Anxiety, Phobias and Panic Attacks

Normally, fear and anxiety can he helpful, helping us to avoid dangerous situations, making us alert and giving us the motivation to deal with problems. However, if the feelings become too strong or go for too long, they can stop us from doing the things we want to and can make our lives miserable.
Anxiety in the mind causes worried feelings, tiredness, loss of concentration, irritability and insomnia.
It affects the body by producing irregular heartbeat, sweating, tense muscles and pain, heavy rapid breathing, dizziness, faintness, indigestion and diarrhea.

These symptoms are often mistaken by anxious people for evidence of serious physical illness and their worry about this can make the symptoms even worse. Sudden unexpected surges of anxiety are called panic, and usually lead to the person having to quickly get out of whatever situation they happen to be in. Panic occurring at depth can lead to near-drowning and lung over-expansion injuries and death.

The normal anxiety induced by the undersea environment is complicated by an over-awareness of the potential but definite dangers, causing a phobic anxiety state in susceptible people. A vicious circle results and the diver may then develop an actual phobia to descent into the water. Some “dragooned” divers experience this while learning to dive but other stronger motivating factors temporarily override their fear. Anxiety is a normal human feeling. We all experience it when faced with situations we find threatening or difficult.

An over-reactive anxiety state usually occurs in response to some inadvertent mishap, such as a mask flooding with water-causing the diver to panic unnecessarily and behave irrationally. Most often this results in emergency ascents with the attendant dangers, frantic grabs for air supplies, and lack of concern for the safety of others. This is seen more often in those divers who have an above normal neuroticism gradient.

Phobias

A phobia is a fear of particular situations or things that are not dangerous and which most people do not find troublesome. A person with a phobia has intense symptoms of anxiety, as described above. But they only arise from time to time in the particular situations that frighten them. At other times they don’t feel anxious. If you have a phobia of dogs, you will feel OK if there are no dogs around, if you are scared of heights, you feel OK at ground level, and if you can’t face social situations, you will feel calm when there are no people around.

A phobia will lead the sufferer to avoid situations in which they know they will be anxious, but this will actually make the phobia worse as time goes on. It can also mean that the person’s life becomes increasingly dominated by the precautions they have to take to avoid the situation they fear. Sufferers usually know that there is no real danger, they may feel silly about their fear but they are still unable to control it. A phobia is more likely to go away if it has started after a distressing or traumatic event.

About one in every ten people will have troublesome anxiety or phobias at some point in their lives. However, most will never ask for treatment. Some divers have true claustrophobia, preventing their immersion into water or even into a recompression chamber. This syndrome may only surface during certain times of stress and diminished visibility, such as in murky water, night diving or during prolonged diving. There is no one cure for it, but there are various treatments, such as Exposure therapy , a behavioral technique that exposes you to the situation you fear most — being in enclosed spaces. The two most popular forms of this therapy are ‘slow desensitization’ and ‘flooding’. Flooding is a rapid and more intense form of desensitization without any relaxation techniques. Rather you are exposed directly to what you most fear until the anxiety subsides. Such direct exposure can be imagined or an actual confrontation with the phobic trigger. This would seem to be a dangerous method of treatment in the underwater milieu.

An agoraphobic reaction – often called “blue orb or dome syndrome “, it also is seen when a diver loses contact with the bottom and the surface and becomes spatially disoriented.

Sensory deprivation can also cause illusions, particularly when there is impaired visibility. Anxiety associated with this environment can cause heightened suggestibility and result in mistaking fish, other divers and objects for sharks.

Panic Disorders

Recent studies are beginning to suggest that episodes of panic or near-panic may explain many recreational diving accidents and possibly throw light on the cause of some diving fatalities. There is also evidence that individuals who have a high level of underlying anxiety are more likely to have greater responses when exposed to stresses, and hence, this sub-group of the diving population is at an increased level of risk. In a recent national survey, more than half of divers reported experiencing at least one panic or near-panic episode. Panic attacks are often spurred by something that a non-diver would deem serious — entanglement, an equipment malfunction or being startled by some unexpected sea creature. The attacks can lead to irrational and dangerous behavior. If divers and instructors knew more about the phenomenon they could screen out people who might be susceptible to life-threatening panic attacks.

The panic attacks are not restricted to beginning divers; sometimes experienced scuba divers with hundreds of logged dives experience panic for no apparent reason. It is thought that in such cases the panic occurs because divers lose sight of familiar objects, become disoriented and experience a form of sensory deprivation. This problem has been labeled the “blue orb syndrome.” However, among inexperienced divers, there is usually an objective basis (e.g., loss of air or a shark) behind the panic response.

Panic response is when a diver behaves irrationally. The diver’s attention narrows and he loses the ability to sort out his options. If, for example, a problem develops with the regulator, the restricted air flow could prompt the diver to ascend rapidly enough to cause an air embolism (bubble) in the bloodstream, which can be fatal. This would be considered a panic response if the diver had other safe options, such as access to a pony bottle (an emergency air supply), or was diving with other divers who could share their air supply, allowing a gradual ascent.

There are some obvious diving activities which tend to lead to panic episodes, such as the stresses of equipment malfunctioning, dangerous marine life (e.g., sharks), loss of orientation during a cave, ice or wreck dive, and so on. Diving with faulty or inappropriate equipment or performing high-risk dives has greater potential for panic episodes; these problems can be prevented or minimized with appropriate training and cautionary actions.

There is a psychological concept known as “trait anxiety” that is regarded as a stable or enduring feature of personality, whereas state anxiety is situational or transitory. In this regard, it can be accurately predicted that individuals who score high on trait anxiety are more likely to have increased state anxiety and panic during scuba activities and are at potentially greater risk than those scoring in the normal range. These people probably should not dive because it has been found that interventions such as biofeedback, hypnosis, imagery and relaxation have not been effective in reducing the anxiety responses associated with the panic attacks. However, David Colvard of Raleigh NC has found that trait anxiety only predicts panic or near panic in student divers, not in certified divers. He feels that this may be self-selecting after initial training.

Psychological research has shown that hypnosis is effective in relaxing scuba divers, but it can also have the undesired effect of increasing heat loss in divers. Relaxation can lead to increased anxiety and panic attacks in some “high anxious” individuals (this phenomenon is known as relaxation-induced-anxiety, or RIA). Individuals with a history of high anxiety and panic episodes should probably be identified and counseled during scuba training classes about the potential risks.

Advice About Diving

Whether or not a person with anxiety, phobias and panic attacks 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 anxiety and phobic problems. Identification of individuals who score high on trait anxiety are more likely to have increased state anxiety and panic during scuba activities and are at potentially greater risk than those scoring in the normal range. Most probably should not dive but if allowed to dive should be carefully monitored and fully informed of their risks.Decision-making ability, responsibility to other divers should be taken into consideration. Prospective divers should in all cases provide full disclosure of their condition and medications to the dive instructor and certifying agency – bearing in mind the safety of buddies, dive instructors, divemasters and other individuals who are always affected by diving incidents.

Medications used to treat anxiety, phobias and panic disorders
(Note: Many of the medications listed under depression are also used for anxiety.)

Benzodiazepines
Medications in this group used to treat anxiety include: Alprazolam/Xanax, Chlordiazepoxide/Librium, Clonazepam/Klonopin, Clorazepate/Tranxene, Diazepam/Valium, Halazepam/Paxipam, Lorazepam/Ativan, Oxazepam/Serax, Prazepam/Centrax.
Side Effects Adverse to diving include
· Drowsiness: This is a common side effect. Make sure you know how you react to this medicine before driving or using dangerous machinery.
· Dizziness: Be careful about standing up quickly, going up and down stairs, and driving.
· Difficulty learning: This is an unusual side effect and tends to go away quickly with continued use.

Beta Blockers
Medications in this group used to treat anxiety include: Propanolol/Inderol, Pindolol/Visken, Atenolol/Tenormin, Acebutolol/Sectral, Betazolol/Kerlone, Bisoprolol/Ziac or Zebeta, Carteolol/Cartrol, Carvedilol/Coreg, Labetalol/Normodyne or Trandate, Metoprolol/Lopressor, Nadolol/Corgard or Corzide, Penbutolol/Levatol, Timolol/Blocadren or Timolide.
Side Effects inimical to diving include;
· Drowsiness: This is a common side effect. Make sure you know how you react to this medicine before driving or using dangerous machinery.
· Dizziness: Be careful about standing up quickly, going up and down stairs, and driving.
· Low Blood Pressure
· Slow pulse. This particularly important to divers, as they may not be able to respond to exercise and stress in case of need.
· Breathing difficulty, wheezing, cough
· Dry mouth: Drink plenty of fluids. Chew sugarless gum. Suck on sugarless candy. Pay special attention to dental hygiene (brush and floss regularly).
Patients with asthma or diabetes may develop special side effects while taking these medications.

Celexa / Citalopram
Citalopram is used to treat depression, anxiety, and obsessive-compulsive disorder.
Possible side effects adverse to diving include: .
· Anxiety/restlessness: This will usually go away with continued use.
· Drowsiness/Dizziness: Avoid driving or working with dangerous machinery until the effect of this medication is known..
· Bruising/bleeding: Use of citalopram can slightly increase risk of bruising and bleeding, but this can be significant when aspirin or non-steroidal anti-inflammatory drugs (e.g naproxen, ibuprofen, ketoprofen, flurbiprofen, diclofenac, sulfasalazine, sulindac, oxaprozin, salsalate, piroxicam, indomethacin, etodolac) are also taken. Barotrauma to sinuses, ears and lungs may cause significant hemorrhage.

Fluoxetine / Prozac
Fluoxetine is used to treat depression, anxiety, and obsessive-compulsive disorder.
Possible side effects adverse to diving include: .
· Anxiety/restlessness: This will usually go away with continued use.
· Tremor: This tends to go away with continued use.
· Bruising/bleeding: Use of fluoxetine can slightly increase risk of bruising and bleeding, but this can be significant when aspirin or non-steroidal anti-inflammatory drugs (e.g naproxen, ibuprofen, ketoprofen, flurbiprofen, diclofenac, sulfasalazine, sulindac, oxaprozin, salsalate, piroxicam, indomethacin, etodolac) are also taken.

Fluvoxamine / Luvox
Fluvoxamine is used to treat depressive, anxiety, and obsessive-compulsive symptoms.
Possible side effects adverse to diving include:
· Anxiety/restlessness: This will usually diminish with continued use. If anxiety causes difficulty, consult with your physician.
· Drowsiness: If this occurs, take this medication 1 hour before bedtime. Make sure you know how you react to this medicine before you drive or use dangerous machinery. This usually diminishes with continued use.
· Tremor: This tends to diminish with continued use.
· Bruising/bleeding: Use of fluvoxamine can slightly increase risk of bruising and bleeding, but this can be significant when aspirin or non-steroidal anti-inflammatory drugs (e.g naproxen, ibuprofen, ketoprofen, flurbiprofen, diclofenac, sulfasalazine, sulindac, oxaprozin, salsalate, piroxicam, indomethacin, etodolac) are also taken. Bleeding with barotrauma would be a concern.

AUTHOR

Ernest S. Campbell, M.D., FACS

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