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/
index.asp
Ernest S Campbell, MD, FACS
2002 Divers Alert Network
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.
2002 Divers Alert Network
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 0.02-0.04%
 sedation, drowsiness,
dizziness, blurred vision,
hypotension, tremor;
 heart irregularities;
 reduced exercise
capability;
 autonomic nervous
system interference
 bruising;
 bronchial spasm (beta
blockers).
2002 Divers Alert Network
Psychotropic Drugs
List of Brand and Generic Names
http://scuba-doc.com/drugpage.html
ANTIDEPRESSANTS:
HYPNOTICS:
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•
•
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• BENZODIAZEPINES
• ANTIHISTAMINES
• OMEGA-1 RECEPTOR
TRICYCLICS
SSRIs
MAOIs
OTHERS
MOOD STABILIZERS:
AGONISTS
• OTHERS
• ANTICONVULSANTS
ANTIPSYCHOTICS:
ANXIOLYTICS:
• TYPICAL
• ATYPICAL
• BENZODIAZEPINES
• OTHERS
2002 Divers Alert Network
Depressive Illnesses
• Symptoms of mania:
• Types
 high mood, optimism
• Causes
 delusions of grandeur
• Symptoms of depression:
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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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irritability, aggression
increased physical
and mental activity
rapid speech, ideas
poor judgment, easily
distracted
reckless behavior
hallucinations,
religiosity
2002 Divers Alert Network
Antidepressives, Tricyclic
Tricyclic Agents
http://www.pharmacypracticenews.com/wworks/
CHARTS/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)
2002 Divers Alert Network
Antidepressives, SSRIs
SSRI Drugs (Selective Serotonin Reuptake Inhibitors)
http://www.pharmacypracticenews.com/wworks/
CHARTS/psycho/text/anti/ssris/ssris2.html
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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
2002 Divers Alert Network
Antidepressives, MAOIs
MAOIs (Monoamine oxidase inhibitor)
http://www.pharmacypracticenews.com/wworks/
CHARTS/psycho/text/anti/maois/maois2.html
• ISOCARBOXAZID (Marplan, Oxford Pharm
Services)
• PHENELZINE (Nardil, Pfizer)
• TRANYLCYPROMINE (Parnate,
GlaxoSmithKline)
• Sedation, orthostatic hypotension,
anticholinergic effects
2002 Divers Alert Network
Antidepressants: Other
Other Drugs
http://www.pharmacypracticenews.com/wworks/
CHARTS/psycho/text/anti/others/others2.html
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AMOXAPINE
BUPROPION (Wellbutrin, GlaxoSmithKline)
MAPROTILINE
MIRTAZAPINE (Remeron, Organon)
NEFAZODONE (Serzone, Bristol-Myers
Squibb)
• TRAZODONE
• VENLAFAXINE (Effexor, Wyeth-Ayerst)
2002 Divers Alert Network
MOOD STABILIZERS
http://www.pharmacypracticenews.com/wworks/
CHARTS/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)
2002 Divers Alert Network
Advice About Diving:
Depression
Individualize according to: The depressed person
should not dive:
 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
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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
2002 Divers Alert Network
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”
2002 Divers Alert Network
Panic Disorders
• 50% + divers experience
• “Trait anxiety" is a stable
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
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).
2002 Divers Alert Network
Anxiolytics
Benzodiazepines
http://www.pharmacypracticenews.com/wworks/
CHARTS/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.
2002 Divers Alert Network
ANXIOLYTICS, OTHERS
Drugs other than benzodiazepines
http://www.pharmacypracticenews.com/
wworks/CHARTS/psycho/text/anxi/others/
other2 .html
• BUSPIRONE (BuSpar, Bristol-Myers
Squibb)
• HYDROXYZINE
2002 Divers Alert Network
Hypnotics
Benzodiazepines
http://www.pharmacypracticenews.com/wworks/
CHARTS/psycho/text/hypno/benzo/benzo3 .html
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ESTAZOLAM (ProSom, Abbott)
FLURAZEPAM
QUAZEPAM (Doral, Wallace)
TEMAZEPAM
TRIAZOLAM
2002 Divers Alert Network
Hypnotics
Antihistamines
http://www.pharmacypracticenews.com/wworks/
CHARTS/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.
2002 Divers Alert Network
Hypnotics
Omega-1 Receptor Agonists
http://www.pharmacypracticenews.com/wworks/
CHARTS/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
2002 Divers Alert Network
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.
2002 Divers Alert Network
Narcolepsy
• Narcolepsy is a chronic
• Driving restrictions for
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.
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.
2002 Divers Alert Network
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.
2002 Divers Alert Network
Schizophrenia
• Schizophrenia is a
• Positive symptoms
• Negative and
serious mental illness
that affects one person in
disorganized
a hundred.
symptoms
• Develops in youth,
though it can start later in • Causes
• Medications (block
life.
chemical
• It is treatable, relapses
messengers, such
are common, and it may
as dopamine)
never clear up entirely.
• Thoughts, feelings and
actions are somewhat
disconnected.
2002 Divers Alert Network
Antipsychotics, Typical
Typical (Dopamine receptor antagonists)
http://www.pharmacypracticenews.com/wwork/
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
2002 Divers Alert Network
ANTIPSYCHOTICS: ATYPICAL
Atypical Dopamine and serotonin receptor
antagonists)
http://www.pharmacypracticenews.com/wworks/
CHARTS/psycho/text/psych/atypical/atyp2.html
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CLOZAPINE
QUETIAPINE (Seroquel, AstraZeneca)
OLANZAPINE (Zyprexa, Zydis, Eli Lilly)
RISPERIDONE ( Risperdal, Janssen)
2002 Divers Alert Network
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.
2002 Divers Alert Network
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.
2002 Divers Alert Network
Marijuana Effects on Divers
• Harmful effects:
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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:
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Bronchitis, Sinusitis,
Pharyngitis, Chronic
cough, Emphysema,
Lung cancer.
Poor immune system
functioning;
Poor motivation,
depressed mental
functioning.
2002 Divers Alert Network
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 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)
2002 Divers Alert Network
Effects of Alcohol, Egstrom
Review of 150 studies
• Ingestion of small
• Alcohol effects are mood
amounts of alcohol
elevation, slight dizziness
degrades performance.
and some impairment of
judgment, self control,
• Variables alter effects of
inhibitions and memory.
alcohol, but they do not
overcome the CNS
• Increases in reaction time
changes.
and decreases in
coordination follow the
• Alcohol can be cleared
dose/response curve
from the blood at a
quite well.
predictable rate of .015%
BAC per hour.
• Multitasking is affected by
alcohol to a greater
• One drink can depress
degree than single
the entire central
focused jobs.
nervous system.
2002 Divers Alert Network
Links and References,
Alcohol & Diving
• ‘Alcohol and Aquatic
Performance’ by Glen
Egstrom, Ph.D
• http://www.jellis.com/ne
ws/96news/may96/alcoh
ol.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):752002 Divers Alert Network
Attention Deficit Disorder
(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