On Panic & Diving

Fathoms of Fear A Case Study of Panic in a Recreational Scuba Diver

Instructors and divemasters are trained to recognize outward signs of diver anxiety and panic...

David Haas Photo

The diver: A 30-year-old female with open-water certification had been diving for less than a year and had made fewer than 10 dives. She was in good health, was taking no medication and had no history of anxiety or panic at the time of the dive in question.

The dive: The situation occurred on an advanced open-water training dive scheduled for a depth of 27 metres on a wreck. The diver noted that she did not have a good feeling about the dive before the boat even left the dock. "The ocean was very rough ... a storm was approaching," she said. "I was hoping the dive would be cancelled. BY DR. DAVID F. COLVARD I didn't feel comfortable and didn't want to be there."

Alert Diver Asia Pacific 6 Her boyfriend-buddy was inexperienced about it, I freak myself out, and it gets as well but had kept an eye on her during worse," she said. "At least now I know previous dives. He pushed her to go it is mostly mental, and if I slow down The most ahead with this dive, however, so they and relax, then everything is OK." could complete the advanced common relative- certification together. The discussion: risk factor for Anxiety and panic are common The diver said she had begun to feel occurrences in recreational scuba seasick before arriving at the dive site. panic in both diving, especially with inexperienced As the boat anchored, she was in a rush divers. Typical features of panic include to get off the boat and into the water. male and female palpitations, pounding heart, Unfortunately, she did not feel any better accelerated pulse rate, sensations of once in the water because the waves divers was shortness of breath or a smothering were so high, kicked up by the increasing feeling. Anxiety-panic also causes winds. hyperventilation choking sensations, chest pain or tightness, nausea, dizziness, The water was very cold, she noted, and associated with unsteadiness, lightheadedness or visibility was only 3 to 4 metres. She faintness, numbness or tingling pushed herself hard to keep up with the anxiety. sensations, and fear of losing control instructor who led the group around the or of dying. perimeter of the wreck. Fear of suffocating and dying is Egstrom (1987), predisposing conditions The complications: common in panic. Instructors and for panic include the physical and Struggling with the currents, the diver's divemasters are trained to recognize emotional state of the diver, presence anxiety increased. She was struggling in outward signs of diver anxiety and of one or more stressors, impaired the water, short of breath and felt that panic, but they may be distracted by functioning, unforeseen event(s), loss of no one was noticing her difficulty. At one other activities in the group. control and then panic. From there, point she became panicked enough that panic and the typically accompanying she thought she was going to die. fear of suffocating or dying can produce Panic surveys an intense urge in divers to flee to the Still, she had made it through most of Morgan (1995) reported in a 1987 surface in a rapid ascent, risking injury. the planned dive at the planned depth. survey of 254 recreational scuba divers She had had enough, however: She had that 64 percent of the females and However, in our 2003 survey of more to escape. The diver made a rapid 50 percent of the males had "panic than 12,000 recreational scuba divers, ascent, alone, at about 30 m / minute or near-panic" episodes on one or we found that among the 3,300 who and without making a planned safety more dives. In 2000 I reported from a had at least one panic episode during a stop. Once on board the boat she started survey of more than 12,000 dive only 15 percent of both males and to cry. recreational scuba divers that 37 females made a rapid or uncontrolled percent of the females and 24 percent ascent with their first panic episode. (See Aside from embarrassment, she suffered of the males had one or more panic Table 1.) no physical signs or symptoms of injury episodes of "an intense fear of losing despite her rapid ascent and missed control or dying" while diving. Within that 15 percent of divers safety stop. reporting a rapid ascent, only 5 percent In a follow-up survey of more than of males and 4 percent of females 4,300 recreational scuba divers, we The outcome: reported signs or symptoms of found that 14 percent of females and decompression illness, and only 1 The diver did not complete her advanced 8 percent of males had panic episodes percent of males and 2 percent of open-water certification. Plus, she while diving during the subsequent females underwent recompression. reported developing anticipatory anxiety one-year period, and another 14 Only one reported a permanent injury: and avoidance to this type of dive. She percent of females and 12 percent of residual numbness in the left toes after no longer dives in colder waters, preferring males had near-panic episodes while five years. clearer tropical seas. She believes she diving during the same one-year could have avoided the panic and rapid period. Overall, in a one-year period, ascent by going with her first instinct and 28 percent of the female divers and How panic affects us not going on the dive. 20 percent of the male divers had In a recent conversation I had with panic or near-panic episodes on one Egstrom, he pointed out that panic by Although she continues to dive, or more dives. (Colvard and Colvard itself does not cause dive accidents and sometimes she becomes short of breath 2003) fatalities. Panic and all its related when she feels rushed to get off a dive complications, he noted, can make a boat or to get to a particular point of a According to dive researchers Dr. bad situation much more difficult to dive quickly. "If I start to think too much Arthur J. Bachrach and Dr. Glen H. manage. On a rare occasion, a fatality

7 results. In all fairness, there were no deaths reported in our surveys. Why did the diver panic? Just say no While our diver apparently had no Any excuse would have allowed the diver to avoid the dive. For example, when I In the opening scenario, the diver felt history of panic disorder, she did report was on a shark cage dive off San Diego anxious even before boarding the dive feeling short of breath from trying to several years ago, a diver suddenly boat because of the threatening keep up with the instructor. It is likely developed stomach problems right weather and rough seas. Her boyfriend- that she was hyperventilating, possibly before her turn in the cage. She received buddy applied peer pressure, and even overbreathing her regulator. only sympathy at missing out on the although it was against her better adventure, no criticism. judgment, she complied to please him. Such behavior in a diver can lead to a The boat ride resulted in seasickness, feeling of suffocation and fear of dying. Our diver was feeling anxious and sick which the diver attempted to relieve by This in turn can lead to panic and a before she even entered the water. entering the water as quickly as rapid ascent. In our study of 12,000- Bobbing on the surface in cold water, possible. Instead she became further plus divers, we inquired about more another well-known stressor, added to stressed by cold water, high swells and than 40 commonly listed dive stressors. her problems rather than relieving them. limited visibility. (See Tables 2, 3 and 4.)

The poor visibility on the bottom required The diver reported having to kick hard The most common relative-risk factor that the diver keep close to the instructor to keep up with the instructor and for panic in both male and female divers and the rest of the group, but the group. Strenuous activity alone does not was hyperventilation associated with sustained physical effort and presumed typically elicit panic. Stein and colleagues anxiety, which the diver also reported. heavy and rapid breathing proved to be (1992) reported in a study of 31 subjects (See Table 5.) more than she could handle. Any one that submaximal exercise testing on a stress factor might have been bicycle ergometer did not appear to What could this diver have done to manageable for her, but a cascade of cause panic attacks in either patients prevent the rapid ascent? As she said factors was too much. Ideally, her dive with a known panic disorder or in normal herself, she wanted to cancel the dive. buddy or the instructor should have control subjects. She could have remained topside, even if it meant disappointing her partner. noticed her struggle to keep up with the group and stayed with her. Hyperventilation, however, proves a Prior to the dive the instructor could different matter. Nardi and colleagues have inquired as to her condition and Instead, the diver became fatigued and (1999) reported in a study of 24 subjects asked about any apprehension she even more anxious, which eventually led that three minutes of hyperventilation did might have had about the planned to panic. At this point, she feared for her appear to cause panic attacks in 69.2 dive. life and made an unwise rapid ascent. percent of panic disorder patients but in The event was made even more only 9.1 percent of normal volunteers. problematic because no one in her dive Table 2. group even noticed her discomfort - or Dive conditions leading to panic her departure. • Poor visibility • Separation from buddy or Table 1. instructor Diver response to first panic • Low on air or out of air Table 3. attack during diving (%) • Sharing air Equipment problems leading to • Rough seas or surf panic Males Females • Strong current or surge • Mask leak (n = 2206) (n = 1099) • Nighttime or darkness • Loss of mask Remembered 82 77 • Overhead environment (cave, • Loss of weight belt training wreck, ice) • Tank slippage Used training 81 73 • Shark • Regulator leak or free-flow Recognized 38 67 • Other dangerous marine life • Broken or loose fin strap offer of help • Deep dive • Uncontrolled ascent Made rapid or 15 15 • Cold dive • Loss of computer or gauge uncontrolled • Solo dive • Dive light failure ascent • Drysuit dive • Poorly fitting equipment Obtained 82 80 • Entrapment or entanglement • Difficulty operating buoyancy more training • Loss of orientation compensation device *p<0.0001 • Long surface swim • Overweighted or underweighted • Other stressful dive conditions not • Other stressful equipment listed above problems not listed above Credit: Colvard, 2000 survey Credit: Colvard, 2000 survey

Alert Diver Asia Pacific 8 Table 4. Table 5. Physical and psychological issues Relative risk of first panic leading to panic during dive in presence of the • Difficulty equalizing ears following: • Fatigue or overexertion • Muscle cramps Males Females • Chest tightness Hyperventilation 4.6 3.1 • Hyperventilation Other physical • Decongestant medication or psycholigical 3.4 2.4 • Other medications factor • Inhaled water instead of air Other equipment 3.4 2.0 • Motion sickness problem • Fear of the unknown Other dive condition 3.4 2.6 • Fear of scrutiny or embarrassment • Task overload Chest tightness 2.6 2.0 • Other stress physical or psychol- Fear of the unknown 2.5 2.1 ogical factors not listed above Cold water 2.1 1.1 Poor visibility 1.9 1.1 Credit: Colvard, 2000 survey Inhaled water 1.8 1.5 instead of air Table 6. Task overload 1.8 1.4 Trait anxiety predicts panic Loss of orientation 1.6 1.3 behavior in beginning scuba diving Fear or scrutiny or 1.6 1.2 students embarassment • 42 students in four-month course • Pre-instruction State-Trait Anxiety Inventory* • 35 of 42 (83 percent) accurate predictions using a trait score + 1 standard deviation above mean Table 7. • Predicted 64 percent of actual Trait anxiety and panic behavior in experienced scuba divers in 2003 panics • Year 2003 male experienced divers (n= 1,415) • Therefore, panic behavior can be • STPI Trait Anxiety (10 items) using average trait score + 1 standard predicted in beginning students deviation to predict panic • Reported panic rate in 2003 was 7 percent (96 of 1,415) * STAI is the definitive instrument for measuring anxiety in adults and is the most • Trait Anxiety predicted only 20 (21 percent ) of 96 actual panics widely used self-report measure of anxiety. • Failed to predict 76 (79 percent) of 96 actual panics

Credit: Colvard, 2004 survey data on file; Colvard, data on file from 2004 survey/poll Credit: Morgan WP, Raglin JS, O'Connor PJ, Trait anxiety predicts panic behavior in beginning scuba students. Int J Sports Med 2004: 25.

9 Remember, repetition is good. Hyperventilation. Arq Neuropsiquiatr 1999; 57(4): What can we do? Overlearning basic dive skills and breath 932-6. When they become aware of stress or control under adverse conditions Stein JM, Papp LA, Klein DF, Cohen S, Simon anxiety, divers are taught to "Stop- J, Ross D, Martinez J, Gorman JM. Exercise remain keys to deeply instilling the skills Breathe-Think-Act" before it gets out Tolerance in Panic Disorder Patients. Biol necessary to cope with whatever may Psychiatry 1992; 32(3): 281-7. of control. The type of breathing that is come during a dive. Still, sometimes most effective at calming an anxious or the best thing a diver can do is to be panicked diver is called "diaphragmatic aware of his or her own state of mind breathing" or "belly breathing." This is a About the Author and the circumstances and be willing skill that has to be learned and practiced to cancel any dive if necessary. David F. Colvard, M.D., is a board- long before it is needed. A 30-minute certified psychiatrist, clinical MP3 file, the "Calming Breath" training REFERENCES program by Dr. T.J. Griffiths, can be investigator and divemaster in downloaded for free at Raleigh, N.C. Since 2000, he has Bachrach AJ and Egstrom GH. Stress and www.DivePsych.com. Performance in Diving. San Pedro, Calif., Best conducted online surveys of Publishing, 1987, p 27. thousands of divers around the Griffiths and others (1985) have identified Colvard DF and Colvard LY. A Study of Panic world and has reported results at trait anxiety as a predictor of panic in in Recreational Scuba Divers. Undersea J scientific meetings, workshops and beginning dive students. (See Table 6.) 2003; First Quarter: 40-44. Griffiths TJ, Steel DH, Vaccaro P, Allen R, and continuing education programs in But our surveys of experienced divers Karpman M. The Effects of Relaxation and the United States and South Africa. Cognitive Rehearsal on the Anxiety Levels and failed to demonstrate that trait anxiety, Performance of Scuba Divers. Int J Sport Psych He hosts the website certification level, years of experience 1985; 16: 113-119. www.divepsych.com, which or number of dives reliably predicted Morgan WP. Anxiety and Panic in Recreational provides evidence-based panic. The bottom line is that most Scuba Divers. Int J Sports Med 1995; 20: 398- information for divers on divers are at risk of panic under both 421. predictable and unpredictable Nardi AE, Valenca AM, Nascimento I, psychological and stress factors in Mezzasalma MA, Zin W. Panic Disorder and circumstances. (See Table 7.) scuba divers.

Alert Diver Asia Pacific 10