Anxiety disorders and diving

[Mantra]

Hey all.

Hope this is the right place to post this.

The recent thread about diving while on antidepressants caused me to ask the board about diving with an anxiety disorder:

http://www.scubaboard.com/forums/ma...3-returning-diving-after-antidepressants.html

To avoid the risk of a thread hijack, I thought I'd move the discussion on anxiety disorders here.

To recap: I have in the past been diagnosed with an anxiety disorder. PTSD with a dash of family history. I wrote: "I don't take medication, and it has been a decade since I have experienced a panic attack. I only ever experienced a handfull of them, and once my doctor worked out what was going on, they rapidly resolved. I generally have a heightened sense of stress and anxiety these days, but not to the extent that it dictates my behaviour.

My gut feeling is that this doesn't hold much in the way of risk for me when diving. If anything, I'm pretty familiar with what stress/panic feels like and have solid practice in not letting it take me over. Panic is often a self-fueling thing, in that one panics because one is feeling paniced and out of control and a spiral happens. Besides, the stuff that triggers a sudden stress response from me (certain thought patterns, explosion-like noises, gunfire-like noises, a certain quality of light) aren't likely to be around underwater

Sould I trust this intuition, do you think? Are there any studies that show correlation between a pre-existing anxiety disorder and likelihood of panic underwater? For me, knowing what I know of my own experience with this, the opposite might almost hold true.

Hope I'm not hijacking. It just seems like a few people read anxiety disorder as being axiomatically problematic for diving, and this is something I should consider, my own intuition notwithstanding."

DocVikingo helpfully replied with a link to this study: http://www.divepsych.com/UJ1Q03p040_044_qxd.pdf

In brief, the study shows that elevated levels of trait anxiety correlate with an increased likelihood (a significantly increased likelihood) of experiencing panic underwater. Trait anxiety, by the way, is an interesting thing, and not necessarily comorbid with an anxiety disorder like PTSD. Trait anxiety refers to a persistent tendency over time to respond with anxiety in anticipation of threat. The study also shows that people with high levels of trait anxiety are much less likely to take up diving in the first place anyway.

On balance, I believe this may indicate that I am at an increased chance of experiencing panic underwater, but that perhaps some of my past experience with panic attacks might prove useful should that happen. This is a big bag of 'if' at the moment, and I am reading more into the literature. The divepsych site seems to indicate the researchers' belief that mental rehearsal and so on are effective ways to mitigate the risk, and in fact there is a free 4 part audio training on this point available from that site. That training might be of use to divers who are worried about feeling panic underwater, regardless of a diagnosed condition. It's a good resource.

Anxiety disorders are poorly understood, even stigmatised, by the general public, despite being very common. And of course they fall on a spectrum from very debilitating to intermittently inconvenient. Anxiety disorders are highly treatable - but that's topside stuff.

Would anyone like to contribute to a discussion on this?

Specifically - what is your feeling about someone like me, with an anxiety disorder, diving in the first place?

Secondly, and of great interest to me, how would you go about training for underwater panic? Making sure ones skills are top notch and that drills etc are regularly performed is clearly part of this. But I wonder if there are other forms of specific practices (like mental rehearsal) that people might suggest? I would be really interested in experiencing panic underwater in a pool or similarly safe underwater environment with an instructor present to see how this plays out for me. Stop-breathe-think-act is clearly the solution to underwater panic (and to above water panic too) - but how does one train onesself to the point where this is an instinctive response? It would seem specific training on this would be prudent for someone who feels they are at risk.

Given the prevalence of anxiety disorders, I suspect this is a broadly useful topic to have a chat about. Any thoughts are appreciated.

Thanks!

 

[koyote1111]

Hi Mantra

I also have an anxiety disorder, so I can somewhat relate to the questions that you have. I don't have PTSD, but I do have panic disorder. What I will share is only my experience as I believe that everyone is a bit different with regard to how their anxiety may manifest. It may also be important to understand that I've been actively managing the condition for about 12 years. So...I've come to know my condition pretty well.

Initially, I was very concerned about how I would be perceived after checking the boxes on the medical release form. I really wasn't concerned with whether or not I could handle diving. In my case, I do not experience anxiety when I am doing things that are sometimes perceived as scary for many others. I'm more likely to experience anxiety related to work and social environments.

It sounds like you know your "triggers", so that is a great thing. Regarding the anticipatory anxiety, I experience it more so with regard to just meeting up to dive (not the dive itself). I've learned to somewhat just view this as "excitement".

One might think that panic disorder and diving are a prescription for disaster, however I feel incredibly comfortable diving and respond well under pressure in physically challenging environments. I have always been "into" more extreme activities and I seem to thrive in that environment.

One thing about diving that may actually be very helpful is that it does require focus on continuous breathing. By focusing on longer deep breaths, it actually relaxes the nervous system. Of course I understand the connection between the breath and buoyancy, but I've never had a problem with taking some nice long deep inhales and exhales along the way.

I might suggest that you do more pool work than is required. This could help you further assess your comfort level and also build confidence. Also, diving with a good friend (at least initially) who understands your situation might bring a bit more comfort. Another tip...doing an ample number of dives that are relatively shallow and known for friendly dive conditions. In other words, do everything possible to set yourself up for success .

Regarding underwater panic, create a strategy and practice it both on land and in the pool. Make it simple! Commit to performing your strategy immediately when you first notice the sensation of stress/anxiety. Perhaps it could go something like this:
Step 1 - stop and kneel on the ocean floor
Step 2 - focus on breathing comfortably deep and comfortably slow. Really slow down your exhale if possible. This can truly encourage the relaxation response.
Step 3 - resume diving when the sensation of stress has completely resided.

AND commit to aborting the dive if the strategy does not work.

Prior to descending, be sure that you are breathing at a relaxed pace. If you dive involves a long surface swim, give yourself plenty of time to slow down and relax before descending.

Also...give yourself all kinds of permission to cut dives short, stay within your comfortable zone, and make changes to the dive plan if necessary. The more permission we give ourselves, the less stress/anxiety we are likely to feel.

It might also be helpful to share your strategy with your buddy and develop a signal to let him/her know that you are taking care of yourself.

I was a person who went from one cert. to the next and completed my DM just over a year ago. Throughout my diving experience, I have not experienced anxiety while in the water...in fact, I tend to be the calmer person in the water. I hope this is what you will also find!!

Just thought I'd let you know that it's possible, yet I do think that each person must consider their specific triggers AND also stay aware of their current level of stress. I do not dive if know that stress is impacting me (for example...if I've been feeling particularly overwhelmed with work). Also, another consideration may be this...anxiety can indeed create a lot of fatigue. So if I'm overly tired, I'll skip a dive.

Knowing yourself is perhaps the most important aspect of it all. For example, I know that I need plenty of down time, alone time, and to make meditation, breathwork and/or relaxation a daily practice. I think of it as preventative medicine.

Now for what could be a good laugh, I also teach stress management...ha! Will say that my journey with anxiety has probably made me a better teacher and in some ways a better diver!

I sincerely wish you the best! (FYI...in the U.S. ... about 18.5% of our population is diagnosed with an anxiety disorder...it indeed is fairly common)

........

 

[pasley]

Not a physician or expert of any kind. The following is for discussion purposes only and does not constitutite advice of any kind. You are advised to seek compentent professional help in seeking information about SCUBA Diving with PTSD and Trait Anxiety Disorder.

I teach disabled veterans with PTSD to SCUBA dive and many of them report it that it works for them. I also use it for my own treatment of PTSD. As you said, many potential triggers are usally absent underwater. The images of the ocean, fish and other aspects of SCUBA contribute to a feeling of calm.

Anxiety disorder is anohter issue. Underwater there are things that can cause you to be anxious. Many are normal responises to "OMG! I am underwater and breathing!" which acounts in part for why newer divers tend to use more air. Other things such as the effects of nitrogen at depth (below 60 feet) also can cause Anxiety independent of any trait disorder.

So when you add it up, PTSD (which can cause anxiety), Trait Anxiety Disorder and the effects of Nitrogen at depth and you have a higher potential to have a panic attack underwater. Panic kills....plain and simple. Can you overcome that? Don't know. Training can help. In training, if done right, you train and rehearse situations until it becomes mussle memory and you react as trained before you even think about it. Example, I recently certified a 12 year old (I normally do not train childeren). On his last dive, I checked if everything was ok. He returned the OK sign and I promptly slapped the regulator out of his mouth. He reponeded calmly with the appropriate dirty look while camly retieveing his regulator and purging it. Had he bolted for the surface (I was ready with the octo and a good grip on the kelp to stop a bolt for the surface) I would not have certified him. So training will help. Will training absolutly stop/prevent a panic attack, particularly in someone who is has multiple issues? No, it will not. Nothing will. You can know in your head that the anxiety attack is comming, think it through and rationalize it all you want, but you can't in all cases stop it. Anxiety attacks IMHO do not need to be rational so you can't talk yourself out of it. Anxiety can lead to panic and full blown panic can lead to death (yours and/or your dive buddies).

Should you dive? I don't know. You have to make that decision. Others do dive. That is not saying they should or should not. But bottom line is, 1. your buddy deserves full disclosure before they start the dive. It is their dive and their life too that you are putting at risk. 2. If you do dive, listen to yourself, and call the dive if anything feels off. Limit your depth to 60 feet or less at least for a while. Night diving adds anxiety...at least at first. Train, train, train. Practice out of air, lost mask, lost regulator until you can do it in your sleep. Practice under the supervsion of an insturctor emergency action drills for out of air, mask knocked off, regultor knocked out of your mouth and be comfortable with any of them happing without notice.

 

[logandzwon]

I find diving to be the most therapeutic activity I've ever experienced. I deal with both general and PTSD related panic attacks and anxiety. Under the water I'm further from those feelings then any other time/place I can be. The more I'm diving the less I'm (over)thinking about anything else.

It also helps that even under a full blow panic attack I can follow pre-rehearsed plans perfectly. I just can't absorb or process new information. I know how to communicate OOA, and I know both how to use a buddy's Octo, and share mine, while ascending safely. I know how to signal to a boat in I am in imminent need of pick up, or just need to to wait to be picked up. I can stay collected and together until I'm safe a board the boat, as there is nothing I need to figure out or think about. I just "do."

That said, I would think someone with diving related anxiety triggers, (vastness, open water, wild life, etc...) should probably keep to shallow waters. Even at 40' dives one can get a feeling of infiniteness.

 

[hotelconucc93]

Do what feels right. Do some pool sessions with someone you can trust or get to know the local instructors and pick one that makes you more comfortable. Or, a family member or buddy of yours.

Pool followed by shallow open water with plenty of rehearsals and fun stress breaks. Problems with concentration are an issue, so keep it simple.

SCUBA as you well know, is a life threatenting hobby, like combat. You can easily feel at home risking your life and rehearsing to stay alive and keeping your buddy's breathing. It calms you under water being in the serene environment with no one talking or walking up behind you fast.

If you get more comforatable, investigate boats. Pick reputable ones, not ninnies who will only inflame your PTSD with lack or respect or unsafe acts. I hide in the forward sleeping bays to stay away from alot of people milling about, and it saves me sun screen and heat exposure too. Great place to sleep.

Slowly work your way up to depth. Take it slow and easy. I have been 100+ with no narc effects, and I use diving as a way to stay mentally fit, and physically. It's a goal. Like hitting the gym between operations, hit the gym to impact your skill underwater.

It has worked for me.

 

[AfterDark]

I think it may help to keep you out of trouble, that is I mean risky behavior. My wife has been troubled by this most of her life. She doesn't dive but wants to get certified next spring. She's been snorkeling a longtime and tried scuba once this year and liked it so I'll be working with her until spring getting her ready for OW. I don't know how bad your problem is but take it slow and have confidence in yourself, your gear and your instructor. Best of luck.

 

[Rogersea]

Hi, Just be aware that you may be exposed to noises similar to the ones you described as you dive or are preparing for a dive. But, I think diving can be a great therapy....

I say go with your intuition and give it a try.... But again, be aware of the likely hood of being exposed to some noises similar to your triggers....

Cheers,
Roger

 

[Mantra]

Hi all!

I just wanted to thank everyone for the great input. I'm in the process of doing a literature review of the academic work done on this subject. I will post the review here when complete FYI.

In short, a tendency toward anxiety will increase the likelihood of experiencing panic underwater. That said, experience seems to mitigate against this. Other variables (like gender, for example) seem to have a much stronger impact on the likelihood of underwater panic.

 

[drbill]

In the far distant past I had anxiety disorder with accompanying panic attacks. Although I had been diving for 25+ years by that time, I did no diving during that period. These issues were associated with an episode of clinical depression. It took about two years to fully resolve the depression and my anxiety disorder and panic attacks disappeared after that. Although I'm not a medical doctor, and my advice is worth exactly what you pay for it, if you have been free from panic attacks for as long as you say and your doctor feels you can dive, it is probably OK. For the past 12-13 years I have been diving pretty intensively (averaging about 200 dives/year). It is my feeling that diving has greatly reduced my stress (well, except when I have to sit at the computer all night to edit the video I shot while underwater!).