disorders

• 50% + divers experience one or more panic/near panic episodes (Morgan)

• Panic response: irrational behavior attention narrows cannot sort out options

• Panic producing activities: malfunctioning

equipment dangerous marine life 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).


AnxiolyticsAnxiolytics

Benzodiazepineshttp://www.pharmacypracticenews.com/wworks/http://www.pharmacypracticenews.com/wworks/CHARTS/psycho/text/anxi/benzo/benzo2 .htmlCHARTS/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, OTHERSANXIOLYTICS, OTHERS

Drugs other than benzodiazepineshttp://www.pharmacypracticenews.com/http://www.pharmacypracticenews.com/

wworks/CHARTS/psycho/text/anxi/others/wworks/CHARTS/psycho/text/anxi/others/

other2 .htmlother2 .html

• BUSPIRONE (BuSpar, Bristol-Myers Squibb)

• HYDROXYZINE


HypnoticsHypnotics

Benzodiazepineshttp://www.pharmacypracticenews.com/wworks/http://www.pharmacypracticenews.com/wworks/

CHARTS/psycho/text/hypno/benzo/benzo3 .htmlCHARTS/psycho/text/hypno/benzo/benzo3 .html

• ESTAZOLAM (ProSom, Abbott)

• FLURAZEPAM

• QUAZEPAM (Doral, Wallace)

• TEMAZEPAM

• TRIAZOLAM


HypnoticsHypnotics

Antihistamineshttp://www.pharmacypracticenews.com/wworks/http://www.pharmacypracticenews.com/wworks/CHARTS/psycho/text/hypno/hist/hist3 .htmlCHARTS/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.


HypnoticsHypnotics

Omega-1 Receptor Agonistshttp://www.pharmacypracticenews.com/wworks/http://www.pharmacypracticenews.com/wworks/CHARTS/psycho/text/hypno/omega/omega3 .htmlCHARTS/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: Diving Advice: Anxiety, Phobias & PanicAnxiety, 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.


NarcolepsyNarcolepsy• 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 for narcolepsy usually entail a narcolepsy-free period of: one year after starting

treatment; and, no drug-related

symptoms.

• Treatment includes stimulants, anti-cataleptic compounds and hypnotic compounds.


Diving Advice: NarcolepsyDiving 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.


SchizophreniaSchizophrenia

• 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, TypicalAntipsychotics, TypicalTypical (Dopamine receptor antagonists)

http://www.pharmacypracticenews.com/wwork/http://www.pharmacypracticenews.com/wwork/

CHARTS/psycho/text/psych/typical/typ2.htmlCHARTS/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 ANTIPSYCHOTICS: ATYPICAL

Atypical Dopamine and serotonin receptor antagonists)http://www.pharmacypracticenews.com/wworks/http://www.pharmacypracticenews.com/wworks/

CHARTS/psycho/text/psych/atypical/atyp2.htmlCHARTS/psycho/text/psych/atypical/atyp2.html

• CLOZAPINE

• QUETIAPINE (Seroquel, AstraZeneca)

• OLANZAPINE (Zyprexa, Zydis, Eli Lilly)

• RISPERIDONE ( Risperdal, Janssen)


Advice About Diving Advice About Diving SchizophrenicsSchizophrenics

• 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 Most probably should not consider diving.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 DiversMarijuana 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 DiversMarijuana 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 HR

Impaired motor skills Depression, panic

(50%)

• Chronic use may cause: Bronchitis, Sinusitis,

Pharyngitis, Chronic cough, Emphysema, Lung cancer.

Poor immune system functioning;

Poor motivation, depressed mental functioning.


Alcohol and DivingAlcohol 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 tracking Concentrated attention Processing data in

divided attention tasks Perception (judgment)


Effects of Alcohol, Egstrom Effects of Alcohol, Egstrom Review of 150 studiesReview 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, Links and References, Alcohol & DivingAlcohol & Diving

• ‘‘Alcohol and Aquatic Alcohol and Aquatic Performance’Performance’ by Glen Egstrom, Ph.D

• http://www.jellis.com/news/96news/may96/alcohol.htm

• 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):1095

• Effects 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 Attention Deficit Disorder (ADHD, ADD)(ADHD, ADD)

• ADHD or ADD is a diagnosis applied to children and adults who consistently display 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.

2002 Divers Alert Network Psychological Issues in Diving From Alert Diver in 1999 and 2000....

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