Article: Stress Management in Scuba Training - What can be done about the Panic Response?

Please register or login

Welcome to ScubaBoard, the world's largest scuba diving community. Registration is not required to read the forums, but we encourage you to join. Joining has its benefits and enables you to participate in the discussions.

Benefits of registering include

  • Ability to post and comment on topics and discussions.
  • A Free photo gallery to share your dive photos with the world.
  • You can make this box go away

Joining is quick and easy. Log in or Register now!

Very good piece by Andy Davis, however far too many instructor's and diver's perceive "Panic" as a behavior, rather than an emotional state, which has it's own signs, and left unaddressed often leads to behavior's counterproductive to the subject's well being. As others have stated early recognition and timely intervention can lead to avoiding of "panic" behavior's.
TheOldMaster
 
Overall, a good article, but it repeats a myth about panic that has been circulating since the sixties: "This situation (panic) results in most, otherwise avoidable, scuba diving fatalities and injuries."

I discussed this with Glen H. Egstrom at DEMA Show 2007 in Orlando since his book Stress and Performance in Diving (1987) is sometimes cited as a reference. Drs. Egstrom and Bachrach's book never made that statement and Dr. Egstrom has been trying to dispel the myth for decades.

I recommend interested divers download the 2010 DIVING FATALITY WORKSHOP proceedings and watch the presentation videos at https://www.diversalertnetwork.org/research/conference/2010FatalityWorkshop/proceedings/index.html if they want to know what really causes diver fatalities. I was at the workshop along with major dive industry figures from around the world and panic does not even show up as a factor in most diving fatalities based upon the available data.

That being said, learning to deal with stress and anxiety and panic are important for all divers. There was some very heated discussion at the workshop on how good a job the dive training agencies were doing at preparing students for the stressors that are inevitable in scuba diving.

I have just returned from a week on Bonaire diving with yet another brand new diver and am a bit tired from getting up at 3:30 AM EST for a flight, so i'll try to comment more fully another day.
 
The failure to teach CO2 build-up at the advanced stage is important also. It should be highlighted and pounded in the divers head. How just a wrestle on the surface with equipment such as a mask coming off, and having to tread water vigorously for a few minutes, followed by a deep dive can easily set off the panic/ high anxiety chain by not allowing yourself ample time to off gas built up CO2 in the body. CO2 is not your friend at depth! It may be taught at this level, but usually just glossed over very quicky. It should be over emphasized!
 
David... nice resources, which I was aware of. However, the crux of my article was the recognition that individuals have different thresholds at which acute panic response occurs. I am sure there are cases to defend both the genetic predisposition to controlling panic, along with the value of training against it. Nonetheless, an individual that is prone to panic, is prone to panic.

Effective training, including the application of Tom Griffiths principles, can allow an individual to recede that threshold, but never eliminate it. Psychological conditioning methods are all well and good... but their application depends entirely on the time criticality of the scenario.... and the individual's capacity for self-control.

Whether panic is a primary and instrumental cause of diving fatalities, or whether it is only a contributing factor that otherwise prevents effective resolution is inconsequential. Less divers would die if panic was removed from the equation.
 
It was very interesting reading your article and the following comments.

I am a recreational diver and I dive mostly with my husband. To begin with a main source of stress was our stubborn bickering. Three years have gone by and fortunately I feel that we have moved on from that unpleasant stage of our underwater relationship. However this does not mean that we have become 'experts' in keeping under control our irrational-emotional selves in case something goes wrong in an unexpected and unfamiliar way.

We have not taken a stress and rescue class yet. It seems to me that your article mostly focuses on the instructor and his/her student. It is a scenario that does not apply to me. I am wondering if anybody has anything to say about on how to reduce stress when you cannot rely on an instructor anymore and you are alone with your buddy. In other words, how can we help each other to reduce the probability of triggering an irrational and uncontrolled panic response?

For example (I don't know whether it is a good one or not, it's late and it is the first one that popped up in my head), I am still nervous about diving in strong current even if I regularly do drift dives. Now, should I dive more often in strong current to get more used to it? Should I gradually increase the speed of the current in which I dive? Or shall I just forget it and avoid diving in strong current because it always makes me nervous?
 
I am a recreational diver and I dive mostly with my husband. To begin with a main source of stress was our stubborn bickering.

I know of at least one diving fatality that could otherwise have been avoided if intra-relationship dispute and/or the associated stress wasn't a factor. It's worth bringing up buddy relationships when considering dive safety - especially where those relationships exist outside of diving and may bring issues into the underwater equation.

Likewise, it's also worth bearing in mind that overall stress levels, which certainly impact on a divers' stability and ability to cope with underwater incidents, must include pre-diving stress that is brought into the water. Marital arguments, financial stresses, medical concerns etc etc - all of these things serve to destabilise the diver psychologically and lower their stress management threshold - bringing closer the potential of acute stress reaction (panic).

I normally give myself an honest physical and psychological examination at the beginning of every diving day. Any factors arising from that self-assessment help to shape the nature/limits of my diving that day. If I'm having "a bad day", I take it easy in the water.

how can we help each other to reduce the probability of triggering an irrational and uncontrolled panic response?

I think there's two primary methods:

1) Stress management: Targeting and reducing stress prior to and during the dive. Mental visualisation, breathing exercises and 'mantras' all help with this. I always have a pre-dive routine of stopping activity (think 'stressed and super-busy instructor' here) before getting kitted up. I do everything I have to do, but then stop everything... retreat 'into my shell' for a few minutes before getting into kit and into the water. Likewise, if an incident happens underwater, the first thing I do is STOP and THINK. My initial thoughts are directed towards psychological control - calm my mind, calm my breathing. My mantra then is "I have air, I can breathe, I am alive". Time and gas are critical - so I seek to maximise them by staying calm and controlling my respiration. Once calm, I approach the problem solving needed to resolve the incident.

2) Comfort Zone: It's important to associate your personal limitations in respect of your comfort underwater. Familiarity with conditions/sites/equipment, along with confidence in your abilities to mitigate potential risks and resolve all reasonable contingencies is a large part of your 'comfort zone'. It's important to be aware that comfort zone exists in both best-case and worst-case scenarios. Generally during a dive, we are aware of our comfort zone in respect of ideal circumstances. However, we should also strive to ensure that our comfort zone extends towards dealing with the foreseeable 'worst-cases'. That means effective initial training and post-training practice and repetition of necessary contingency skills and procedures. There's a wide gulf between saying "I am confident to cope with this dive" or saying "I am confident to cope with anything that may go wrong on this dive".

Another method/approach combines both of the above. It is to prepare and familiarise yourself with stress. In essense, to develop a comfort zone that encompasses dealing with stressful events and situations through stress management. Under controlled circumstances, safely apply dive stress through task loading, role-play or other methods so that you can gain more capacity to operate and control your psychological balance under those circumstances.

should I dive more often in strong current to get more used to it? Should I gradually increase the speed of the current in which I dive? Or shall I just forget it and avoid diving in strong current because it always makes me nervous?

That's a good idea of comfort zones. There really is no right answer - it's a personal decision based upon how you feel you are developing. Diving should be fun - if you don't enjoy doing something, then you shouldn't do it.

However, if you want to challenge yourself and/or have a direct need to increase that capability (current diving), then you should attempt to increase your familiarity in those conditions, gain positive experiences and extend your comfort zone to encompass those conditions. It's vital that these experiences are positive, otherwise you'll only reinforce negative connections you make with those conditions - your comfort zone won't develop... worse still, it may retract and/or become more intractable.

For that reason, you must ensure that any development you make is going to be positive - that could mean a more progressive and measured approach with staged exposures to gradually increasing stressors over longer timescale. On other occasions, for other people, it may mean 'jumping in feet first' and simply proving to yourself that there was nothing to be worried about in the first place.

Of course, you must also remember to consciously apply all aspects of your personal stress management strategy during those occasions - that's good practice and also helps ensure a positive outcome.

Another factor in developing your comfort zone is the benefit of external support. Most divers feel more comfortable when supervised by an experienced divemaster or instructor, or when diving in the care of a more experience and capable buddy. In this respect, the diver is utilising the existence of support to off-set certain personal stressors. Put simply, you are never quite as concerned when you know you have someone available to get you out of trouble.

Using assistance to off-set stress can be a useful tool in developing comfort zones. It allows you to develop familiarity with the specific stressor conditions, without an over-load of stress that could otherwise make the experience negative. Of course, it does also increase your safety in very real terms. The only downside to using assistance to reduce stress, is that it can be easy to become reliant on that support. Once the original stressors become familiar and your comfort zone expands to encompass them, then you still have to gain the confidence to deal with them without support. Having your metaphorical hand held is a good thing for a while, but can become a bad thing if allowed to persist as reliant behaviour.
 
A comment about hazing during training got me to thinking about training, panic and hazing. It is important we define what we mean by hazing, within the context of this conversation. I'm limiting my comments to training procedures in which leadership personnel take an active role in making a student's situation in the water more difficult, without warning, for example turning off a student's air or removing a student's mask. While I am against hazing, I think it is useful to examine the underpinnings of hazing so that any useful elements may be retained, and the retrograde elements may be rejected

To my way of thinking the argument if favor of this sort of hazing is that, when judiciously applied, it is a fairly realistic simulation of what happens in the course of a "diving accident." There is one failure piled on top of another until both the diver's ability to deal with the immediate crisis and the diver's situational awareness (in this case the ability to see other problems coming and head them off before they compound the crisis) are compromised. So judicious application of hazing can simulate this situation and take a student right to panic, and even a hair over it, whilst they are still protected from real harm by leadership personnel.

There are some who would have you believe that everyone will panic at some level of stress and that you can not be trained not to panic. Let’s first take a cursory look at what panic is. A panic attack is defined as "a discrete period of intense fear or discomfort that is accompanied by at least 4 of 13 somatic or cognitive symptoms," as described by the American Psychiatric Association in 1994. The somatic symptoms described include shortness of breath, dizziness, and accelerated heart rate, whilst the cognitive symptoms consist of fear of dying and fear of going crazy or losing control. The distinction between somatic and cognitive symptoms, lead Clark in his, “Cognitive Approach to Panic" (Behavior Research and Therapy, 24, 461-470) to advance a cognitive model of panic in which panic resulted from the "catastrophic misinterpretation" of bodily sensations whereby the perception of these sensations as far more dangerous than their cause(s). Palpitations may be interpreted as a sign of an impending heart attack, slight breathlessness may be perceived as evidence of cessation of breathing and possible resulting death, shakiness may be interpreted as signaling loss of control or insanity. He also proposed that such catastrophic misinterpretation may play a critical role in the vicious cycle which culminates in a panic attack and panic disorder. When you combine “normal” diving sensations with the fear that many people have of drowning or suffocating then it becomes easy to see why many divers are operating at close the edge of panic (oft without realizing it) much of the time. All it takes is one small incident or addition to push them right over the edge into a full blown panic state where offering a regulator or shouting "inflate your BC" are completely ineffective treatment modalities.

We were “designed” by either evolution (or a creator with truly lousy design capabilities) to operate properly only within our natural environment. We have altered our natural environment, created technologies that do not conform to its rules and that expanded the natural world to include items and locations that we did not evolve to deal with. SCUBA equipment is a great example, divers are subjected new experiences that they misinterpret, e.g., an illusion of lack of air brought as a result of a tight fitting wet suit, the mechanical failings of a regulator, or the increasing density of the air they are breathing. When we subject ourselves to such phenomena and do not take the time to provide comprehensive learned feedback for these sensations, we guarantee that panic will result. Panic is only dealt with in one of two ways, technical solutions to help avoid the trigger sensations (e.g., a properly fitting wetsuit, a balanced first stage and “over-balanced” second stage and less dense bas mixtures for deeper dives) or comprehensive learned feedback to desensitize us to the sensations and/or retrain our responses. I am not a big believer in technological solutions. They have a way of going awry , either through the perversity of the universe or the stupidly of human kind. Rather I seek solutions through desensitization exercises and the retraining of responses.

We teach our students to hold their breath for rather long periods of time. This has several salubrious effects, it’s a great place to jump off to a discussion of shallow water blackout with the innumerable attendant physics and physiology topics; it gives the students an immediate feeling of major accomplishment, their having completed something that they doubted they could; it creates incredible confidence amongst the students in their instructors; and it provides a wonderful way to get them “back on the horse” when they hit a snag. There are several reasons for doing this, one is to teach them a relaxation technique, another is to help them to gain confidence that what we ask them to do and be done and yet a third is help them to gain confidence in themselves and their own ability to master things that they initially see as difficult or even impossible. Permit me to expand on some of these ideas.

We use a series of exercises, built into a kata, to teach our students breath holding. I am not, here and now, going to describe exactly how we teach breath holding (that‘s a separately priced product). First we conduct a “raise your hand” poll: “I can hold my breath for about three minutes! How long can you hold your breath?” one of the staff says, “Ten seconds? Raise your hand. Twenty? Raise your hand, if that’s too long for you lower it. Thirty? Forty-Five? A minute? Minute and a half? Two minutes? Longer than two minutes?” Everyone raises their hand for ten seconds. We lose a few at twenty, a few more at thirty. At forty-five way less than half the class is left and at a minute there might be two, one of whom gave up at a minute and a half, the other will still be going (usually with a slight smirk) at “Longer than two minutes?” Those last two we’ll have to watch, they’ll be paired up and put with two of the best free divers on the staff (they go out, free dive and spear tunas! A little out of my league).

The session continues: “Okay class … let me tell you what’s going to happen. Today each and every one of you will hold your breath for a minute. Most of you will reach a minute and a half and a few of you will reach two minutes. By the midterm every one of you will be able to breath hold for two minutes. Okay?” The general reaction is usually one of slight nervousness and insecurity. Then we describe and teach the kata and we do the kata, out to two minutes at the beginning of every pool and open water session. You can imagine the level of psych in the class when at the end of the first pool session they all make a minute or more. If you told that next class we will have a session where they learn to walk on water they’d believe it.

So what’s the big deal? So what if students can hold their breath? They’re here to learn to scuba diving not free dive! Right? Wrong! One quick example: think about how easy it is to teach a student to clear their mask who can confidently hold his or her breath for a minute. We spent 15 minutes on breath holding and now in less that five minutes everyone in the class has actually "mastered" repeated clears, effortlessly. That tradeoff alone makes it worth while, everything else is gravy.

But I was discussing desensitization exercises and the retraining of responses. We concentrate on exercises that force students to the edge of discomfort due to moderate exertion whilst breath holding and then we ask them to perform a fine motor skill that takes a little time. An example of this is our free diving doff and don:

  • In full gear, including 7mm wet suit and gloves, but no hood:
  • surface dive to 13',
  • remove mask and place it on the bottom,
  • roll out of weight belt place it on the bottom,
  • make a flared ascent,
  • recover your breath on the surface,
  • surface dive down against the buoyancy of your suit,
  • roll into your weight belt and fasten it (wire or SeaQuest buckle really helps here),
  • and now to the fine motor skills: recover mask and don it,
  • clear mask,
  • surface with hand up, circling, with mask and snorkel clear.
There are a great number of other skills learned here too, a powerful surface dive, the advantage of dolphin kick for low gear and flutter kick for higher gear propulsion, operating without a mask, weight belt removal and replacement, etc. But most important is learning how to do something slowly and methodically when you’ve got an accelerated heart rate, trembling or shaking sensations, shortness of breath, feeling of choking, and chest pain or discomfort, tight-chested feeling. Heck, according to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders you only need four of those five to be diagnosed with a full blown panic attack.

Almost no one succeeds in this exercise on their first try, we build up to it with propriary receptor training for pike surface dive position, diving to the bottom with and without a weightbelt, doing just the mask, doing just the weight belt and then finally doing both. After each attempt of each skill the student lies flat at the surface and engages in the breathing kata. This is extremely relaxing and teaches them how to click quickly into a meditative state that desensitizes them and retrains their responses.

By the time we are done, the student is in an entirely different “head space.” He or she knows that they can comfortably hold their breath for two minutes, that they can comfortably hold their breath for a minute, even on exhalation. This make concerns over things like emergency swimming ascents or sharing air (regardless of technique) rather irrelevant to them.

In my experience it is relatively easy to design exercises that are “self-stressing” so that there is no need to bring leadership personnel into them to make them more difficult. Well designed exercises will, without breaking the chain of trust, serve to allow students to experience panic and the kind of situations that lead up to it so that they are able to lean not just the correct mechanical response to a situation (what some instructors refer to as “relevant“ or “practical“ or “realistic” exercises), but are also taught to identify, control and work with the physical sensations and mental processes that are part an parcel of panic (such “irrelevant“ or “impractical“ or “unrealistic” exercises).

Please note that we accomplish this without any recourse to hazing of any form. I do not believe in hazing because I feel that first and foremost it will have a souring effect on the relationship between the diving instructor and the diving student. Hazing diminishes, even destroys, the absolute trust that a diving student should have in his or her instructor. Less mature diving instructors may, if permitted to haze, cross over the line and actually endanger diving students all in the name of fun and games. Hazing can bring out the worst in human behavior.
 
This is the one thing I worry about with my boyfriend, he gets panicing when something goes wrong. I've always loved to dive and I don't panic, but I worry about him. I will show him this article thanks!
 
Panic can be reliably predicted in scuba students using the Spielberger State-Trait Anxiety Inventory. However, it does NOT predict panic in certified divers as i showed in our surveys about ten years ago. Panic can not be absolutely prevented. In fact, most divers will experience it at some point in their diving careers. Divers with a history of panic attacks before or during or after learning to scuba dive are more likely to have more panic attacks during diving. But, very few will experience an adverse event as a result of panic. Again, I refer readers back to the Diver Fatality Workshop data.



David... nice resources, which I was aware of. However, the crux of my article was the recognition that individuals have different thresholds at which acute panic response occurs. I am sure there are cases to defend both the genetic predisposition to controlling panic, along with the value of training against it. Nonetheless, an individual that is prone to panic, is prone to panic.

Effective training, including the application of Tom Griffiths principles, can allow an individual to recede that threshold, but never eliminate it. Psychological conditioning methods are all well and good... but their application depends entirely on the time criticality of the scenario.... and the individual's capacity for self-control.

Whether panic is a primary and instrumental cause of diving fatalities, or whether it is only a contributing factor that otherwise prevents effective resolution is inconsequential. Less divers would die if panic was removed from the equation.
 
Last edited:
Jeez there is a lot to read here. Thanks for the replies!:) I will tackle them as soon as I am a little bit more settled, I have just come back from Mexico.

Is there a way to forward this discussion directly (without cutting and paste) to another scubaboard member?

Hasta luego!
 
https://www.shearwater.com/products/swift/

Back
Top Bottom