Clinical Practice Guideline



Developed for the

Aerospace Medical Association

by their constituent organization

American Society of Aerospace Medicine Specialists


Overview: The anxiety disorders are generally characterized by fear/apprehension, obsessions, fear of loss of control, and physiological symptoms severe enough to interfere with social or occupational functioning.  There are several DSM IV anxiety disorder diagnoses and they include Panic Disorder, Specific Phobia, Social Phobia, Obsessive-Compulsive Disorder, Posttraumatic Stress Disorder, Acute Stress Disorder, and Generalized Anxiety Disorder.  Anxiety is seen in many other psychiatric disorders, but, in its benign form, is part of normal emotional experience.  Symptomatic anxiety can be constant or nearly so, as in Generalized Anxiety Disorder, or episodic.  Episodic spells of anxiety can come on without warning or provocation, as in Panic Disorder, or predictably in certain situations, as in Simple or Social Phobia.  In this case, efforts to avoid the anxiety-provoking stimulus can drastically impact the victim’s lifestyle.  In obsessive-compulsive disorder, the anxiety can lead to bizarre, ritualized behavior.


Three terms that relate specifically to anxiety and flying, manifestations of apprehension (MOA), fear of flying (FOF), and phobic fear of flying (Specific Phobia in DSM-IV) are used in Aerospace Medicine.  MOA and FOF are used to denote a non-phobic fear based on uneasiness, lack of motivation, feelings of inadequacy, rational decision, life circumstance, etc.; MOA is used with student aviators and FOF for experienced aviators.  A mental health consultation may be helpful to clarify the issues in MOA and FOF.  Phobic fear of flying is a true phobia, often involving only flying, though the symptoms can spread to other areas of life if not treated.  Phobic fear of flying is handled like the other anxiety disorders by medical disqualification, referral to mental health for evaluation and treatment, and then return to flying when the disorder is resolved.  Persistence of anxiety symptoms despite adequate treatment should raise questions about the aviator’s motivation to fly.


Two anxiety disorders, Acute Stress Disorder (ASD) and Posttraumatic Stress Disorder (PTSD), warrant special concern in the deployed/operational environment.  Both occur after exposure to a life-threatening event in which one experiences intense feelings of horror and/or helplessness.  Symptoms include blunting or absence of emotional responsiveness (“thousand-yard stare”), insomnia, diminished awareness of surroundings, depersonalization, derealization, dissociation, and amnesia for the traumatic event. ASD is similar to the Combat Stress Syndrome, and is diagnosed if the symptoms have been present for less than four weeks.  After four weeks the diagnosis is changed to PTSD.  In this case signs of autonomic hyperarousal, such as an exaggerated startle response, flashbacks or other intrusive, disturbing recollections of the traumatic event, and efforts to avoid settings or situations that remind one of the traumatic event, are seen.  Treatment of ASD is intended to return the member to duty and avert the development of PTSD.  Critical Incident Stress Management (CISM) is intended to diminish the incidence of ASD and PTSD in populations at increased risk (IE: mass casualty survivors/medical personnel).


Aeromedical Concerns: Many of the emotional and behavioral manifestations of anxiety disorders can interfere with flying safety and mission completion.  Severe anxiety can markedly impair ability to focus and concentrate on the task at hand.  Trembling may diminish ability to manipulate controls.  Palpitations, sensations of shortness-of-breath, chest pain, nausea, and dizziness, for example, can be distracting.  Some of the more severe symptoms of anxiety, such as those seen in panic disorder (overwhelming anxiety, derealization, and fear of losing control) may be acutely disabling.  Anxiety is often a factor in depression and psychosomatic complaints as well as being associated with substance misuse, particularly alcohol.


Medical Work-up: Treatment should include a mental health evaluation, which outlines any social, occupational, or administrative problems connected with the condition, and in the case of a military aviator or a first or second class civilian aviator, a letter from the aviator’s supervisor supporting a return to flying status.  Both psychosocial and pharmacological treatments have been shown to be effective with a number of the Anxiety Disorders.  Psychosocial treatments involve cognitive-behavioral therapy, exposure (behavioral) therapy, relaxation therapies, and social skills training.  Pharmacological approaches have generally utilized selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, benzodiazepines, buspirone (an azapirone anxiolytic and 5HT-1A receptor partial agonist), and monoamine oxidase inhibitors.  There is no “right way” to treat these disorders.  The aviation physician needs to monitor the progress of the flyer very closely before consideration of return to flying duties.


Aeromedical Disposition (military): If the diagnostic criteria for an Anxiety Disorder are met, the aviator may need to be disqualified from flying duties.  A waiver may be requested once the aviator has completed treatment successfully, and has remained asymptomatic without medications for 3-6 months.


Aeromedical Disposition (civilian): No specific waiting time is recommended for civilian aviators; however, they must be symptom-free and off medication with appropriate supporting documentation provided by their treating physician.  No civilian airmen are granted medical certification during the acute episode.  In general, airmen with Panic Attacks are not granted medical certification.  As mentioned above, the medications that are utilized for the chronic treatment of these conditions are also not acceptable in the civilian sector.


Waiver Experience (military): The US military has accumulated considerable experience in the evaluation and recommendations for anxiety disorders in pilots and navigators.  Based on a 15-year (1981-1996) review of the USAF Waiver File, 57 aviators were diagnosed with anxiety disorders and 34 (60%) were waived to return to fly. 


Waiver Experience (civilian): The impact of this disorder on civilian flying is most likely not as severe, but cases need to be handled with care before returning to aviation duties.  In the year ending 2000, there were 1226 first class, 1270 second class, and 5198 third class active airmen who had medical certificates with a variety of psychoneurotic conditions in remission.




American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. DSM-IV. Washington DC, 1994.


Nathan & Gorman, (Eds.), A Guide to Treatments That Work, Treatment of Psychiatric Disorders, 2nd edition, Oxford Press, 1998.


Kaplan & Sadock (Eds.), Comprehensive Textbook of Psychiatry, 6th edition, 1995.


Rayman RB. Clinical Aviation Medicine, Third edition, New York, Castle Connolly Graduate Medical Publishing, LLS, 2000, pp. 296-7.



October 9, 2001