On a typically clear New England October day in 2006, my friend, Fred, who’s a wonderful pilot but at that point didn’t own an airplane, asked if I could fly his wife to Teterboro from the suburban Boston area where we all live. He would join us. I was a relatively new pilot, and beyond my being happy to help a friend, it would be a great experience to fly into that very busy airport in that completely lunatic airspace with Fred at my side to show me the way.
The return trip is today’s focus—VFR at 5500 feet and everything nominal, to borrow from NASA, until a little bit southwest of the Worcester, Massachusetts, airport when I spotted the 1,560-foot tower I had been looking for as we navigated our way home. I pointed it out to Fred, who looked down thoughtfully and after a while mused, “I wouldn’t want to be the guy who has to change the light bulb on top of that thing.”
Well, that did it. For the first time in any aircraft, I suddenly started asking myself what I was doing up there. I don’t remember my stomach churning or heart racing, but I sure do remember feeling incredibly uncomfortable and sensing that I needed to get a handle on myself. Of course, I didn’t want Fred to know that I definitely had the wrong stuff, so I said nothing and focused intently on the instrument panel—head down, in the cockpit, focusing. After just 10 or 15 seconds, I felt under solid control again and very soon after I was able to look outside the cockpit. Out, that is. Not down. For the rest of that uneventful flight, it seemed wise to avoid looking directly down.
I’ve never liked heights, but thankfully, acrophobia, the fear of heights, and aviophobia, the fear of flying, are separate entities even though they overlap for more than a few people. It’s easy to imagine a person who’s afraid of flying because he doesn’t like heights. It’s also easy to imagine lots of reasons to fear flying without being afraid of heights. It may be harder to imagine a person who doesn’t like heights, but is comfortable in airplanes, but it happens all the time, and I’m one of those people. I’ve heard and read that acrophobia is more common in pilots than it is in the general population, but I’ve never been able to find primary data to substantiate that. Whatever the case, these fears of heights or of flying are subsets of anxiety, and almost everyone has at some point in his life been gripped by a sense of anxiety over something.
The Many Flavors Of Anxiety
If you don’t feel anxious from time to time as a specific reaction to some challenge or other, you had better see a psychiatrist and find out what’s wrong with you. This kind of occasional anxiety is normal, and without it, we would be in real trouble in a hurry. It keeps us from doing stupid things, just as pain helps us minimize physical injury. This kind of focused reaction is obviously in contrast to generalized anxiety disorder (GAD) and related problems where the anxiety is more frequent, more crippling, and in the generalized version, less clearly associated with any particular provocation. This more severe anxiety keeps us from doing good things that we ought to be able to do. Clearly, like all kinds of things in medicine, anxiety doesn’t occur as a binary phenomenon where it’s normal or abnormal. Rather, it’s a spectrum, and somewhere between those two poles is where most of us live our lives.
The best definition I know for GAD comes from the Anxiety and Depression Association of America, who say it “is characterized by persistent, excessive, and unrealistic worry about everyday things.” The National Institute of Mental Health tells us that, in any 12-month period, 3.1% of people in the United States will have this problem and one third of those cases will be severe. Over a lifetime, 5.7% of people will have GAD at some point, so we’re pretty clearly not talking about a rare problem. Average age of onset is 31, but it’s a rather flat curve. Anxiety can become a problem at any time.
Phobias might be thought of as subsets of anxiety triggered by specific provocations. Social phobia is pretty common, and I don’t need to define that for you. Agoraphobia, from the Greek agora, or gathering place, is a fear of being in public places from which escape might be awkward or otherwise difficult. I suspect that most people with phobias develop them as a learned behavior rather than see them sprout de novo one morning as completely endogenous afflictions. For example, if you’re prone to unheralded fainting because of some cardiac condition or perhaps you have an inflammatory disease of the colon such that you can’t be sure of your bowels, it would be pretty normal to be uneasy in public places.
Depression is worth mentioning with anxiety. Although they’re distinct, they frequently coexist. Many patients have features of both, and they can be difficult to tease out. Like anxiety, depression occurs on a spectrum from normal feelings of sadness triggered perhaps by loss to crippling, entirely endogenous feelings of hopelessness and lassitude. It’s the major depression that, if present, poses a suicide risk, and that’s what seems to have happened in the fairly recent Germanwings pilot suicide crash. This leads to a topic for a separate article on the limits of doctoring: What can any medical examination reveal of a problem that the patient wishes to conceal? And with regard to depression and the risk of suicide, to what extent should we invade a person’s privacy given how fantastically rare it is for a pilot to commit suicide by airplane, let alone to do so with other people along for the ride?
“At the end of the day, pilots are people who fly, and there’s no reason to think they have more or less anxiety than people who don’t fly.”
Another condition to break out is panic disorder, which can accompany anxiety or depression or occur on its own. We all know what panic is, but not so many are familiar with panic attacks. Those can be sudden and unbelievably intense, with feelings of impending doom accompanied by some combination of tremor, sweating, heart pounding and racing, shortness of breath and chest pain. As a cardiologist, the last 30 years I’ve seen lots of people for chest pain, and it’s not at all rare for that to turn out to be panic disorder rather than a cardiac condition. Panic is important to us as pilots because it can be suddenly and truly incapacitating, which I think would be a bad deal for the PIC and his passengers in flight.
One last thing: You know the truth is rarely pure and never simple. What’s normal, and what’s abnormal? The line is often blurry, and it should be. People are complicated and, as doctors, we know a lot, but there’s a lot more that we don’t know. Depression isn’t a rare problem in the United States. In some other societies, depression simply doesn’t exist. Of course, we don’t believe people don’t have feelings of sadness, but culturally it’s not seen as an abnormality in need of treatment. Pharmaceutical companies selling antidepressant medications market heavily in those places. They believe that they’re creating awareness of a problem so people can be treated and live better lives. To some observers, though, they’re creating pathology to hawk their products. The truth is surely in between.
Are There Solutions?
Many people with isolated episodes of mild anxiety manage the problem without ever being diagnosed. That’s what I did at 5500 feet over Worcester, and for me, that problem never returned. Was that abnormal? Probably not. People with more frequent and severe symptoms, on the other hand, really do have GAD and need help, but happily, they’re often fairly easily helped. For many with anxiety, especially if it’s not associated with panic, talk treatment and psychotherapy can be sufficient to get things under good control and keep them there. Cognitive behavioral therapy, CBT, is a popular form of tightly focused psychotherapy these days, and it’s good for anxiety.
Other treatments such as meditation, mindfulness and stress/relaxation programs are also useful. When anxiety is triggered by a specific provocation, exposure therapy can be effective. The concept is simple. Patients are exposed in a controlled fashion gradually to progressively complete versions of whatever their particular trigger is and the therapist helps them to get through it, understand it and become desensitized to it. Sometimes galvanic skin resistance, a measure of stress, is monitored during the exposures to help patient and therapist identify the point at which anxiety really starts to occur.
When the problem is severe or psychotherapy is insufficient, and especially if panic or impulsive behaviors are part of the picture, we’re talking about medications along with psychotherapy or sometimes in place of it.
Another general rule of medicine: If people have some chronic intermittent recurring problem like asthma or anxiety, it’s often sufficient to give them medications or nonpharmacological strategies to use only when needed. I tell people we’re filling their quivers with arrows to shoot at the problem when it happens. For asthma, it might be an inhaler. For anxiety disorder, it might be meditation or a short-acting drug in the class of Valium, a benzodiazepine.
If the problem is severe or if it’s mild but so frequent that the patient is shooting arrows all the time, we’ll add a suppressive medication to the mixture. That daily suppressive medication may eliminate the problem altogether, but more often it falls short of that. Still, with fewer and less severe attacks, the patient has control and lives a better life. Suppressive medications for anxiety might be longer-acting benzodiazepines, or more commonly these days, SSRI (selective serotonin reuptake inhibitors) medications such as Prozac and many others. There are other drug categories, as well, which can be useful in these cases.
As in all of doctoring, it then becomes a question of balance. We want to maximize the benefit while minimizing side effects. If someone has a mild problem, the patient and doctor would probably accept no side effect at all—better to just leave the problem untreated. On the other hand, for a patient with a severe and crippling or perhaps dangerous problem, not treating it isn’t an option, and if you can’t find a medical program that the patient tolerates with no side effect, your goal becomes to find the medical program with minimal side effects.
Anxiety In Pilots: How Big A Problem?
At the end of the day, pilots are people who fly, and there’s no reason to think that they have more or less anxiety than people who don’t fly. Anxiety about flying, per se, is probably less common in pilots than in the general population, but even in that area, you might be surprised. The Israeli Air Force is sufficiently brave and bold to have actually put some information about this online. They talk about screening recruits, but they also talk about evaluating and managing experienced pilots who develop a problem well after training. Their approach is practical and sensible. They evaluate the pilot’s anxiety with regard to how it might harm the pilot, the aircraft and the mission. Pilots are treated as needed, in any case, but based on that three-point assessment, some are grounded while others may fly during treatment.
From a practical perspective, if you’re suffering from anxiety that might interfere with your ability to cope easily and readily with the routine or non-routine demands of piloting an aircraft, you need to ground yourself and get treatment. It’s only sensible, it’s a legal requirement attached to your pilot’s license, and, of course, it applies whether the anxiety is specifically related to the act of flying or anything else.
From a regulatory perspective, things are more complicated, of course. Let’s look into why that’s the case and maybe why it makes sense. As your personal physician, my job is to do the best that I can to make you the best you can be under whatever circumstances we’re stuck with.
Let’s say that I’m not your personal physician. Perhaps I work for an insurance company and I’m examining you for the purpose of issuing a life insurance policy. My job in that scenario—a scenario to which I’m personally allergic—is to feed the insurance company the data they require to decide how much of a gamble you are so they can decide not only whether to insure you at all, but at what price. Your Aviation Medical Examiner similarly works not for you, but for your government, and just like in the insurance company example, the job is to understand risk. Flying, like driving a car or getting life insurance, is a privilege and not a fundamental right. It’s a bit pejorative, but when it comes to flying, you’re guilty until proved innocent.
Clearly and properly, the FAA must look at the risk to safe flight whether that risk comes from a medical condition itself or from any treatment needed for that condition. Mild generalized anxiety not requiring any medication and not associated with panic attacks is a very low-risk condition. A psychoanalyst I interviewed for this article told me about a private pilot patient she treated for exactly that kind of anxiety. It never occurred to her until I started asking questions that he might have been an unsafe pilot and now, in retrospect, she continues to have no concern at all. That was the right choice for him. It was a mild condition. My suspicion is that he never told the FAA that he was getting psychotherapy for anxiety, and while I don’t approve of nor recommend hiding things from the AME, he certainly saved himself a lot of hassle and a lot of time out of the cockpit if, in fact, he kept this a secret.
The FAA, Anxiety And Pilots
Not long ago, depression was simply disqualifying, as were all psychoactive medications. More recently, special issuance is possible for many people and some medications. The FAA now accepts the concept of situational depression—the patient who needs help with therapy and even medications for a relatively short time around a major life event such as a divorce or the death of a child and then goes on to normalize. One of the AMEs with whom I spoke surmised that the more liberal FAA policy, in part, comes from their understanding that the relatively punitive black-and-white prior approach forced pilots to leave these kinds of things unreported while a more liberal policy, analogous to the ASRS system, would encourage reporting, promote treatment and actually improve the system. He did, however, speculate that most people with quite mild anxiety and perhaps even requiring rare self-treatment with something like Valium almost certainly don’t report their condition to the AME and that likely does them no harm at all.
Clearly, a patient with relatively severe anxiety, associated panic disorder, more than a little impulsivity or things like that would raise red flags with the FAA, and that’s as it should be. They would ground that pilot and require a mountain of paperwork from a squad of physicians before allowing that person to fly an aircraft again.
The situation with psychoactive medications is more difficult. Any pilot taking any of them would require special issuance, at best. Special issuance is possible for pilots taking Zoloft, Prozac, Lexapro and Celexa, but no other SSRI class medications. Special issuance is possible for pilots taking only one of the benzodiazepines, Valium, but there must be a fairly long interval between most recent dosage and any particular flight.
Why these particular medications and not others are potentially compatible with flight, no one I spoke with can say. It’s not related to how long they have been on the market and hence our experience with them. Their side effects are more similar than different. All of the benzodiazepine and SSRI medications can cause fatigue, lightheadedness, stomach upset and many other symptoms in some people. The SSRI medications are of particular concern in depressed people, especially depressed young people. Depression causes feelings of hopelessness, and it causes a lack of ambition to do anything about anything. Imagine if a medication lifted the lack of ambition before it lifted the hopelessness. That could propel a person from suicidal thought to suicide, and that’s exactly what happens in a few sad cases.
A last word on side effects. Those long and intimidating lists we read on package inserts are designed by lawyers to be hyper-inclusive. That way, no patient in our litigious society can say he wasn’t warned. But just because a drug can do something doesn’t mean that a drug will do something in any individual. It never ceases to amaze me how many smart people don’t understand probability, at least when it comes to healthcare. How often have I been told by a patient that “I won’t take that medicine because it causes erectile dysfunction.” Well, it can, but it usually doesn’t. And, if it does, we’ll stop the medication and all will soon be right in the kingdom. And, best of all, once an individual patient has done well for a while on a stable dosage of almost any medication, he’s very unlikely to go on to develop a problem later on.
At 24, my primary flight instructor was exactly half my age, but he had wisdom that I’ve relied on ever since. So, what would Steve do if he developed anxiety? Like one of the C’s in the lost procedure, he would confess—maybe only to himself, if it was rare and mild, but he would confess and cope. Anything more than rare and mild anxiety would lead him to his general doctor and whatever consultation and treatment might be needed. He would ground himself, inform his AME, and get better.
Life is a good deal. As much as we may love to fly, you need to be alive and at least mostly untroubled to take joy in it.
John Levinson, MD, PhD, practices and teaches Cardiology and Medicine at Massachusetts General Hospital and Harvard Medical School in Boston. An instrument-rated private pilot, he uses his Mooney for business and personal transportation, flying mostly with his non-pilot wife whose very different perspective adds greatly to all he sees and writes.