When someone is physically harmed in an accident, we tend to have a rough understanding of the urgency of medical help. If the person has severe bleeding, broken bones, respiratory distress or other obvious signs of physical trauma, immediate healthcare is required. Some diving-related injuries are less obvious, particularly decompression illness, where symptoms can be mild. Yet, the advice is clear: if the person has been scuba diving seek medical assessment immediately. But when should you seek help if PTSD after a diving accident is suspected?
How is PTSD after diving accidents different from physical injury?
Psychological trauma and stress injury are physical injuries, with an impact on the nervous and endocrine (hormone) systems especially. However, there are several ways PTS or stress-injury differs from other bodily injuries. These can make it harder to identify the problem, or know when help is needed.
It’s less visible
Some of the signs and symptoms of PTSD can be seen. However, the impact of psychological trauma tends to lie dormant until “triggered”. So visible cues like fascial expression, shaking or sweating may only appear occasionally. In addition, PTSD after diving accidents can be caught up in shame, guilt or embarrassment, so many people may ignore or hide these issues.
It is hard to tell the difference between a normal reaction to trauma and PTSD
When someone has been involved in a distressing event, it is normal to be upset and shaken for a while. People may also experience medical shock in the immediate aftermath. In the days and weeks after such an event, it is considered normal to experience some difficult thoughts/memories, unwanted emotions (e.g. anxiety, sadness, guilt) and even bad dreams or nightmares. This can be part of the brain processing what happened, and does not always mean the person has PTSD.
It’s development is complex
Whether a particular person develops PTSD after a given traumatic event is hard to predict. The development depends on many factors such as: previous history of trauma, role during the incident, proximity to the event, relationship to other people involved, perceptions of responsibility, control or safety, response of others, access to support ….
It can be delayed
Severe barotrauma is apparent in minutes, decompression illness within hours (occasionally days). PTSD can emerge days, weeks, months or (in some cases) years after the traumatic event.
It can be independent of physical injury or illness
Psychological trauma or stress-injury can occur for people with no apparent physical injury or illness. It is possible for someone to experience a distressing event like an entanglement/entrapment, rapid ascent or narcosis/hypercapnia and escape unharmed. It is also possible that no such subjective event has taken place, because it is the person’s subjective experience that matters. This means that if the person believed they were about to die or be harmed, they can develop PTSD. And, in diving, it does not take much to generate this perception! Even where the experience was short, such as an unsuccessful mask clear, a trauma memory can be formed. It can also be the case that the person who develops PTSD after a diving accident is not the person who was hurt, but a witness, buddy or rescuer.
When is it recommended to provide intervention after trauma?
Just talking with non-professionals – straight away
Self-care and social network support is generally recommended immediately. The therapeutic effects of talking to friends and family are well-known. This alone can sometimes be enough to assist a person to process what happened and move on. However, there are some risks: the listener may have their own stresses and lack the “bandwidth” for providing emotional support; an untrained listener is at risk of responding unhelpfully (e.g. bringing up additional fears or focusing on their own issues); and the listener is also at risk of vicarious trauma (i.e. hearing the distress and the details of the account impacts their own mental health). This said, talking to someone you know and has the capacity to listen effectively is one of the most helpful things you can do after a distressing incident.
Talking to professionals – not so straight forward
You may be surprised to learn that the optimum timing of professional intervention is not entirely clear. There are different approaches and local procedures vary. This may make more sense when considering that the idea that trauma is a relatively common experience was only recognized in the 1990’s. How healthcare services and organisations respond to people after a traumatic experience is still evolving.
For a while, trauma-focused debriefs were delivered in group interventions in the first 24-72 hours after a critical incident. However, the research on these interventions has produced mixed conclusions. Some studies found the debriefs effective in reducing the incidence of PTSD; some studies found they made no difference; and some found they actually made the problem worse!
In the UK, there are guidelines for mental health professionals and medical doctors. These come from the National Institute for Clinical Excellence (NICE). The NICE guidelines on PTSD set out which interventions are helpful. These guidelines state:
- trauma-focused psychological debriefs are not to be carried out, based on the mixed evidence and risk of harm
- a period of one month of “watchful waiting” is advised (this means if you visit your GP, no treatment is given, you would instead book a further appointment and see if there is improvement or not).
- not to prescribe certain medications unless psychological therapy has been ineffective
- the psychological therapies are recommended where the problem persists for more than four weeks after the incident
- the two therapies that are known to be effective are cognitive-behavioural therapy (CBT) and eye-movement desensitisation and reprocessing (EMDR). They are both equally effective, though EMDR tends to work faster.
ABBREVIATIONS
PTS / PTSD Post-Traumatic Stress (Disorder) – a physiological and psychological condition that occurs when the natural processes of healing from trauma gets stuck. Many people dislike the term “disorder” because it can imply that there is something wrong with the person, whereas Post-Traumatic Stress focuses more on the condition being the result of what happened to the person.
CISM Critical Incident Stress Management – a crisis intervention approach to support people after a traumatic incident
TRIM Trauma Risk Management – a trauma focused peer support approach where people are supported by peers who have been trained to listen and support, and who are supported themselves by someone with trauma expertise.
CBT Cognitive-Behavioural Therapy – an established psychological therapy which has proved effective for PTSD.
EMDR Eye-Movement Desensitisation and Reprocessing – an established psychological therapy which has proved effective for PTSD. There are also several case studies describing its application in diving trauma.
R-TEP Recent Trauma Episode Protocol – a specific EMDR protocol for use immediately after a traumatic event
Talking to peers or professionals – perhaps straight away now
Although there has been a move to delaying intervention for PTSD, waiting to see if symptoms resolve, more recently this seems to be shifting again, with a couple of approaches:
Another early intervention, not to be confused with CISM, is TRiM. The Trauma Risk Management approach is one of peer support and does not involve psychological debriefings. This type of approach can be considered consistent with the social support and watchful waiting recommendations in the NICE guidance. Where available, it has the potential to be low cost and accessible, as it is offered via volunteer peer networks. There are also advantages of talking to a peer rather than a professional. This approach has potential to address some of the issues with talking to non-professionals that was described above.
Finally, the Recent Trauma Episode Protocol (R-TEP) is an EMDR therapy that can be provided straight after a traumatic event to assist people in processing what has happened. This protocol is newer, and has not yet been evaluated by NICE, however, studies are showing some promise to treat psychological trauma before PTSD develops. As understanding of psychological trauma and stress injury improves, it seems likely that early, effective, intervention will be part of the approach. I wonder whether “watchful waiting” recommendation will endure when/if short, soon therapies can prevent issues. It would seem odd to wait, where people are experiencing significant sleep disturbance, risk of secondary conditions (anxiety, depression etc.) and potential losses in relationships or work.
The short answer would be that if you are experiencing symptoms of PTSD after a diving accident, to contact your GP.
Signs that help is needed for PTSD after scuba diving accidents
Experiencing difficulties in everyday life
Signs and symptoms of post-trauma conditions fall into three main categories: hyper/hypoarousal (feeling physically and emotionally stressed, anxious, tense or shutting down / feeling numb) which can make it difficult to concentrate and sometimes includes sleep disturbance; avoidance (this can include not thinking or talking about the event, avoiding feelings, using activities or substances like alcohol to avoid feeling bad); and reliving the experience in nightmares, flashbacks or talking through what happened as if you are there. There are more signs and symptoms listed here.
You may not feel like this all the time. Trauma memories are a bundle of unprocessed thoughts, sensations, emotions, images and beliefs that take up there own space in the nervous system. The brain doesn’t want them to be part of the rest of your memories and tries to keep them separate. Unfortunately, because they are unprocessed, when something reminds you of what happened, the whole bundle can fall apart. As the trauma memory spills out, its common to feel very overwhelmed, and sometimes this leads to a panic episode.
People who have experienced ptsd after diving accidents often tell me they have issues with panic when driving. Something about driving connects to something in the trauma memory bundle, and the trauma is triggered. Once someone has a first panic episode while driving, this is more likely to happen again. It’s like the trauma memory gets linked to driving, even though the trauma happened when scuba diving. This can happen with other activities, and is due to “generalisation”. If this is happening, it would be advisable to seek professional support straight away.
Experiencing issues when scuba diving
If you are unhurt, or recovered and medically cleared to dive, you may want to be diving again. Some people can be involved in a dive that went wrong and are able to dive again without significant issues. However, there is a risk that the trauma memory gets triggered by a reminder to the accident while diving. This can be a bit unpredictable. What is really strange is that someone who has no issues following an incident may find they suddenly feel terrible. For example, going back the the site it happened, reaching the depth the problem occurred, encountering similar conditions etc. When this happens, then there is a risk of panic. The risk may be greater underwater due to gas density effects like hypercapnia and narcosis. Since panic tends to get into a repeat pattern quite quickly, you will want to prevent this.
“back on the horse?”
Even if unharmed, it is still a good idea to cancel the rest of the days’ dives after a dive has gone significantly wrong. You may feel ok and keen to keep diving, but these things can shake up our systems in a way that makes it more likely things will tip over the edge on the next dive. I quite often work with people who have developed repeat panic episodes when diving where forcing themselves through dives after a bad dive is a factor.
On the other hand, avoidance can also lead to issues, which is why many people prefer not to leave it too long to dive again. If you are fit to dive, it would be recommended to dive easy for a while. Then, if you are diving without problems, gradually work up to the sort of dive that the accident happened on. If you find you are reacting badly to the dives, stop. Take a break and seek support. It is far easier to fix a psychological issue with panic before it develops. Processing trauma is relatively straightforward for one-off incidents, but undoing an entrenched issue with panic or anxiety when diving is going to take longer. In any case, it is not safe to dive when at risk of panic underwater.
So, when to seek help?
The simple answer is, if you have concerns / signs / symptoms of post-traumatic stress, then seek help straightaway. In some cases you may be advised to wait four weeks, but this will likely be with a screening process in place to monitor your symptoms. There are also therapy approaches that can be used effectively much sooner, and may reduce the risk of PTSD developing. More information about self-care and how to access support is available here.
