Psychological Issues in Diving

1. 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 Ono Island, AL

2. 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. Mental Problems & Diving

3. 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) Hazards of Medications

4. ANTIDEPRESSANTS: Tricyclics SSRIs MAOIs Others MOOD STABILIZERS: Anticonvulsants Anxiolytics BENZODIAZEPINES OTHERS Hypnotics BENZODIAZEPINES ANTIHISTAMINES OMEGA-1 RECEPTOR AGONISTS OTHER Antipsychotics TYPICAL ATYPICAL Psychotropic Drugs

5. 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 Depressive Illnesses

6. Antidepressives, Tricyclic • Tricyclic Agents http://www.pharmacypracticenews.com/wworks/CHARTS/psycho/text/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)

7. Antidepressives, SSRIs http://www.pharmacypracticenews.com/wworks/CHARTS/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.

8. 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. Don’t take with SSRIs.

9. ANTIDEPRESSANTS:OTHERS • Other Drugs • http://www.pharmacypracticenews.com/wworks/CHARTS/psycho/text/anti/others/others2.html • AMOXAPINE • BUPROPION (Wellbutrin, GlaxoSmithKline) • MAPROTILINE • MIRTAZAPINE (Remeron, Organon) • NEFAZODONE (Serzone, Bristol-Myers Squibb) • TRAZODONE • VENLAFAXINE (Effexor, Wyeth-Ayerst)

10. 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)

11. 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 Advice About Diving: Depression

12. 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” Anxiety, Panic & Phobias

13. 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) . Panic Disorders

14. 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.

15. ANXIOLYTICS, OTHERS • Drugs other than benzodiazepines • http://www.pharmacypracticenews.com/wworks/CHARTS/psycho/text/anxi/others/other2 .html • BUSPIRONE (BuSpar, Bristol-Myers Squibb) • HYDROXYZINE

16. Hypnotics • BENZODIAZEPINES • http://www.pharmacypracticenews.com/wworks/CHARTS/psycho/text/hypno/benzo/benzo3 .html • ESTAZOLAM (ProSom, Abbott) • FLURAZEPAM • QUAZEPAM (Doral, Wallace) • TEMAZEPAM • TRIAZOLAM

17. 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.

18. 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

19. 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.

20. 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. Narcolepsy

21. 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.

22. 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) Schizophrenia

23. 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

24. ANTIPSYCHOTICS:ATYPICAL • Atypical • (Dopamine and serotonin receptor antagonists) • http://www.pharmacypracticenews.com/wworks/CHARTS/psycho/text/psych/atypical/atyp2.html • CLOZAPINE • QUETIAPINE (Seroquel, AstraZeneca) • OLANZAPINE (Zyprexa, Zydis, Eli Lilly) • RISPERIDONE ( Risperdal, Janssen)

25. 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.

26. 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

27. 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 Marijuana Effects on Divers

28. 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) Alcohol increases nitrogen narcosis(Michalodimitrakis) Alcohol and Diving

29. 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. Effects of Alcohol, Egstrom Review of 150 studies

30. ‘Alcohol and Aquatic Performance’ by Glen Egstrom, Ph.D 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- Links and References, Alcohol & Diving

31. 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.