Transcript Psychological Issues in Diving

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:
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 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%
Sedation, drowsiness,
dizziness, blurred vision,
hypotension, tremor
Heart irregularities
Reduced exercise
capability
Autonomic nervous
system interference
Bruising
Bronchial spasm (beta
blockers)
Psychotropic Drugs
ANTIDEPRESSANTS:
Tricyclics
SSRIs
MAOIs
Others
MOOD STABILIZERS:
Anticonvulsants
Anxiolytics
BENZODIAZEPINES
OTHERS
Hypnotics
BENZODIAZEPINES
ANTIHISTAMINES
OMEGA-1
RECEPTOR AGONISTS
OTHER
Antipsychotics
TYPICAL
ATYPICAL
Depressive Illnesses
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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
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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, 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:
• 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 & 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 Disorders
o
o
o
o
o
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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) .
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
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
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: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
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, 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
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 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.
May predispose to DC.
Effects may be potentiated
by depth
Alcohol 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
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)
Alcohol increases
nitrogen narcosis
Effects 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
Links and References,
Alcohol & Diving
‘Alcohol and Aquatic
Performance’ by Glen
Egstrom, Ph.D
Alcohol use and
aquatic activities-Massachusetts.
(1990). JAMA (Chicago), 264(1), 1920.
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
(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.