Clinical Practice Guideline
for
ANXIETY DISORDERS
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.
References:
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition. DSM-IV.
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,
October
9, 2001