Addictions in Aviation PTSD Catastrophic Events CAMA Sep 2016 Jay Weiss, MD

Transcription

1 Addictions in Aviation PTSD Catastrophic Events CAMA Sep 2016 Jay Weiss, MD

2 Substance Dependence Mandatory denial, except where there is established clinical evidence, satisfactory to The Federal Air Surgeon, of recovery, including sustained total abstinence from the substance(s) for not less than the preceding two years Recovery training (HIMS) Clean UDS over time

3 Substances-DSM V Alcohol Caffeine Cannabis Hallucinogens Inhalants Opioids Sedatives Stimulants Tobacco Other Club drugs Designer Drugs

4 Substance Dependence DSM 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

5 Substance Dependence Increased tolerance FAA (1 needed) Manifestation of withdrawal symptoms Impaired control of use Continued use despite damage to physical health or impairment of social, personal or occupational function Exception: caffeine/ xanthene beverages

6 Substance Abuse DSM 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

7 Substance Abuse FAA (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 by Federal Air Surgeon)

8 DSM V Discards Dependence and Abuse Replaces these with Substance Use Disorder Substance Induced Disorders now listed after specific substances

9 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

10 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

11 CAGE Cut down? Annoyed? Guilt? Eye opener?

12 Diagnosis Problem with some aspect of living Cannot make diagnosis reliably on basis of reported amount, frequency, pattern as reported by individual (Usually more than initially reported by patient) Legal, financial, interpersonal, education, job, professional, licensing, social, hygiene, housing, responsibilities

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

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

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

16 What To Do? Disqualifying for at least two years of sustained abstinence from substances Evaluation HIMS program Professional programs Inpatient Outpatient AA/ ALANON

17 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

18 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 % Enduring/Iraqi Freedom % Returning combat Vets around 25%

19 PTSD DSM V Exposure Intrusion symptoms Avoidance Altered Cognition Altered Arousal Duration more than one month

20 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)

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

22 PTSD Avoidance 1. Distressing memories 2. External reminders

23 PTSD Cognition/Mood 1. Inability to remember 2. Negative beliefs/expectations 3. Distorted cognitions/beliefs 4. Negative emotions 5. Diminished interest/participation 6. Detachment/estrangement 7. Inability to experience positive emotions

24 PTSD Arousal/Reactivity 1. Irritability/Anger 2. Reckless/self-destructive behavior 3. Hypervigilance 4. Exaggerated startle response 5. Problems with concentration 6. Sleep disturbance

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

26 Mental Status Exam Suicide by Aircraft Jay Weiss, MD 2016

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

28 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

29 Suicide by Aircraft Jones Split S into runway Morocco. 44 dead dead. Pilot recently demoted Egyptair dead. Nantucket Botswana Grounded for medical reasons. Unauthorized takeoff in turboprop plane. Deliberately crashed it into 2 other planes on ground

30 Suicide by Aircraft Spirit Airlines. Haiti Erratic behavior and history of same. Self medicating with St. John s Wort. Disconnected autopilot and executed high G pullup with passengers on board Malaysia flight 370 March 2014 Common theme of denial by authorities after apparent suicide by aircraft. Embarrassing

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

32 Suicide Statistics Suicide risk with ETOH abuse is 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

33 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

34 Why Hide? MD licensure versus pilot licensure If MD had to pass FAA Class I Flight Physical each 6 months in order to exercise privileges of MD license-----?????? Would MD with physical/psychiatric history be tempted to minimize history? Just asking

35 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

36 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

37 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

38 Background Lived with girlfriend (Montabaur) And parents (Dusseldorf) Always laughing and happy Visited glider club late Seemed fine Treated by psychotherapists for suicidal tendencies long before flight training No one in Germanwings knew

39 Background Depressive episode 2008/2009 Not first episode (Depression prior to age 14) No issues Commercial Pilot Certificate 2012 Germanwings Flight Attendant 2013 Awaiting Copilot Slot for 11 months Copilot 2014

40 Background Flight medical August Passed Security check January Passed Visited numerous Doctors (double digits) Numerous somatic complaints Vision difficulties. Psychosomatic? Did not inform employer

41 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

42 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

43 Audit 1988 FAA Computer cross checks 27 pilots Lied ref drug/etoh convictions Legal sanctions Not a new problem Occasional grounding item hidden

44 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

45 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

46 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?

47 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?

48 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?

49 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?

50 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

51 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

52 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 tries hard to explain, and you try hard to listen, and you still don t get it, it s probably the flyer s problem. Find out what it is. Possibilities include simple misunderstandings, language barrier, education, culture, intelligence, neurological or psychiatric problems.

53 AME Pearls Past behavior is the best predictor of future behavior 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 the vast majority of those who are not

54 AME Pearls Vast majority of applicants are honest and trustworthy, but the temptation to hide a grounding item is always possible Watch for the rare pilot who has successfully hidden a severe psychiatric or medical problem over time Explore indicators

55 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?

56 Conclusion Substance dependence PTSD Catastrophic Events