cdr arlene saitzyk, william a. mcdonald, md, & cdr...

CDR Arlene Saitzyk, William A. McDonald, MD, & CDR Christopher Alfonzo

Naval Aerospace Medical Institute Psychiatry Department850-452-2783

15 MAY 2013 - AsMA Annual Meeting

Disclosure Information84th Annual AsMA Scientific Meeting

CDR Arlene Saitzyk

I have no financial relationships to disclose.

I will not discuss off-label use and/or investigational use in my presentation.

Pilot Mental Health: Expert Working Group Recommendations

(Aviation, Space, and Environmental Medicine, 2012)

Extensive psychiatric evaluations not productive or cost effective, BUT …

More attention to MH issues by AMEs, especially more common conditions & life stressors affecting pilots & flight performance

Aircrew, families, & flight organizations (civil & military) should be made more aware of MH issues in aviation

Learning Objectives

Learning Objectives

1. With 100% accuracy, you will never ever miss screening for substance use disorders, PTSD, personality disorders, sexual perversions, etc. amongst pilots, air traffic controllers, other aircrew, co-workers, & your boss.

2. As it says in the program, use films to facilitate empathy, examine cultural & ethical principles, & improve decision-making to save lives & money.

Aerospace Psychiatry Topics & Films

1. Alcohol Abuse/DependenceWhen a Man Loves a Woman, Flight

2. Aviator Personality (& Personality Disorders)The War Lover, Dive Bomber

3. Motivation to Fly/Fear of FlyingLittle Dieter Needs to Fly, Pearl

4. Combat StressThe Best Years of Our Lives, Catch-22

Human Factors Analysis & Classification System (HFACS)

Alcohol Abuse/DependenceASAM definition: Alcoholism is a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by continuous or periodic: impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial

Alcohol Abuse - DSM-IV-TR A maladaptive pattern of substance use leading to

clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

Recurrent substance use resulting in a failure to fulfill major role obligations

Recurrent substance use in situations where it is physically hazardous

Recurrent substance-related legal problems Continued substance use despite having persistent or

recurrent social or interpersonal problems caused by or worsened by the effects of the substance

Alcohol Dependence - DSM-IV-TR Maladaptive pattern of use, leading to significant

impairment or distress, as manifested by at least 3 of 7 criteria in the same 12-month period: Tolerance Withdrawal Often taken in larger amounts or over longer period than

intended Persistent desire or failed attempts to cut down or control

use Great deal of time obtaining/using/recovering Important activities given up or reduced Continued use despite knowledge of physical/psychological

problems

Substance Dependence – FAA Definition (14 CFR Part 67)

A condition in which a person is dependent on a substance, other than tobacco or ordinary xanthine-containing (e.g., caffeine) beverages, as evidenced by— Increased tolerance; Manifestation of withdrawal symptoms; Impaired control of use; or Continued use despite damage to physical health or

impairment of social, personal, or occupational functioning

NIAAA GuidelinesLow Risk Drinking:

Men: 14 drinks/week; 4 drinks/occasionWomen: 7 drinks/week; 3 drinks/occasionNo use in risky situations

Hazardous (At Risk) Drinking: Men: 14 drinks/week; 4 drinks/occasionWomen: 7 drinks/week; 3 drinks/occasionOver 65: 7 drinks/week; 3 drinks/occasion

Can you find the alcoholic?

Denial Individual lying Enabling/codependent spouse covering Peer Alcohol use is “normal” in this culture (& “romanticized”) Institutional enabling Enabling health care provider

failure to diagnose alcoholism failure to treat alcoholism as a primary disease treating the alcoholic with sedatives or tranquilizers treating the co-alcoholic with sedatives or tranquilizers

What to watch for:

- Loss of control - Roles/problems family members- “I choose to drink” adopt

Screening/Intervention

First, ASK: In a typical week, how many drinks do you have? What’s the most drinks on any one occasion in the last month?

CAGE: Cut-off: 2 positiveCut down on your drinking?Annoyed at others’ criticism of your drinking?Guilty (upset) by something that happened when you were drinking?Eye-opener (drink first thing in the morning)

More screening …FOY:F - Has anyone in your Family been concerned about your drinking?O - Have any Others been concerned about your drinking?Y - Have You been concerned about your drinking?

Screening (continued)TWEAK:Tolerance - How many drinks can you hold? Worry - Have close friends or relatives worried or complained about your drinking in the past year? Eye Opener - Do you sometimes take a drink in the morning when you first get up? Amnesia - Has a friend or relative ever told you about things you said or did while you were drinking that you could not remember? K/Cut Down - Do you sometimes feel the need to cut down on your drinking?

One more screening - AUDIT-CHow often do you have a drink? (0) Never (1) Monthly (2) 2-4x/mo (3) 2-3x/wk (4) 4x/wk How many drinks on a typical day? (0) 1-2 (1) 3-4 (2) 5-6 (3) 7-9 (4) 10

How often 6 on 1 occasion? (0) Never (1) Month (2) Month (3) Week (4) Daily (or almost)

Positive screen: 4 for males (identifies 86%), 3 for females (identifies 84%)

The Interview Expect resistance The Method: curiosity, red flags, life course The Task: connect problems with use (not the other

way around) Denial makes the job painful, not harmful: use

explicit information, show empathy, offer hope, educate about addiction, disease concept (ASAM)

Brief Intervention: FRAMESF: FeedbackR: ResponsibilityA: ActionM: Menu of optionsE: EmpathyS: Support self-efficacy SBIRT (Screening Brief Intervention Referral to Treatment) Training: Skills Training for Primary Care Providers”

AA Meetings

Types of meetings: Open: anyone (GO!) Closed: members only Home group

Affiliation and participation associated with: less alcohol use more alcohol abstinence more employment less psychiatric symptomatology

Birds of a Feather

Recovery Status Examination (Chappel, 1992)

“What are you working on in your program of recovery?” “What are you working on with your sponsor?” “What step are you working on?” “What meetings are you attending?” “What are you doing with your home group?” “How are you using your phone list?”

Aviator Personality (& Personality Disorders)

Sorry, Goose, but it's time to buzz a tower.

Modern AviatorsAbove-average intelligence (IQ ≈ 120) Supportive family (parents, spouse/significant other)Calculated risk-taker (accident-free)Compulsive (obeys NATOPS, checklists)Concrete (avoids ambiguity)Thinks quickly in novel situationsStrong need for control

Modern Aviators (con’t)Independent (but a team player)Confident, big ego (BUT healthy narcissism)Achievement-driven/action-orientedEmotionally reserved - avoids/denies difficultiesAccepts implications of combat flying (being killed, killing enemy/civilians)Compartmentalizes

“Big 5” or FFM of Personality Openness (to new experience) - flexible Conscientiousness (high) - does it right Extraversion (high) Agreeableness (average) Neuroticism (low) – low generalized anxiety

(compartmentalization), Impulsiveness (low)

Healthy Behaviors

Good impulse control (e.g., absence of MVAs, delinquent behavior, starting fights)

“Track record” of accomplishments Healthy stress coping skills (successfully handled

significant life events/milestones) Group participation (relationship skills) Leadership skills

Healthy Defenses Affiliation – Ready Room Humor Anticipation Suppression/compartmentalization Denial – of intrinsic dangers Rationalization – dangers are not significant Magical thinking – “I’ll never have an accident” Omnipotent fantasy – to overcome adversity Sublimation

Unhealthy: 5 Hazardous ThoughtsAnti-authority: don’t like anyone telling them what to do. Resent

it. Regards rules, regs, procedures as silly or unnecessary.

Impulsivity: just don’t stop to think about it

Invulnerability: feel accidents happen to others, but never to them. May be more likely to take chances, unwise risks.

Macho: always trying to prove they are better than anyone else by taking risks, trying to impress others.

Resignation: think “what’s the use?” Don’t see selves as making a difference in what happens. If outcome positive, think it’s good luck; if negative, think someone “out to get them.” Leave the action to others. Go along with unreasonable requests to be “nice.”

Personality Disorder- Enduring pattern of inner experience & behavior that

deviates markedly from the expectations of the culture. - 2 or more:

- Cognition (perception of self, people, events)- Affect (range, intensity, lability, appropriateness)- Interpersonal functioning- Impulse control

- Inflexible, pervasive, stable/long duration, problematic

Narcissistic Personality Disorder- Pervasive pattern of grandiosity, need for admiration, lack

of empathy. - 5 or more:

- Grandiose sense of self importance- Preoccupied w/ fantasies of unlimited success- Believes s/he is “special”- Requires excessive admiration- Sense of entitlement- Interpersonally exploitative- Lacks empathy- Envious of others or believes others envious of him/her- Arrogant

Antisocial Personality Disorder

- Disregard for rights of others, since 15 years old (i.e., Conduct Disorder).

- 3 or more:- Deceitfulness, lying, conning others- Impulsivity, failure to plan ahead- Irritability, aggressiveness- Reckless disregard for safety of self or others- Irresponsibility- Lack of remorse

What to watch for:

“There’s a fine line between being a good pilot & being a psychopath.”

Is there a fine line between hazardous attitudes & personality disorders?

Motivation to Fly/Fear of FlyingFlying is …

Fascinating & dangerous Loved & feared Emotional & cognitive

“All my life I’ve always wanted to fly!” “When I was 20, I decided.”

A dynamic balance between positive (joy, meaning, coping skills) & negative factors (anxiety, anticipated or experienced danger).

Healthy Motivation to Fly Usually apparent in childhood Aviation-related activities Aviator role model Enjoy & participate safely in risky hobbies Learn to enjoy an innately terrifying activity Recognize real dangers/realistic demands Transform drives into calculated risk-taking

Unhealthy Motivation to Fly Impulsive decision to escape family/problems Pressure/live out parent’s dreams “One up” a parent Prove not afraid Risk-taking in search of thrills Immature wish to be an aviator, not wish to fly Improve self-esteem

Motivation Evolves With Age Young/student aviator (“Nugget”):

Thrilled & in denial Older aviator:

More diverse interests Can acknowledge dangers

Seasoned aviator: More cautious Pride in skill & experience Competing interests

Assessing Motivation to Fly How did you get interested? (family hx?) What do you tell yourself about the danger? How does your family feel about the danger? How do you feel about prospect of killing? Past successes/achievements & impulsive/risky

behavior Observe “grace under pressure” Plan B Member of the “tribe”

Fear of FlyingWhen an aviator’s response to a situation doesn’t make sense (is irrational), or involves an inappropriate emotion, or seems disproportionate to the stressor involved – look further.

These 3 factors—irrationality, inappropriateness, and disproportionality—are true clinical indicators of psychological stressors.

Assessing Fear of Flying

Step 1:

- Do the symptoms stem from a preexisting disorder? - What are the situational stressors? - Have life circumstances temporarily altered motivation & defenses?

Step 2: “I’d like to fly, but …” What will happen “if you continue to fly…?”What will happen “if you continue to fly…?”

Minimizes vs. amplifies symptomsMinimizes vs. amplifies symptoms

Will you “fly when we get you well?”Will you “fly when we get you well?” Listen for ambivalenceListen for ambivalence

What do you think about “this problem?”What do you think about “this problem?” Look for “la belle indifference”

What to watch for: < - - Childhood dreams, role models, & overcoming obstacles - - >

- Healthy motivation & defenses - Supportive family

Combat StressStress in the aviation community, seriously?

Combat Stress vs. PTSD

Combat Stress Reaction (CSR): “The expected, predictable, emotional, intellectual, physical and/or behavioral reactions of Service members who have been exposed to stressful events in combat or military operations other than war” (DoD Directive 6490.5)

• Section

Risk Factors for CSR

Environmental/Situational – weather, food supply, adequacy of rest, injury/tx

Operational/Organizational – leadership, cohesion, equipment, training, predictability of schedule, accuracy of information

Individual – age, family stress & support, fitness, physical/mental health

PTSD Symptoms: Reexperiencing, Avoidance, & Hyperarousal

Avoidance?

Moral Injury

Guilt or remorse felt when troops witness, perpetrate, fail to prevent, or learn about bad things or acts that transgress deeply held moral beliefs & expectations during war:

- Betrayals - Atrocities - Within ranks violence - Incidents involving death/harm to civilians

What to watch for:

- Challenges with reintegration for service members & their families- CSR vs. PTSD

- Avoidance/compartmentalization- “Attitude reflects leadership”

Improving Your Evaluation

Get collateral history

Screening scale: PCL-M Cut-off scores differ for screening vs. diagnosis OEF vs. Viet Nam

cdr arlene saitzyk, william a. mcdonald, md, & cdr...

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