Addictions in AviationPTSD

Catastrophic EventsCAMA Sep 2016Jay Weiss, MD

Substance Dependence Mandatory denial, except where there is

established clinical evidence, satisfactory toThe Federal Air Surgeon, of recovery,including sustained total abstinence from thesubstance(s) for not less than the precedingtwo years Recovery training (HIMS) Clean UDS over time

Substances-DSM V

Alcohol Sedatives Caffeine Stimulants Cannabis Tobacco Hallucinogens Other Inhalants Club drugs Opioids Designer Drugs

Substance DependenceDSM IV TR (3 needed)

Tolerance Withdrawal Larger amounts/ longer time Cannot cut down or control Increased time spent seeking/using Social, occupational, recreational problems Continued use despite problems

Substance DependenceFAA (1 needed)

Increased tolerance Manifestation of withdrawal symptoms Impaired control of use Continued use despite damage to physical

health or impairment of social, personal oroccupational function Exception: caffeine/ xanthene beverages

Substance AbuseDSM IV TR(1 needed)

Failure to fulfill major obligations Use when physically hazardous Legal problems caused by substance Social/ interpersonal problems caused or

exacerbated by substance

Substance AbuseFAA (1 needed)

Use in physically hazardous situation Positive drug test (0.04 ETOH or refusal to

test) Misuse of substance in a way that could

affect aviation safety ( determined byFederal Air Surgeon)

DSM V

Discards Dependence and Abuse

Replaces these with Substance UseDisorder

Substance Induced Disorders now listedafter specific substances

Substance Use Disorder DSM V

Larger amounts or longer period Can’t cut down or control Great deal of time to obtain, use recover Craving Failure to fulfill major role obligations Social/Interpersonal problems Social, recreational, occupational activities

Subst Use Disorder DSMV Cont

Recurrent physically hazardous activities Physical or psychological problem Tolerance Withdrawal

Need at least two of above 11 No longer Dependence and Abuse

CAGE

Cut down? Annoyed? Guilt? Eye opener?

Diagnosis

Problem with some aspect of living Cannot make diagnosis reliably on basis of

reported amount, frequency, pattern asreported by individual (Usually more thaninitially reported by patient) Legal, financial, interpersonal, education,

job, professional, licensing, social, hygiene,housing, responsibilities

Insight

I use a substance I have a problem There is a connection These two are related Cause and effect

Employment

Job loss Demotion Decreased performance Tardy, absent, missed deadlines Accidents on job Inordinate sick leave Embarrassing behavior

Family

Family complains/ protests/ threatens Social activities curtailed Arguments/ abuse/ incidents Abdication of family responsibilities Divorce/ separation/ embarrassment Protection/ enabling/ secrecy

Recommend ALANON/ Counseling

What To Do?Disqualifying for at least two years ofsustained abstinence from substances

Evaluation HIMS program Professional programs Inpatient Outpatient AA/ ALANON

HIMS

Human Intervention Motivational System Politically correct AA for pilots Formal program Alcoholics Anonymous Inpatient training Outpatient program/ strict monitor Drug screens Similar to medical board programs

PTSD Prevalence

Lifetime USA 7% Men 3.6%. Women 9.7% Veterans Lifetime men 31%. Women 27% Vietnam 1988 men 15.2%. Women 8.1% Gulf War 1997 10-12% Enduring/Iraqi Freedom 2008 13.8% Returning combat Vets around 25%

PTSD DSM V

Exposure Intrusion symptoms Avoidance Altered Cognition Altered Arousal Duration more than one month

PTSD Exposure

1. Direct experience 2. Witness in person 3. Close family member or friend 4. Extreme exposure (e.g. picking up body

parts after aircraft crash)

PTSD Intrusion

Recurrent, involuntary, intrusive: 1. Memories 2. Dreams 3. Flashbacks 4. Distress at internal or external cues 5. Physiological reactions to cues

PTSD Avoidance

1. Distressing memories2. External reminders

PTSD Cognition/Mood

1. Inability to remember2. Negative beliefs/expectations3. Distorted cognitions/beliefs4. Negative emotions5. Diminished interest/participation6. Detachment/estrangement7. Inability to experience positive emotions

PTSD Arousal/Reactivity

1. Irritability/Anger2. Reckless/self-destructive behavior3. Hypervigilance4. Exaggerated startle response5. Problems with concentration6. Sleep disturbance

PTSD Treatment

SSRI medications VA Seroquel (atypical antipsychotic) Cognitive Behavioral therapy Group therapy Family therapy 3-6 months duration

Mental Status ExamSuicide by Aircraft

Jay Weiss, MD2016

Overview

Suicide by aircraft Statistics German Wings crash (and others) Weaknesses in current system AME responsibilities Mental status exam by AME Pearls

Psychiatric Pearls

Crazy people do crazy things Normal people do crazy things Crazy people do normal things Normal people do normal things No ironclad way to predict But there are indicators Systemic failures

Suicide by Aircraft

Jones 1977. Split S into runway 1994. Morocco. 44 dead. 1997. 104 dead. Pilot recently demoted Egyptair 1999. 217 dead. Nantucket Botswana 1999. Grounded for medical

reasons. Unauthorized takeoff in turbopropplane. Deliberately crashed it into 2 otherplanes on ground

Suicide by Aircraft

Spirit Airlines. Haiti. 2010. Erratic behaviorand history of same. Self medicating with St.John’s Wort. Disconnected autopilot andexecuted high G pullup with passengers onboard Malaysia flight 370 March 2014 Common theme of denial by authorities after

apparent suicide by aircraft. Embarrassing

Statistics

Bills, Grabowski, Guhoa 2005 1983-2003. 37 pilots All male. All General Aviation Alcohol 24%. Drugs 14% (combined-38%) Social problems 46 % Legal problems 40 % Psychiatric problems 38 %

Suicide Statistics Suicide risk with ETOH abuse is 60-120 times

general population NIMH. 90% of suicides committed by those

who suffer from some form of mental illness

62 % pilot suicides October-March 38 % pilot suicides April-September Pilots tempted to hide mental illness Pilots tempted to hide all illness

Pilots/Docs

Doc is natural enemy of pilot Pilots like to win, defy gravity, adapt,

innovate, overcome, conquer, progress Flight physical is no win situation Best outcome is status quo Worst outcome is precipitous end to flying

career/income/identity Much is at stake

Why Hide?

MD licensure versus pilot licensure If MD had to pass FAA Class I Flight

Physical each 6 months in order to exerciseprivileges of MD license-----?????? Would MD with physical/psychiatric history

be tempted to minimize history? Just asking

Weaknesses in system

Pilot suicide very rare Not expected Pilots generally a happy bunch Love flying and airplanes Train to avoid crashes, not cause them Privacy issues Pilots tempted to hide from Docs

Germanwings Crash

March 24, 2015 Andreas Lubitz, Copilot, A320 Barcelona to Dusseldorf Locked Pilot out of cockpit Autopilot descent from 38,000 to 100 feet Impacted mountain at 6,000 feet Suicide by aircraft. 150 dead

Background

27 years old Flying since age 14 (gliders) Described as gifted and precise Quiet but fun. Affable Airline training 2008 Bremen/Phoenix (5%) Training interrupted for 6 months Depressive episode

Background

Lived with girlfriend (Montabaur) And parents (Dusseldorf) Always laughing and happy Visited glider club late 2014. Seemed fine Treated by psychotherapists for suicidal

tendencies long before flight training No one in Germanwings knew

Background

Depressive episode 2008/2009 Not first episode (Depression prior to age

14) No issues 2010-2011 Commercial Pilot Certificate 2012 Germanwings Flight Attendant 2013 Awaiting Copilot Slot for 11 months Copilot 2014

Background

Flight medical August 2014. Passed Security check January 2015. Passed

Visited numerous Doctors (double digits) Numerous somatic complaints Vision difficulties. Psychosomatic? Did not inform employer

Background

Notes from specialists Unfit for work Did not give these to employer Torn scraps found in wastebasket Hid depressed mood from employer Hid depressed mood from friends/family

Ronald Crews 2002

Pilot Cessna 402 Commuter Airline Diabetic seizure at controls Overflew Hyannis Port Eastbound Melanie Oswalt, Student Pilot (Security) Landed plane gear up Crews hid IDDM from FAA for years Prison time

Audit 1988 FAA

Computer cross checks 27 pilots Lied ref drug/ETOH convictions Legal sanctions Not a new problem Occasional grounding item hidden

Weaknesses

Pervasive privacy culture Strict data protection rules Lack of systemic screening Medical and Aviation systems separate Inadequate communication Oversight failure Lufthansa/German Wings unaware

More Weaknesses Psychiatry has poor track record for predicting

specific actions in specific individuals We do not read minds People lie to us, and we believe them No reliable way to predict with accuracy when

and where an individual will snap Vast majority of pilots are safe/stable We do not expect to discover severe medical

or psychiatric problems in a pilot

AME Responsibilities

Fiduciary responsibility to public Objectivity crucial Transferrence/Countertransferrence Disqualifying conditions: Yes or no Do not hide problems Would you fly with this pilot?

AME Responsibilities

Aviation is very unforgiving of carelessness,incapacity, or neglect Explore background and report accurately 15 disqualifying conditions. 5 psychiatric Think aeromedical significance Think impairment, incapacitation Do not ignore psychiatric indicators Would you fly with this pilot?

Mental Status Exam (AME)

Not a full Psychiatric exam Screening exam Look for Bipolar, Psychosis, Depression,

Personality Disorder, Substance problems Describe findings Report accurately Would you fly with this pilot?

Mental Status Exam

General to specific Appearance, gait, orientation,

consciousness Mood and affect Delusions, hallucinations, Psychosis Thought processes and content Cognition, insight, executive function Would you fly with this pilot?

Suicide Indicators/Risk Factors

Loss, real or imagined, Social isolation Alcohol problems Crises: Legal, social, financial Serious medical illness, delirium Depression, Psychosis, Cancer, Renal

failure Previous attempt Positive family history

More Indicators

Prior Psychiatric diagnosis Personality disorder Lack of rapport with examiner Hopelessness, intolerable pain Isolation, loneliness, lack of belonging Life-long coping difficulties Vague answers to specific questions

Jones’ Rule of Irrational Data If you don’t understand what a flyer

means, assume it is your problem.Ask again, clearly. If the flyer trieshard to explain, and you try hard tolisten, and you still don’t get it, it’sprobably the flyer’s problem. Findout what it is. Possibilities includesimple misunderstandings,language barrier, education,culture, intelligence, neurological orpsychiatric problems.

AME Pearls

Past behavior is the best predictor of futurebehavior Suicidal pilots are very rare. You will

probably never see one. Very hard to detect Flying training selects for well adjusted,

trustworthy individuals and weeds out thevast majority of those who are not

AME Pearls

Vast majority of applicants are honest andtrustworthy, but the temptation to hide agrounding item is always possible Watch for the rare pilot who has

successfully hidden a severe psychiatric ormedical problem over time Explore indicators

AME Pearls

Depressed people make you feel depressed Crazy, disorganized people make you feel

crazy and disorganized Jones’ rule Get a good history, particularly if any of the

indicators are seen Would you let your family fly with this pilot?

Conclusion

Substance dependence PTSD Catastrophic Events