Diving & Post Traumatic Stress Syndrome

May 18, 2010

Doc Vikingo“Dear Dr. Vikingo. I’m an already certified 600+ dive diver who after tours in Iraq and Afghanistan with the Military developed PTSD. For the last 2 years I have been in therapy and have done inpatient treatment. I’m now stable and have no side effects. I’d love to get back to diving but need to do it right I take depakote blood test are fine and citalopram. When would you suggest I talk to my Drs. about this? I have been through CBT therapy, Individual, and group therapies. Honestly the most peacefull times of my life have been while I was diving.”

(A) 05.20.10

“Hi DD,

Per the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, (DSM-IV-TR), 17 possible symptoms that can develop following the experience of a traumatic event are divided into three clusters.

Re-Experiencing Symptoms

-Frequently having upsetting thoughts or memories about a traumatic event.

-Having recurrent nightmares.

-Acting or feeling as though the traumatic event were happening again, sometimes called a “flashback.”

-Having strong feelings of distress when reminded of the traumatic event.

-Being physically responsive, such as experiencing a surge in your heart rate or sweating, to reminders of the traumatic event.

Avoidance Symptoms

-Making an effort to avoid thoughts, feelings, or conversations about the traumatic event.

-Making an effort to avoid places or people that remind you of the traumatic event.

-Having a difficult time remembering important parts of the traumatic event.

-A loss of interest in important, once positive, activities.

-Feeling distant from others.

-Experiencing difficulties having positive feelings, such as happiness or love.

-Feeling as though your life may be cut short.

Hyperarousal Symptoms

-Having a difficult time falling or staying asleep.

-Feeling more irritable or having outbursts of anger.

-Having difficulty concentrating.

-Feeling constantly “on guard” or like danger is lurking around every corner.

-Being “jumpy” or easily startled.

Clearly many of these could pose a significant danger to diving.

All divers must show attention, concentration, decision making capacity, impulse control and behavioral modulation that are fully adequate to meet the demands of scuba. These faculties may be compromised in persons diagnosed with PTSD and treated with mood stabilizers such as the SSRI citalopram (Celexa) and the anti-convulsant divalproex sodium (Depakote).

Before returning to SCUBA, it would be prudent that: (a) mental status examination demonstrates the condition to be well controlled; (b) the diver who is taking medications has been on them for an extended period and side effects dangerous to scuba are neither reported nor observed upon careful examination; (c) there are no other contraindications, mental or physical, in the clinical picture; (d) the diver feels he is up to it and fully comprehends any additional risks; (e) the diver has been cleared for diving by his physician and makes full disclosure to the dive op (which likely will want to see written clearance) and to his/her dive buddy.

Best of luck and thanks for serving your country.



This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice to you or any other individual and should not be construed as such. Consult with your physician before diving.”

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7 thoughts on “Diving & Post Traumatic Stress Syndrome”

  1. Thanks for posting this blog.

    I am a dive instructor and a vet with over 24 years of diving experience. I currently run a 501c3 non profit for veterans and first responders that uses diving exclusively for helping wounded, rehabilitating, and transitioning veterans.

    80% of my divers will not go on to open water certification so we run confined water sessions that help to deal with rebuilding of motor skills, refocus of hyper vigilance, confidence training, trust building, and other aspects of therapeutic diving,

    Dr. Viking has offered some great advise, I am fortunate that within our board of directors, I have an advisory committee of psychologists, medical doctors, and veteran counselors that we run activities through as well as having each vet receive a physicians approval prior to diving in cases where there are constrictions to diving. We also do quite a bit of pre-screening prior to taking on divers and understand this program is neither a “silver bullet” for seen and unseen wounds, or is it the right activity for everyone.

    We are receiving feedback of increased motor skills with both our divers who have received wounds or injuries to the extremities, spine, and brain. Our divers who have endured muscle spasticity a decrease as long as we keep body temps up, and increase in sleep 1-3 nights post confined water sessions.

    When our divers have a change in medications we have them consult with both their physician as well as ours to determine together if diving that day is in the best interest of everyone involved. Either way, we find some type of activity for them to be a part of ( we strive for increased oxytocin release- the trust chemical).

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  2. Your buddy, not your dive op, is most likely to be faced with the issue.

    Dive with someone who knows you well, or dive with someone who’s been through some of the same things. Pre-think the sorts of issues that might be a challenge or a trigger–feeling overly exposed if the water is too clear, as if you’re “lacking cover”? The “crack” of an anchor chain? A tap on your shoulder? And think what the maladaptive responses might be–taking “cover” on the bottom, when it’s time to ascend? Whirling in response to a sound (which may sound right next to you, or right behind you, as sounds do, underwater)? How would you respond to a buddy who carelessly flashed a light in your face on a night dive?

    Warn your buddy in specfic, concrete ways if there’s someway you should not be touched or approached, or if there’s some warning sign that you’re getting stressed, so they don’t compound your risk, and theirs.

    As to the dive operator, whether or not you say PTSD, you might tip them off in some way. How do you respond to signal flares? Fireworks?

    I have to agree that diving is usually a serene and powerful source of balance and sanity, and you should absolutely get back into it. But don’t use it as a way to push limits. For a while, consider your self (medicated and all) as a new piece of equipment, and dive not only within your “official” limits, but within the limits of a much less experienced diver. The delight and benefits will still be there.

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  3. I agree that the dive operator does not have a real need to know everything about you. Do you tell the local DMV everything that happens? And most people operate some kind of vehicle every day…The really important stuff is the extra requirements that come about from medication or physical problems that effect the immediate operation of the dive. I have PTSD. My biggest concern for myself would be the suicidal thoughts that pass through every day. If I acted on even one I would not have any more thoughts, so I make the adjustment and put in place the mental steps to get past the immediate mental low point and carry on. I have been successful for over 40 years–so far.
    Diving has its rewards in many ways; the marvel of another kind of life adjusted to an environment different from ours, the physical exercise rewards and an accomplishment of another dive well done.
    Keep diving.
    I still have to adjust to the “fear of the dark” from my nights in combat, but that is a private story.

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  4. Doc,

    I loved your thorough and gracious response to the issue raised about PTSS. Our men in uniform deserve all the support we can give them. If diving can give this guy some peace, I hope his physician clears him. My thanks to the soldier as well for his service. I hope they all can come home soon.

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  5. Hi Rob,

    I agree this is a topic open to debate. In this regard, you might enjoy the following recent Undercurrent articles where Ben and I intentionally took somewhat differing positions.

    Oct ’09 issue:

    Why Divers Fail to Disclose Medical Conditions http://www.undercurrent.org/members/UCnow/issues/y2009/UC1009/DiscloseMedicalConditions200910.pdf

    Jan ’10 issue:

    Lying About Your Health Could Be Lethal
    our medical expert tells you why you shouldn’t fib to dive shops



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  6. Hello DD & Dr. Vikingo,

    I was interested to read the list of symptoms Dr. V listed. As a Vietnam vet who would have been diagnosed with PTSD, had that been recognized at the time, I found this very interesting.

    When I returned from Vietnam, the first night I was very uncomfortable going to sleep NOT behind barbed wire with someone on gaurd. For many years, when I went hunting, I’d hit the dirt when someone else fired a shot nearby, especially if close enough in my direction that I’d hear the double crack-pop which indicates the bullet passed you before the sound of the original shot could reach you. That still gets my accute attention. I still have the hair on my neck stand up if I even drive through an area near a river that is brushy and reminiscent of the Cambodian border and the Oriental River. I came back and trying to get ahold of “The Real World”, got married in short order. That proved unfair to my wife, myself and her daughter. We didn’t have that much in common and it broke up in a few years. Only later, when watching an early show about PTSD did I realize why I had gotten married.

    I had started diving in 1967, a year before getting drafted. I instantly became a diving nut, and was in the ocean at Monterey pretty much every week at least once. On returning from Vietnam, I resumed diving just as intensly.

    You mentioned that you were most at ease and peaceful diving. That was and is certainly one of my favorite situations. PTSD never was a problem with diving for me. I certainly recognize that if you are on medication that might warp your judgement, that is a real issue, but if you can avoid that sort of medication, I say go for the diving. Certainly I would start with an easy local dive with no stress, maybe even a refresher pool course, and see how you react, then build up from there.

    I can’t help thinking that with all PC things we deal with, this has become highly over rated. You develop conditioned responses to serious situations. That is just natural. When people are trying to kill you in ambushes in certain terrains, you damn well will be leary of that same terrain for a very long time. That’s not being ‘sick’, that’s being smart!

    Thanks for your service, I hope you have a very long and happy life diving.

    Tom Reese

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  7. Hello DD. I think Dr. Vikingo has offered wise, ethical and considered counsel on resuming diving while taking medications for a nervous condition. However, I might hold back on making full disclosure to the dive operator. Once you have been cleared by a competent physician, once you have cleared yourself according to the dictates of your conscience and your confidence in your ability to safely resume diving, it may not be in your best interest to disclose your condition to the dive operator. Many dive operators are strictly interested in protecting their own legal interests. In a case like yours, you might get a knee-jerk response from even the best-intentioned operators. It’s far easier for the dive operator to “just say no.” And looking at it from the dive operators’ point of view, I understand that. The dive operators have to make a quick decision based on limited and perhaps biased information from the customer. Few dive operators are capable of making an intelligent judgement call or reasoning through your particular case the way Dr. Vikingo did. My main question is, once you have been legitimately cleared, does the dive operator NEED to know? Likewise, once you’re cleared, does your buddy NEED to know? Sometimes being too honest is just asking for needless trouble. The scuba forums of the world are filled with rueful tales of divers whose vacations were ruined when they made unwarranted health disclosures in the interest of “being honest.” Sometimes there is a fine line between being honest and being foolish.

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