Content uploaded by David Colvard
Author content
All content in this area was uploaded by David Colvard on May 02, 2018
Content may be subject to copyright.
40
feature
PADI.COM
A Study of Panic
in Recreational
Scuba Divers
by David F. Colvard, MD and Lynn Y. Colvard, PhD
Introduction
Out of millions of certified divers, about 90 recre-
ational scuba divers have died each year during the
past decade, but little is known about the precipi-
tating events for many of these deaths. A coroner’s
report of “drowning” tells us nothing about what
led to, or caused, a diver’s death. Bachrach and
Egstrom state in Stress and Performance in Diving
(1987), “Most researchers in diving accidents im-
plicate panic, as a response to stress, as the major
cause of diving fatalities.” In Medical Examination
of Sport Scuba Divers (1998), Alfred Bove states,
“panic, or ineffective behavior in the emergency sit-
uation when fear is present, is the single biggest
killer of sport divers.” The 1998 Recreational
Scuba Training Council (RSTC) guideline for the
Recreational Scuba Diver’s Physical Examination
listed “a history of panic disorder” as an absolute
contraindication to scuba diving. However, the
2001 guideline lists “a history of untreated panic
disorder” as a severe risk condition, recognizing
that many individuals now receive treatment for
this condition and could possibly dive at less risk.
In a 1987 survey of 254 recreational scuba
divers, William Morgan reported that 64 percent of
female respondents and 50 percent of male respon-
dents had “panic or near-panic” episodes while div-
ing on one or more occasions. Clearly, panic while
diving rarely results in death. (One could point out
that there is no way to determine panic in acci-
dents resulting in fatalities.) So what is going on?
For one thing, not everyone who has panic meets
the American Psychiatric Association’s (APA) Diag-
nostic and Statistical Manual of Mental Disorders,
4th Edition, (DSM-IV, 1994) criteria for a panic
attack or panic disorder. The goal of our study was
to examine the incidence of panic while diving, the
relationship to a history of panic prior to diving
and the results of panic during a dive.
Methods
With the help of Rodale’s Scuba Diving magazine and website, and PADI, which
provided a hotlink through its e-newsletter, Dear Fellow Diver, to about 200,000
divers, we surveyed certified recreational scuba divers from 14 September 2000 to
2 January 2001. The survey addressed demographics, diver certification, dive his-
tory and any history of panic while diving or at other times. Because “panic” can
be an imprecise or vague term used in a casual sense, the survey defined a panic
experience as “an intense fear of losing control or dying,” consistent with a panic
attack as defined by the APA in DSM-IV. “[The] essential feature of a Panic At-
tack is a discrete period of intense fear or discomfort that is accompanied by at
least 4 of 13 somatic or cognitive symptoms… often accompanied by a sense of
imminent danger or impending doom and an urge to escape…or desire to flee
from wherever the attack is occurring.” An expected result of a diver having a
panic attack would be a rapid ascent or other flight response. Respondents with a
panic experience while diving were directed to additional questions about the sit-
uation and results of the panic.
The data were sorted according to history of panic prior to diving and panic
during diving, and were compared while controlling for gender and whether the
first panic during diving occurred during or after initial training. The relative
risks and 95 percent confidence intervals were computed from the incidence rates
of first panic. The calculations were made using the computer program “Confi-
dence Interval Analysis” from Statistics With Confidence, 2nd edition, Altman, et
al, BMJ Books 2000. (Relative risk is the ratio of the incidence of some outcome
in two groups of individuals defined by the presence or absence of some charac-
teristic.)
Results
Demographics — Complete responses came from 12,087 individuals; 76 percent
male and 24 percent female, with more than 60 percent being PADI-certified
divers. We categorized the divers into two groups: Those with a history of panic
prior to diving and those with no history prior to diving. We subdivided them
into those who had a panic on a dive, and those who had not. Age, years diving
and lifetime number of dives were similar for each group, as shown in the follow-
ing figures. The average range of dives during the past three years was 26-50 for
both males and females.
Figure 1
Age and Gender of Divers
41
Incidence of panic and prediving panic
in divers — Similar percentages of males
and females (16 percent and 18 percent, re-
spectively) reported a history of panic be-
fore they took up scuba diving. But, over-
all, significantly more females reported one
or more panic experiences while diving (37
percent versus 24 percent of males). Proba-
bility (p) was calculated to better than
99.99 percent confidence that this differ-
ence wasn’t random (p < 0.0001). Forty-
five percent of males and 57 percent of fe-
males with a history of panic before they
began diving reported panic during one or
more dives, compared to only 19 percent of
males and 33 percent of females without a
prediving panic history (p < 0.0001 for
both). [Editor’s note: References to “prediv-
ing panic” indicate prior to becoming in-
volved with diving, not panic immediately
prior to a specific dive.]
The risk ratio for a first panic during a
dive for divers with a prediving panic histo-
ry compared to those without was 2.3 for
males (95 percent confidence interval, 1.9
to 2.7) and 1.7 for females (95 percent
confidence interval, 1.4 to 2.0). This means
that individuals with a prediving history of
panic are about twice as likely to panic
while diving compared to those without a
prediving history of panic.
Panic during and after initial certifica-
tion training — Eleven percent of males
with a prediving history of panic experi-
enced their first dive panic during their ini-
tial certification training, compared to four
percent of those without a prediving histo-
ry of panic. Thirty-four percent of males
with a prediving history of panic had their
first dive panic after their initial training,
compared to only 16 percent of those with-
out a prediving history of panic. Twenty-
one percent of females with a prediving his-
tory of panic had their first panic experi-
ence during their initial training compared
to 11 percent of those without a prediving
history of panic. Thirty-five percent of fe-
males with a prediving history of panic had
their first dive panic after their initial train-
ing, compared to 21 percent of those with-
out a prediving history of panic.
For both males and females whose first
THE UNDERSEA JOURNAL – FIRST QUARTER 2003
The average range of dives since initial certification was 51-100 for males and 26-50 for females.
Most divers (47 percent of males and 59 percent of females) had been
certified for less than five years.
Figure 3
Number of Dives Since
First Certified
Figure 2
Years Since First Certified
as Diver
Figure 4
Number of Dives in Past 3 Years
The average range of dives during the past three years was 26-50 for both males and females.
dive panic occurred after their initial train-
ing, the average number of dives during the
year prior to the first panic experience dur-
ing a dive was 11-25 dives, suggesting that
recent dive activity made little difference.
We found no statistically significant
difference in the highest certification levels
attained between divers with or without
panic during diving. Unfortunately, the
survey did not ask the level of certification
at the time of the panic dive, just the high-
est level they had obtained at the time of
the survey.
Prediving history of panic and number
of panic experiences during diving — A
prediving history of panic was also associ-
ated with having multiple panic experi-
ences during diving. Thirty-eight percent
of males and 41 percent of females with a
prediving history of panic reported more
than one panic experience while diving,
compared to only 25 percent of males and
30 percent of females without (p < 0.0001
for males and p < 0.001 for females). The
risk ratio for having more than one panic
experience while diving for divers with a
prediving history of panic compared to
those without a prior history was 1.5 for
males (95 percent confidence interval, 1.1
to 2.0) and 1.4 for females (95 percent
confidence interval, 1.0 to 1.9).
Incidence of panic and subsequent panic
in divers — Some divers reported panic
before and after they began diving, but not
during diving (two percent of all divers).
Others reported having their first panic
during diving and then having another,
nondiving panic (two percent of all males
and three percent of all females). Still other
divers reported a prediving history of
panic, panic during diving and panic after
they began diving (three percent of all
males and four percent of all females).
Diver’s perceptions and consequences of
first panic experience during a dive —
Males and females differed in their percep-
tions and reactions to their first panic dur-
ing a dive. While females were more likely
to have a panic during a dive (37 percent
versus 24 percent, p<0.0001), more males
perceived their first panic during a dive as
life-threatening (37 percent versus 27 per-
cent, p< 0.0001).
42
PROFESSIONAL ASSOCIATION OF DIVING INSTRUCTORS®
Figure 5
Highest Level of Certification of Divers
Figure 6
Incidence of First Panic During and After Initial Training
Figure 7
Number of Dives During Prior Year for Divers Whose
First Panic Dive Occurred After Initial Certification Training
Open Water Diver was the most common highest level of certification (29 percent of males
and 38 percent of females).
Table 1. Relative Risk of First Panic With vs. Without Prediving Panic
Relative Risk (95% C.I.)
Males – Total (N = 9190) 2.3 (1.9, 2.7)
Males - Panic during initial training (N = 1426) 3.2 (2.6, 3.8)
Males - Panic after initial training (N = 7764) 2.1 (1.9, 2.3)
Females - Total (N = 2897) 1.7 (1.4, 2.0)
Females - Panic during initial training (N = 527) 1.9 (1.6, 2.3)
Females - Panic after initial training (N = 2370) 1.6 (1.4, 1.9)
43
Most divers who had a panic during a
dive reported they remembered their train-
ing in how to deal with panic and used
that training (81 percent of males and 73
percent of females). More females than
males recognized offers of help during
their first dive panic experience (67 per-
cent versus 38 percent, p<0.0001).
Fifteen percent of both males and fe-
males made a rapid or uncontrolled ascent
during their first panic while diving. But,
within that 15 percent, only five percent of
males and four percent of females reported
signs or symptoms of DCI, and only one
percent of males and two percent of fe-
males underwent recompression. Only one
reported a permanent injury: Residual
numbness in the left toes after five years.
Granted, deceased divers made no reports
of injuries or deaths. Eighty-two percent of
males and 80 percent of females obtained
additional training or retraining as a result
of their first dive panic.
Discussion
Demographics — Seventy-six percent of
our respondents were male and 24 percent
were female, comparing favorably with 75.6
percent male recreational divers reported in
a Rodale’s Scuba Diving random subscriber
survey of August 2000. The median age of
our male and female survey respondents
was 35 to 39 years old. A Gallup Organi-
THE UNDERSEA JOURNAL – FIRST QUARTER 2003
Table 2. Diver Response to First Panic Attack During Diving
Males (N = 2206) Females (N = 1099)
Remembered Training 82% 77%
Used Training 81% 73%
Recognized Offer of Help* 38% 67%
Made Rapid or Uncontrolled Ascent 15% 15%
Obtained More Training 82% 80%
*p<0.0001
zation random telephone poll in December
1997 and January 1998 found the average
active diver is 36 years old, with about 62
percent of divers between 25 and 44.
Our survey participants differed from
those in other published polls in at least
two ways: certification level and dive activi-
ty. Essentially all our participants were cer-
tified, however, in the previously men-
tioned Gallup poll, only 29 percent of
those who had tried scuba diving were cer-
tified recreational divers. Our participants
were also certified to higher levels: 71 per-
cent of males and 62 percent of females
had certifications beyond open water, com-
pared to only 56.6 percent in a recent Ro-
dale’s Scuba Diving survey.
In all fairness, uncertified and certified
divers who had dropped out of the sport
were unlikely to have participated in the
survey. Divers who dropped out of diving
because of severe panic problems while div-
ing would not be represented in the survey
unless they had maintained a passive inter-
est or a friend or spouse encouraged them
to participate in the survey. Analysis of the
survey suggested that most respondents were
active certified divers, with 70 percent of
males and 65 percent of females having
made more than 25 dives in the past three
years.
Incidence of panic — The incidence of panic
during diving reported in our survey was
lower than that reported by Morgan and
Griffiths. One explanation could be that
Morgan and Griffiths asked about “panic or
near panic” without further definition,
which would broaden what a respondent
might report as a “panic experience.” Our
survey asked only about panic and, as noted
earlier, provided a limited definition
We also found that 82 percent of males and
77% of females remembered their training
in response to the first panic attack. This
contradicts previous conclusions.
.
Conclusions
Within a 95 percent confidence interval,
the survey found that male recreational
scuba divers with a prediving history of
panic were 1.9 to 2.7 times as likely to
panic during a dive as those without a prior
history. Females with a prediving history of
panic were 1.4 to 2.0 times as likely as
those without a prior history. Most divers
who panicked during a dive reported they
remembered their training in how to deal
with panic and used that training. Eighty-
five percent of those who panicked while
diving did not make a rapid or uncon-
trolled ascent. Even among the 15 percent
who made a rapid or uncontrolled ascent,
only five percent of males and four percent
of females reported suffering from symp-
toms of decompression illness.
Limitations of Survey
This survey and its conclusions have obvi-
ous limitations. First, the survey was not
random: A large number of participants
does not make up for possible selection
bias. Our participants were self-selected and
there is no way to know how representative
they were of the certified recreational diver
population. This was a survey of active
divers and may tell us nothing about other
divers. Little is known about divers who
drop out of the sport or what leads to their
dropping out. If panic dives led many of
them to drop out and lose interest in the
sport, then this survey’s results must be in-
terpreted very conservatively. On the other
hand, this survey shows that many divers
are able to continue diving despite having
experienced panic while diving.
Second, our survey was retrospective and
subject to convenient and favorable revi-
sion of memories by participants. A
prospective study is needed using new dive
students before their first training session
and then following up with them each year
for at least three years. Such a study might
also offer new information as to what leads
divers to drop out of the sport.
Third, the data provided by partici-
pants was self-reported. We did not ask to
see dive logs or certification cards, etc. We
made no attempts to verify information or
claims other than to follow up by email on
seemingly extreme and mutually exclusive
responses. Some respondents volunteered
additional information and a few offered
to have their medical records sent to me
and asked for advice. Over the two years
since the study began, we have been im-
pressed with how eager divers were to talk
about their panic dive experience and how
much they wanted to help us understand
what had happened to them. ◆
References and Bibliography
American Psychiatric Association. Diagnostic and
Statistical Manual of Mental Disorders, 4th
Edition. Washington, DC, American Psychiatric
Association, 1994, p. 394-396.
Bachrach AJ and Egstrom GH. Stress and Perfor-
mance in Diving. San Pedro, California, Best
Publishing, 1987, p 1.
Bove AA. Medical Examination of Sport Scuba
Divers, 3rd edition. San Antonio, Texas, Medical
Seminars, 1998, p. 20-25.
Dillman DA. Mail and Internet Surveys: The
Tailored Design Method, 2nd Edition. New York,
John Wiley & Sons, 2000.
Divers Alert Network. Report on Decompression
Illness, Diving Fatalities, and Project Dive Explo-
ration. 2001 Edition (Based on 1999 Data),
Durham, NC, Divers Alert Network, 2001.
Elliott DH and Bennett PB. Underwater Acci-
dents. In: Bennett PB and Elliott DH (Eds.). The
Physiology and Medicine of Diving, 4th Edition.
London, WB Saunders, 1993, p 238-252.
Griffiths TJ, Steel DH, Vaccaro P, Allen R, and
Karpman M. The Effects of Relaxation and Cogni-
tive Rehearsal on the Anxiety Levels and Perfor-
mance of Scuba Divers. Int J Sport Psych 1985;
16: 113-119.
Guidelines for Recreational Scuba Diver’s Physical
Examination, Recreational Scuba Training Coun-
cil, Inc., 1998 and 2001.
Hunt JC. Divers’ Accounts of Normal Risk. Sym-
bolic Interaction 1995; 18(4): 439-462.
Ingle J. Diver Safety Is Linked with Repetition
Training. NDC Bulletin of British Sub-Aqua Club
2000.
Morgan WP. Anxiety and Panic in Recreational
Scuba Divers. Int J Sports Med 1995; 20: 398-
421.
Morgan WP. Psychological Characteristics of the Fe-
male Diver. In: Fife WP (ed.). Women in Diving.
Bethesda, MD: Undersea Medical Society, 1987, p.
45-54.
Nevo B and Breitstein S. Psychological and Be-
havioral Aspects of Diving. Flagstaff, Arizona,
Best Publishing Co, 1999.
United States Department of Commerce. NOAA
Diving Manual: Diving for Science and Technol-
ogy. 4th Edition. Joiner JT (Ed). Flagstaff, Arizona,
Best Publishing Co, 2001, Ch. 21, p. 1-4.
Panic Attack:
A discrete period of intense fear or discomfort, in
which four (or more) of the following symptoms
developed abruptly and reached a peak within 10
minutes:
1. palpitations, pounding heart, or accelerated
rate
2. sweating
3. trembling or shaking
4. sensations of shortness of breath or
smothering
5. feeling of choking
6. chest pain or discomfort
7. nausea or abdominal distress
8. feeling dizzy, unsteady, lightheaded or faint
9. derealization (feelings of unreality) or deper-
sonalization (being detached from oneself)
10. fear of losing control or going crazy
11. fear of dying
12. paresthesias (numbness or tingling
sensations)
13. chills or hot flashes
Panic Disorder:
1. recurrent unexpected panic attacks
2. at least one of the attacks has been followed
by one month (or more) of one (or more) of
the following:
• persistent concern about having addition-
al attacks
• worry about the implications of the attack
or its consequences (e.g., losing control,
having a heart attack, “going crazy”)
• a significant change in behavior related to
the attacks
3. The panic attacks are not due to the direct
physiological effects of a substance (e.g.,
drug abuse, a medication) or a general med-
ical condition (e.g., hyperthyroidism).
The panic attacks are not better account-
ed for by another mental disorder, such as
Social Phobia, etc.
From the American Psychiatric Association. Diagnostic and
Statistical Manual of Mental Disorders, 4th Edition. Wash-
ington, DC, American Psychiatric Association, 1994, p. 394-
403.
What is Panic?
Editor’s Note:
What the Panic Survey Tells
Us About Diver Training
The panic survey has some interesting im-
plications for diver training. The data
suggest that training is largely effective;
81 percent of males and 73 percent of fe-
males reported remembering their train-
ing in the emergency. Eight-five percent
made no panicked ascent, and only five
percent of those who did reported DCI
symptoms.
This supports current training proto-
cols; panic arises when individuals lack
solutions to a critical problem. One train-
ing goal is to provide responses; the sur-
vey indicates that most respondents drew
upon their training.
The data suggest divers with a predive
panic history are about twice as likely to
panic as those without. Those with a pre-
dive panic history were also more likely to
have more than one panic episode.
All divers benefit from repetitive skill
practice. The more familiar divers are
with skills, the more likely they are to re-
spond appropriately to panic. Repeated
practice in confined water, including
spontaneous drills, raises the response
availability level.
Student divers who show elevated
stress may be more panic prone. This may
be evident if they exhibit stress when un-
successful with a new skill, like standing
abruptly when mask clearing in shallow
water. These individuals benefit from rep-
etition, though the practice required may
be higher than for other individuals.
Females were almost twice as likely to
recognize help than males. The data don’t
show why, but cultural influence is a rea-
sonable speculation. Male self-reliance is
common in many cultures. Asking for
help may threaten male esteem, or males
may be conditioned to not readily look
for assistance.
Emphasizing diving as a team activity
may help make males more receptive to
external assistance and may offset self es-
teem issues by relating asking for and ac-
cepting help with the characteristics of a
good diver.
