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Aviation Psychiatry
KCL 2011
Aviation Psychiatry
Introduction
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The scope of psychiatry is in a constant state of evolution.
Important to distinguish between:
o Psychiatric symptoms
 Mild anxiety symptoms are part of the common human experience in response to
stressful events
o Psychiatric syndromes
 Anxiety symptoms may also reflect the presence of the other disorders of anxiety
such as panic disorder, PTSD…
 They may not necessarily be associated with the presence of any current external
stressor.
Important to be clear on the difference between form and content:
o The content of a mental phenomenon may change in response to psychosocial and
historical influences
o The form remains a constant.
Occupational psychiatry
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Risk of becoming identified more closely with the needs of the employer than the employee.
Clinical psychiatric syndromes
Adjustment disorders
 Subjective distress and emotional disturbance arising in the course of adaptation to a significant
life event or life change.
Occupational risks
o Need to avoid the unnecessary and inappropriate use of antidepressant medication.
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Clinical features
These disorders are states of subjective distress and emotional disturbance arising in the
course of adaptation to a significant life event or life change.
Lie between normal behaviour and major psychiatric morbidities.
May occur after disruption of an individual's social network.
Variable manifestations:
 Low mood
 Anxiety and worrying thoughts
 Feeling of inability to cope
 Conduct problems.
Management
o Problem-solving approach is helpful
o Pharmacological management has little role
Occupational disposal
o Good prognosis
o Mild adjustment problems are compatible with routine flying duties
o More severe or prolonged problems or involved in high-demand tasks should be unfit to fly
until recovery.
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Mood disorders
Aviation Psychiatry
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Occupational risks
o Use and safety of antidepressant medication
o Risk of impaired performance of safe-critical task
o Cause of fear of flying
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Clinical features
Normal mood variation is related to sad or happy events.
Clinical depression and mania are more than extremes of normal mood variation.
Manic states often start as hypomania:
 Heightened mood (=euphoria)
 More and faster speech (logorrhoea)
 Quicker thought
 Brisker physical and mental activity levels
 Irritability
 Perceptual acuity
 Paranoia,
 Heightened sexuality
 Impulsivity.
Can easily progress to frank psychosis
A common presentation of mania is a mixed episode in which depressive mood
predominates.
Depressive states mood is:
 Bleak
 Pessimistic
 Despairing
 There is a slowing or decrease in almost all aspects of emotion and behaviour.
 The constant mental pain and suicidal symptoms seriously affect the quality of life.
Unipolar depressive disorder is characterized by:
 Depressive episodes without any hypomanic or manic states.
Bipolar disorder is characterized by:
 Manic or hypomanic states
 The patient may be:
 Depressed
 Euthymic
 Hypomanic/manic.
 Only 1 manic/hypomanic episode is required to diagnose bipolar rather than
unipolar disorder.
Biochemical understanding of depressive mechanisms is associated with:
 Monoamine neurotransmitters
 Noradrenaline
 Serotonin
 (Dopamine)
Stressors may not only precipitate episodes but also increase such a pre-existent
vulnerability (kindling effect).
All patients thought to be suffering from any form of depressive disorder must be assessed
for the risk of suicide, employing direct questions on suicidal thoughts and intent.
Psychiatric rule of thumb:
 Anyone presenting in middle age with anxiety symptoms without a previous history
of anxiety disorder and in the absence of a definite exceptional major stressor
should be regarded as suffering from a depressive illness until proved otherwise.
Most mood disorders have a course characterized by multiple recurrences.
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 Precipitating events play an important role in the onset of the first few episodes.
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Management
 Clinical guidelines have been produced by the National Intistute for Clinical Excellence
(NICE 2004a).
 Antidepressant medication is not recommended for the initial treatment of mild
depression.
 When antidepressant medication is required, SSRIs are recommended and should be
continued at least 6 months following remission of depressive symptomatology.
 Lithium and Valproate are the drugs of first choice in the management of mania.
Occupational disposal
 Aircrew with mood disorder are unfit to fly:
o Cognitive difficulties
o Neurophysiological disturbances
o Risk of suicide.
 At least 3 months close monitoring after successful drug treatment and withdrawal of
medication.
 Patients requiring maintenance therapy are currently unfit to fly.
 The very high recurrence rate with bipolar disorder together with the nature of the
mood disorder itself makes a return to flying duty unlikely.
Self-harm, including attempted suicide and para-suicide
Occupational risks
 Risk of aircrew using an aircraft to commit suicide.
Clinical features
 Much of self-harmful behaviour is impulsive and associated with psychosocial stressors.
 In about ½ of all suicides, a previous attempt is found in the person's history.
 Suicide is a leading cause of premature death.
 Psychosocial characteristics of repeaters include:
o Substance abuse
o Depression
o Hopelessness, powerlessness
o Personality disorders
o Unstable living conditions, living alone
o Criminal records, previous psychiatric treatments
o History of stressful traumatic lifer events.
 The use of aircraft to commit suicide is uncommon (≤ 3‰ of all fatal aviation
accidents).
Management
 Clinical guideline from NICE 2004c.
Occupational disposal
 Unfit to fly until professional assessment by a psychiatrist with occupational
experience.
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Acute stress disorder
Occupational risks
 Combat stress is of military operational importance.
Clinical features
 ASD is a transient reaction to exceptional physical or mental stress.
 Polymorphic condition with an initial stage of a "daze":
o Narrowing of attention
o Inability to comprehend stimuli
o Disorientation
o With subsequent anger, anxiety or low mood.
Management
 In accord with the principles of P.I.E.
o Proximity: in close proximity to their place of duty,
o Immediacy: as soon as possible after the onset of symptoms,
o Expectancy: with the expectation that they will return to duty when recovered.
 Casualties with ASD are at risk of developing PTSD.
Occupational disposal
 Military aircrew suffering from ASD have recovered, returned to duty and functioned
effectively.
 Should be the subject of psychiatric review.
Post-traumatic stress disorder
Occupational risks
 Impaired performance of safety critical tasks.
Clinical features
 Chronic, frequently disabling disorder that develops following exposures to a stressful
event or situation of an exceptionally threatening or catastrophic nature.
 Is not associated with "normal" events such as a divorce or a job loss.
 Common disorder in the general population.
 Three characteristic areas of symptomatology:
o Involuntary re-experiencing = intrusive memories:
 Repetitive
 Intrusive
 Other sensory impressions (smells…)
 Nightmares
 Flashbacks.
o Avoidance of any reminders
o Symptoms of chronic hyper-arousal:
 Hyper-vigilance
 Exaggerated startle response
 Irritability
 Concentration difficulties
 Insomnia
 Often associated with depressive symptoms, conduct problems, substance misuse,
marital disharmony…
 Symptoms may be delayed or develop immediately after an event:
o ASD
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o PTSReaction
Often abnormally low levels of cortisol
Various vulnerability factors for PTSD have been identified:
o Previous personal or family history of anxiety or affective disorders
o Neuroticsm
o Lower intelligence
o Female gender
o History of previous trauma.
PTSD is one of the differential diagnoses in fear of flying.
Management
 Clinical guidelines produced by NICE 2005
 The delivery of a brief, single-session psychological intervention shortly after the
precipitating event does not prevent the development of PTSD.
 Substantial natural recovery rate
 ⅓ of patients develop chronic PTSD
 Severe PTSD symptomatology should be treated with trauma-focused CBT (Cognitive
Behavioural Therapy)
 Chronic PTSD should be similarly treated with CBT or with EMDR (Eye Movement
Desensitization and Reprocessing).
 Benefits from drug treatment (paroxetine, mirtazapine…), but should not be used as the
routine first treatment for PTSD in preference to CBT or EMDR.
 The chances that PTSD will recover with appropriate treatment do not decrease with
time elapsed from the precipitating event.
Occupational disposal
 Aircrew diagnosed with PTSD should not fly.
 Following treatment and a good recovery, a return to flying can be expected.
Agoraphobia with panic disorder
Occupational risks
 Severe and incapacitating form of anxiety.
 Cause of fear of flying.
Clinical features
 Panic disorders are characterized by:
o Spontaneous "Out of the Blue"
o Inappropriate character of panic attacks.
 Symptoms of panic attack include:
o Palpitations, pounding heart & tachycardia
o Sweating, chills or hot flushes
o Trembling or shaking
o Shortness of breath or smothering, feeling of choking
o Chest discomfort or pain
o Nausea or abdominal distress
o Dizziness, unsteadiness, light-headedness, faintness
o Derealisation or depersonalization
o Fear of dying…
 Distinct from situational or phobic anxiety.
 Patients develop an anticipatory anxiety of having more attacks
 ➪Develop avoidance of situations that were associated with previous attacks.
o There is a cluster of situations associated with avoidance:
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 Public transportation (bus, train, airplane…)
 Riding in or driving a car
 Crowds
 Shopping
 Bridges, tunnels, elevators and other enclosed spaces.
o Patients fear situations where escape is difficult or impossible.
75% of patients who meet criteria for panic disorder also have associated significant
agoraphobic avoidance.
Agoraphobia may develop without a history of panic disorder.
The dissociative experience of break-off can precipitate a panic attack and agoraphobic
avoidance.
Management
 NICE 2004b
 Psychological CBT, pharmacological (SSRI) and combination treatments have been
shown to be effective.
Occupational disposal
 One of the differential diagnoses of fear of flying.
 Aircrew with panic disorder should be unfit to fly.
Obsessive-compulsive disorder
Occupational risks
 Impaired performance of safety-critical tasks.
Clinical features
 OCD is a common, chronic, disabling disorder marked by:
o Obsessions and/or
 Intrusive
 Repetitive thoughts
 Unpleasant
 Produce anxiety
o Compulsions that are egodystonic.
 Repetitive goal-driven behaviours that have to be performed in order to
prevent anxiety.
 Both are experienced as being irrational.
 Differential diagnosis:
o Anxiety disorders
o Schizophrenia
o Tourrette syndrome
o Autism
o Brain disease
o Anankastic personality disorder:
 Lifelong presence of obsessional behavioural traits
 Ordered, rigid, humourless & un-spontaneous personality traits.
Management
 CBT
 SSRI
Occupational disposal
 A person diagnosed OCD is unfit to fly.
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Personality disorder
Aviation Psychiatry
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Occupational risks
 Impaired performance of safety-critical tasks.
Clinical features
 Deeply engrained and enduring behaviour patterns, manifesting themselves as
inflexible responses to a broad range of personal and social situations.
 Affect ≈ 10% of the general population.
 Divided in 3 clusters:
o Cluster A: Paranoid, schizoid and schizotypal personality disoders
o Cluster B: Dissocial (antisocial), emotionally unstable (borderline) and histrionic
personality disorders.
o Cluster C: Anankastic, anxious and dependent personality disorders.
Occupational disposal
 An individual with a formal diagnosis of personality disorder should be unfit to fly.
Schizophrenia and other delusional disorders
Occupational risks
 Impaired performance of safety-critical tasks.
Clinical features
 Schizophrenia is characterized by:
o Delusions
o Hallucinations
o Thought-alienation phenomena deriving from abnormal mental processes.
 Most patients have a lifelong, remitting and relapsing course of illness.
Occupational disposal
 Unfit to fly.
Substance misuse
Occupational risks
 Impaired performance of safety-critical tasks.
Clinical features
 Humans have made use of psychotropic drugs since at least the Neolithic period, but
generally not while flying…
 Associated with a variety of disorders:
o Harmful use
o Development of dependence
o Development of withdrawal states
 Acute intoxication possible with:
o Alcohol
o Opioids
o Cannabinoids
o Sedatives and hypnotics
o Cocaine
o Stimulants
o Hallucinogens
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o Tobacco
o Volatile solvents
Psychoactive drugs reduce performance, disinhibit and impair judgement.
Phenomenon of flashbacks with LSD.
Acute intoxication due to alcohol:
o Disinhibition
o Argumentativeness
o Aggression
o Lability of mood
o Impaired attention and judgement.
Acute intoxication due to opioids:
o Apathy and sedation
o Disinhibition
o Psychomotor retardation
o Impaired attention and judgement.
Acute intoxication due to cannabinoids:
o Euphoria and disinhibition
o Anxiety or agitation
o Suspiciousness or paranoid ideation
o Temporal slowing
o Impaired judgement
o Impaired reaction time
o Auditory, visual or tactile illusions
o Hallucinations with preserved orientation
o Depersonalization and derealisation.
Acute intoxication due to stimulants (including caffeine):
o Euphoria and sensation of increased energy
o Hypervigilance
o Grandiose beliefs or actions
o Abusiveness or aggression
o Lability of mood
o Repetitive stereotyped behaviours
o Auditory, visual or tactile illusions
o Hallucinations with preserved orientation
o Paranoid ideation.
Dependence syndrome develops after repeated substance use.
Withdrawal states are described with features characteristic of the particular drug, but
typically including marked anxiety.
Alcohol misuse
Occupational risks
 World's favourite drug
 Major contributor to disease, disability and premature mortality.
 In the UK, hazardous drinking is considered to start @ 21 units/week for men and 16
units/week for women.
Clinical features
 Euphoria @ 25mg% (0.25g/l) BAC (blood alcohol concentration)
 Lack of coordination @ 50-100 mg% BAC
 Unsteadiness @ 100-200 mg% BAC
 Stupor @ 200-400 mg% BAC
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Subsequent respiratory depression and death.
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Alcohol reduces processing capacity, disrupting the ability to divide attention between
competing tasks, the secondary task suffering more than the primary.
The degree of impairment increases with the complexity or difficulty of the task.
The detrimental effects persist after the drug has been eliminated from the blood
stream.
The symptoms of a hangover are worse when almost all ethanol and its metabolite
acetaldehyde have been cleared.
The types of drink containing higher quantities of methanol (red wine, brandy, whisky)
are associated with more severe hangovers.
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Physiopathological disturbances following alcohol ingestion include:
o Dehydration
o Metabolic acidosis
o Hypoglycaemia
o Disturbed prostaglandin synthesis
o Abnormal secretion of vasopressin, cortisol, aldosterone, renin and testosterone
o Increased cardiac output, vasodilatation and tachycardia.
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Excessive use of alcohol may exacerbate an existing psychiatric disorder.
Individuals may drink as a result of psychiatric disorder.
Alcohol misuse itself is often the primary condition and the main cause of any
psychological disturbance.
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CAGE questionnaire asks 4 questions:
o Have you tried or felt you should cut down your drinking?
o Have you ever felt annoyed by criticisms about your drinking?
o Have you ever felt bad or guilty about your drinking?
o Have you had a drink first thing in the morning ("eye-opener") or before lunch to
steady your nerves or get rid of a hangover?
Any single positive answer is significant.
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Biological indicators include:
o ➚ GGT (γ glutamyl transferase)
o ➚ MCV (mixed corpuscular volume)
o ➚ (GGT & MCV) ++
Management
 Aircrew should not fly unless their BAC is "zero" (< 5 mg%)
 Post-alcohol impairment (PAI) suggests that aircrew should not fly until well after the
BAC has reduced to zero.
 FAA imposes the 8-hour rule (from bottle-to-throttle), but 8 hours is really a strict
minimum (12 hours in Europe, ideally 24 hours)
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3 particular aspects of the management of alcohol misuse:
o Withdrawal may require inpatient admission for detoxication
o Relapse prevention
o Management of any co-morbid psychiatric disorder.
Benzodiazepines for the management of withdrawal.
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Occupational disposal
 CAA regulations state that an aircrew member with alcohol misuse is to be assessed as
medically unfit.
 The return to flying of RAF aircrew is dependent upon compliance with the
requirements of the RAF's alcohol policy which integrates the medical and disciplinary
aspects.
o Recertification may be considered provided that:
 There is a minimum of 4 weeks' inpatient treatment
 Review by an approved psychiatric specialist
 Ongoing review including blood testing
 Peer reports for a period of 3 years.
o Requirement for continued attendance at AA or equivalent organization
o Relapse may lead to permanent withdrawal of the aviation licence.
Caffeinism
 Aircrew consume prodigious quantities of coffee.
 Caffeinism:
o Feeling of anxiety and nervousness
o Initial insomnia
o Restlessness
o Irritability
o Diuresis
o Tremulousness
o Palpitations and cardiac arrhythmias.
 Can aggravate anxiety disorders.
Transsexualism
Occupational risks
 Transition from one sexual identity to another is a process with considerable demands.
 Risk of adjustment disorders.
Clinical features
 Stated desire to be the other sex.
 Recent findings would implicate the brain bed nucleus of the stria terminalis.
Management
 Harry Benjamin International Gender Dysphoria Association.
 Philosophy of treatment is to do reversible procedures before those that are
irreversible.
Occupational disposal
 On completion of the surgical procedure, full fitness to fly can be granted.
Eating disorders
Occupational risks
 May be associated with metabolic disturbances compromising physical health and
placing aircrew at risk of incapacitation.
Clinical features
 Anorexia nervosa
 Bulimia nervosa
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Management
 NICE 2004d
Occupational disposal
 Individual assessment on fitness to fly.
Specific issues in aviation psychiatry
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Selection to fly
Selection for flying training, for employment, and fitness to fly once trained are separate issues
with different criteria.
Use is made of psychometric aptitude tests combined with an interview board for the assessment
of personality factors.
o Eysenck's Personality Inventory (EPI) has shown some promise.
o Defence Mechanism Test
o The available evidence has not demonstrated adequate reliability and predictive value for
such tests, and they are not used routinely in service aircrew selection.
The use of psychological tests for selection for training or employment must always be evaluated
adequately against specified criteria for reliability and predictive value.
JAR-FCL3 for both class 1 and class 2 medical certificates state that:
o The applicant shall have no established medical history or clinical diagnosis of any
psychiatric disease or disability, condition or disorder, acute or chronic, congenital or
acquired, that is likely to interfere with the safe exercise of the privilege of the licence.
A single self-destructive act or repeated overt acts are disqualifying.
Alcohol, psychotropic drug or substance abuse, with or without dependence, is disqualifying.
Fitness to fly
 Normal behaviour in normal circumstances is associated with a significant risk of error.
 There are only a few active psychiatric diagnoses that can be compatible with unrestricted flying.
Motivation to fly
 Two types of motivation:
o Approach
o Avoidance
 Social-cognitive theory of motivation:
o An individual's inclination to achieve specific goals depends on their feelings of selfefficacy.
o Self-efficacy is mediated by a person's beliefs or expectations about their ability to
accomplish certain tasks.
o These expectations determine whether:
 A certain behaviour or performance will be attempted,
 The amount of effort the individual will contribute to the behaviour,
 How long the behaviour will be sustained when obstacles are encountered.
o 4 ways in which self-efficacy is learned and self-efficacy expectations are acquired:
 Performance accomplishments
 Vicarious learning
 Verbal persuasion
 Physical/affective status.
 Flying has intrinsic rewards:
o Acquisition and performance of high-level skills
o Social exclusiveness of the flying world
o Social high esteem in which aircrew are held
o High levels of physical health expected.
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o The task itself has high levels of satisfaction
o There are emotional rewards
 Mastery and control are powerful reinforcers of behaviour.
 Motivation to fly is a dynamic drive, subject to change:
o Cost/benefits ratio of a flying career may not have been assessed realistically
o Close relationship may put pressure on readiness to accept frequent absences
o Aviator's priorities and/or values may change throughout years
 These factors may result in the appearance of anxiety, a re-evaluation of the aviator's aims, a
change in motivation to avoidance and a decision to leave flying.
Psychoactive medication and fitness to fly
 Any medication with significant psychoactive properties is not compatible with flying.
 There is a controversy over the compatibility of antidepressant medication and flying.
o Aircrew can successfully recover from depressive illness on medication (with modern
drugs) that may have no demonstrable impairment of mental function.
o However, these drugs do continue to have potentially significant side-effects, including the
induction of hypomanic and manic mood disorders.
o Nonetheless, aircrew with long-term stability on maintenance treatment may become
candidates for assessment by the regulatory authorities.
 USAF have used and still use stimulant drugs (amphetamines) for aircrew.
o > ½ of those pilots consider them to have been beneficial
o However abusers are prone to accidents, because the drugs produces excitation and
grandiosity followed by excess fatigue and sleeplessness.
o Sleep-hygiene measures and the maintenance of an appropriate work-rest schedule are of
greater long-term merit.
Operational aviation psychiatry
Anxiety will be experienced by the majority of aircrew in a war environment.
o Gastro-intestinal syndromes, low back pain, headaches and exacerbations of pre-existing
medical disorders are likely to be common.
o Reassurance and support from medical services in the field are appropriate.
o They must be credible, educative and specific, addressing both the expressed and the
concealed fears.
 Fears of more long-term problems (development of PTSD…) should be addressed.
 A supportive environment will do much to contain such difficulties and maintain morale.
 Aircrew developing an acute stress disorder or a severe adjustment disorder, and who are no
longer able to function should be managed as closely to their working environment as possible
with regard to operational and medical conditions.
o They should not be isolated from their peers.
o Attention should be given to correcting risk factors.
o They should be encouraged to talk.
o 100mg Chlorpromazine is sedation is necessary.
o Full recovery within 72 hours of a large majority of cases.
o Any doubts as to full recovery and fitness to return to flying duties should prompt a
request for psychiatric assessment.
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Fear of flying
Common in the general population (10-20%)
Simple phobia, but is rather more complex:
o Fear of flying of experienced aircrew is a different issue than fear of flying of a
novice/naive flyer.
Habituation is a decrease in the strength of a behavioural response that occurs when an initially
novel eliciting stimulus is presented repeatedly.
Habituation is probably the most ubiquitous of all forms of learning.
The process of habituation has been utilized in the therapeutic tactic known as desensitization, in
the treatment of specific phobias.
In vivo exposure is the most effective way of dealing with situational fear.
The development of fear of flying in the aircrew population should lead to a differential
psychiatric diagnosis.
o Disorders to be considered should include:
 Adjustment disorders
 Acute stress disorder,
 PTSD
 Agoraphobia with panic disorder
 Agoraphobia without panic disorder
 Depressive illness.
Break-off
Example of a dissociative state.
Described as "sensations of separation from the ground, their environment, or from the aircraft
while flying @ high altitude in single seat jet aircraft".
≈ ⅓ of the aircrew have reported such feelings, among which:
o ⅔ reported that the experience was pleasant,
o ⅓ expressed fear or anxiety in association with the phenomenon.
Other similar experiences:
o Giant-hand
 "Inability" to move the controls
 May appear for the first time against a background of environmental and
psychosocial stressors.
o Balanced on a knife edge…
May be described by aircrew as developing a fear of heights.
Aircraft accidents
Concept of "accident-proneness".
o Retrospective evidence of a temporary increase in the risk of accidental injury in
association with clusters of life events.
Flying accidents are a cause of distress and illness.
RAF medical policy requires the psychiatric assessment of aircrew following an accident before
returning to flying duties.
o Station medical officer must take a full psychological history from anyone who has been
involved in an aircraft accident before their return to duty.
o Assisted by screening instruments:
 Impact of Event Scale
 Impact of Event Scale - Revised
All aircrew should be provided with an assessment before returning to flying duty.
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Psychiatric aero-medical evacuations
 Patients have to be properly classified and prepared, adequate equipment has to be available on
board the aircraft, and properly trained personnel is essential.
 Most psychiatric patients require only the good medical care and common courtesy needed by
other ambulatory patients.
o But from time to time, some patients may behave unpredictably or/and unacceptably.
o Some may not see themselves as ill.
o May be cause of anxiety or anger in other patients or aircrew.
 ➪The decision to move a psychiatric patient by air should be made carefully.
o It is highly desirable to ensure that the patient is stabilized before aeromedical evacuation.
 Civilian airlines may require prior notification and have their own requirements.
 Assessment of the patient should pay particular attention to the risk of self-harm or violent
uncontrolled behaviour.
o Such a patient should be transported on a stretcher with sedation and restraint
immediately available.
o Women attempt suicide more often than men.
o Men are more violent and successful in their suicidal behaviour.
 Patients actively withdrawing from alcohol are unfit to travel except in an emergency.
 Preparation of the patient for aeromedical evacuation is important.
 A stretcher flight harness together with the use of sedative medication provides sufficient
restraint.
o Avoidance of psychoactive drugs that have not been used previously in the patient;
o Awareness of side effects (extrapyramidal effects of major tranquillisers…)
o Patients requiring lithium therapy preferably should be evacuated before it is commenced
or delayed until stabilization on the drug.
Air-shows and disaster planning
 Ramstein 1988 ➪> 500 casualties (70 killed).
 Such a disaster will generate severely distressed people:
o people with acute stress disorder
o people with acute exacerbation of pre-existing disorders,
o acute psychotic illness
o distraught parents and relatives of injured children and adults.
o Risk of survivors developing PTSD.
Conduct disorder in passengers
 ≈ 1/4M passengers is the cause of a serious disruptive incident.
 78% of the incidents involved male passengers.
 Control of conduct disorders requires the training of cabin crew in de-escalation and restraint
techniques.
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