Experiencing some lingering distress , mental or emotional issues after a traumatic experience is relatively common. Mostly, the person heals and the problem resolves naturally. However, for a proportion of people this reaction may develop into psychological stress injury or post-traumatic stress (disorder, i.e. PTSD). Divers do occasionally face challenging incidents or circumstances, such as decompression illness, barotrauma, entrapment/entanglement, lost gas events and rapid ascents. So it is reasonable to anticipate that some divers would be affected by psychological trauma issues. But how common is scuba diving PTSD?
Short answer: we don’t know how common scuba diving PTSD is!
Diving incident reports, such as those produced by Divers Alert Network and the British Sub Aqua Club show that incidents and accidents do happen. These reports classify incidents according types of events, such as gas/air supply problems, equipment issues or missed stops. They also look at the type of physical injury or illness, for example barotrauma or decompression illness, broken bones or cardiac arrest. Psychological conditions are not usually reported.
This is likely partly due to the fact that these reports relate to the incident, any rescue and acute medical treatment. Data from longer-term follow up is harder to access. With psychological conditions, the impact of a traumatic event is not always apparent immediately. Also, during an incident and subsequent medical treatment, distress may be a normal response to what has happened. Diagnosis of PTSD would be much later, and so this data is not available for those reports.
Comparison to road traffic accidents
Across a range of sources, the rate of post-traumatic stress after being involved in road traffic accidents is estimated at around 10 to 30 per cent. Diving is often compared to driving when exploring issues like risk, cognitive capability and capacity. There are some similarities, so perhaps its a useful proxy. However, there are significant differences. For example, scuba diving is more remote and isolated than most RTAs and there are factors that may increase the victims perception of threat (darkness, depth, prolonged distress during stops). It may be that rates are higher. On the other hand, it could be argued that diving is an extreme sport and that divers are more accepting of adverse events. It may be that rates are lower. Clearly, actual scuba diving studies are needed.
Psychological Impact of accidents on recreational scuba divers
A significant minority of diving accident victims (between 25% and 50%) continued to suffer from the psychological impact of the accident, some for over a year. This has important implications for their future health care, for their safety on subsequent dives, and for dive training.
Trevett, Peck & Forbes, 2010.
There is one study that specifically examined the psychological impact of accidents on recreational scuba divers. The research was carried out at the hyperbaric chamber in Orkney, which covers diving-related injuries in one of the world’s best known wreck diving locations: Scapa Flow. The study followed up all divers attending the chamber for diving-related conditions across two years. (Issues included: DCI, barotrauma, non-fatal drowning, marine stings, missed deco stops due to buoyancy or lack of gas supply). It measured reported symptoms of psychological trauma in: (a)victims of scuba diving accidents, (b) their buddies, and (c) another member of group who was not (or at least less) involved in the incident. All were measured at 3 months, 6 months and 12 months after the diving medical contact.
A few optional notes on quality of evidence
Before looking at the results of a study, it’s important to check the quality of the design and methods. This one has some good points. First of all, it’s prospective, that means it took a sample of people and followed them to see if there was an issue. (This is different from studying a group of people who are already reporting symptoms, for example). It could be said that to be truly prospective, it would start prior to the incident occurring at all. However, the authors considered this, and included assessments of general mental health and a control group. In addition, they considered the statistical power of the study in advance and made sure to get enough participants to be confident that any difference in symptoms was not due to chance. The study also used a reliable and validated measure, one which is also clinically useful.
The results?
The study found that quite a substantial portion of the divers reported symptoms of psychological trauma, 3 months, 6 months and (in some cases) 12 months after the event. The victims reported significantly more symptoms than their buddy or the control. Divers were reporting symptoms of trauma on all three domains: avoidance, re-experiencing and arousal. So, we have an estimate that 25 to 50 % of divers are experiencing scuba diving PTSD symptoms after accidents. It is important to be clear that this does not mean that many divers get diagnosable PTSD. Instead, it is the number of the divers who reported some symptoms psychological trauma.
Victims should be informed of the likelihood and possible duration of psychological problems around the time of this debriefing and advice given as to how these might be minimized.
Trevett, Peck & Forbes, 2010.
Reading between the lines
First, it’s important to note the diving environment. The study was carried out in remote islands, north of the Scottish mainland. This is cold water diving, pre-dominantly wearing dry suits. Although there are excellent scenic dives there, it can tend to attract more advanced and technical divers. Conditions can be challenging. It’s questionable to what extent these results can be generalised to other types of diving environment and divers.
The second important point is that this study only looked at divers who had attended a chamber for medical assistance. Post-traumatic stress can occur without any physical injury, or for events that have not lead to the diver seeking medical support. This study would not have included those divers whose issue was limited to the psychological.
Symptoms of PTSD does not mean diagnosis of PTSD
The third thing to note here, which is not mentioned in the study, is the clinical cut-off. I use the same measure as that used in the study with my clients, so I know that there are two suggested scores: one that states a person is at risk of PTSD, and one that is associated with an actual diagnosis. Looking at the scores in the results section, it looks as if only a small number of the divers reached those suggested clinical cut-offs. This means that, although the divers were reporting symptoms, many would not have enough symptoms to be formally diagnosed. The study did not measure or ask whether any of the divers was diagnosed with PTSD.
However, the measure used relates to every day life: there was no assessment of impact of the experience when diving. Trauma can be context dependent and if an event happened underwater, the triggers may be mainly present only when diving (e.g. low vis, feelings of buoyancy changes, pressure etc.). In addition, trauma data lingering in the nervous system can become an issue even if symptoms do not reach the threshold for PTSD.
Implications
It is important to examine the psychological impact of diving accidents because victims may, in subsequent dives, experience a reduced ability to cope with the stresses of diving and start to panic, thereby increasing the hazards for themselves and others. Many diving deaths may occur as a
Trevett, Peck & Forbes, 2010.
result of panic underwater, and divers with high levels of anxiety may be at greater risk of accidents after a previous traumatic incident.
Unresolved trauma after scuba diving accidents
People do heal naturally from distressing events. This study also shows that the divers were reporting less symptoms with time. However, sometimes the experience of an adverse or distressing event can linger in the nervous system. Occasionally it will also bring up, (and get stuck to) older disturbances. When these issues have not resolved through rest, time, talking and natural processing, they can have multiple impacts. Trauma can get very sticky, especially where there is also grief, shame, guilt or anger.
In some cases, people may choose to give up diving. This can be a loss in itself, particularly where diving is part of a person’s identity and social life. In fact, the authors of the study noted in their introduction:
Injuries sustained during sporting and recreational activities appear to have a particularly profound psychological impact. This may be because such activities are often used as a coping method via the effects of relaxation and mood enhancement; the loss of sporting activities could therefore be expected to result in low mood and general psychological distress. Moreover, for many sportspersons, their social lives and friendship circles are closely linked to active participation in their chosen sport, and inability to participate is likely to result in a marked reduction in social activities.
Trevett, Peck & Forbes, 2010.
Increased risk of future incidents when diving
When people decide to continue diving, unresolved psychological trauma can lead to greater risk of accidents. There are a few routes to that outcome. For example, after a traumatic experience, any stimuli that reminds us of that experience can re-trigger the trauma. This leads to issues with regulating arousal (stressed, anxious, angry or conversely, disconnected and numbed). Encountering this reaction underwater is stressful in itself, so it means that even a minor concern on subsequent dives could turn into a major source of stress.
There is also a potential impact on how the diver learns from experience. When we have survived a dive gone wrong, ideally we would want to learn something that would help in future. However, whilst an adverse event can serve to improve our awareness, when there is unresolved trauma there are blocks to learning. The increased reactivity in our nervous system in similar environments means that we can be too stressed to learn new skills effectively. We may get caught up in avoiding unpleasant experience to such an extent that it’s hard to gain useful perspective. For example, avoiding thinking about what happened or talking through the event to understand what went wrong.
Social factors
Unwitting peer pressure within dive groups may discourage divers from openly discussing accidents and their resulting fears, with potentially dangerous consequences. If these individuals continue to dive with these fears unresolved, they may well be at higher risk.
Trevett, Peck & Forbes, 2010.
Social contexts will also influence trauma processing due to various complex factors, such as “peer pressure” mentioned by the authors. There is also a lot of potential for blame, shame, embarrassment and guilt getting in the way of diving well and comfortably. There is some research on the social reactions to diving-related incidents. Clinically, when people get stuck with unresolved trauma, it’s often fueled by misplaced guilt, shame or blame and anger. In fact, I often see people in therapy stay stuck because they are looping between “it was my fault” and “it was their fault”. The cycle is endless because the situation is always complex and most minds can argue either way. Blame processes not only keep people stuck in trauma, they also make it difficult to make progress in real improvements to safety.
Secondary problems
Think about the experiences people are having. Nightmares, intrusive thoughts, feeling guilty. This is stressful in itself and disturbs sleep and rest. Over time, this can lead to issues like anxiety and depression. Avoidance is not only common in PTSD, it’s a diagnostic feature. People avoid talking, going out, connecting to people. They avoid their own experience in many creative ways. Self-medication with alcohol or drugs is not unusual.
There is a whole continuum of ways that psychological trauma can impact diving. From relatively minor barriers to learning and increased stress load, through risk of panic and errors to development of mental health conditions.
Should we stop scuba diving?
…as diving is a high risk sport, it is inevitable that accidents will occur, but they should be seen as an unavoidable part of the diving experience and not necessarily as a sign of poor diving practice or incompetence. Knowing how to manage and recover from a traumatic experience may be an important
Trevett, Peck & Forbes, 2010.
skill for divers to learn.
Earlier in this article, driving was considered as a parallel. How many driving incidents and accidents are there every day? Stopping all driving would be a sure prevention for RTA related trauma. If there was no scuba diving, there would be no risk of scuba diving PTSD (or DCI, or diving barotrauma). But then we lose access to all the benefits. The risk of being hurt, physically or psychologically, when diving, can be balanced against the benefits. Like driving, horse-riding and mountain climbing, most societies allow scuba diving as an acceptable risk activity for those who choose to do it. On an individual level, many divers will advocate for the benefits as far outweighing the risks. For most divers, if you suggest diving to friends or co-workers, you will be used to a few “hard no”s.
That’s okay, it is a high risk activity. There is a lot we can do to manage risk and prevent accidents and incidents. But they will occur, and that’s where the rescue and medical support systems exist to mitigate the immediate impact. After that, there is a need to address that impact to aid recovery and move any useful experience back into the management and prevention of future incidents.
If you had a physical injury that left pain, tension or weakness in the muscle, physiotherapy is standard. It’s the same with psychological, there are treatments that address the emotional pain, tension or weakness and build strength out of it. National and international guidance gives well-evidenced approaches to single event trauma. Although scuba diving accidents are not listed in the guidelines (as they are not as common), a distressing, adverse event in diving is a single event trauma.
Do divers know how to manage and recover from adverse events or scuba diving PTSD?
Based on the evidence of their research, the authors recommended that divers would benefit from knowing how to manage and recover from a traumatic experience. There is not a lot of information available on how to do that. This is why Fit To Dive has a resources and self-help page for scuba divers after an accident or incident. The page includes simple and easy-to-follow recommendations to support natural processing of trauma, advice on when to seek professional help and some options. There is also a downloadable guide in development. Do check the page and share it to help other divers be aware.
Beyond healthcare support, there are also benefits in trauma-awareness. Understanding our reactions to adverse, distressing or traumatic events is more than just knowing when to go for professional support. Knowing how psychological safety can help divers in the event of a distressing incident to support healing and learning. When you understand trauma, you also get to know more about your own blocks and barriers to learning from experience. Divers (even perfectly healthy ones who haven’t had accidents) can benefit from learning about trauma. This year, I am developing the “Talk Trauma in Scuba Diving” course to provide an option for diver who would like to do that.
Reference: Trevett, Peck and Forbes (2010). The psychological impact of accidents on recreational divers: A prospective study. Journal of Psychosomatic Research 68 (2010) 263–268
Photo courtesy of Life Saving Training from thorough rescue scenario training for Fifth Point Diving Centre. Regular staff training in rescue is one way to help build systems that protect divers when accidents do occur and reduce the impact of physical and psychological trauma.
