Aerospace Psychiatry
David R. Jones
But let us set before the eyes of the mind a much more lovely spectacle … in which people, who while still alive become earthly gods rising on a golden chain toward Heaven … who know all arts and sciences …
God denied to men the faculty of flight so that they might lead a quiet and tranquil life, for if they knew how to fly they would always be in perpetual danger.
Aeromedical practitioners (civilian aviation medical examiners and military flight surgeons) select fliers and maintain their physical health in a manner that differs considerably from the conventional practice of clinical medicine. Likewise, aerospace psychiatry affirms normal cognition, emotional stability, coping skills, and behavior as defined in terms of flying safety and effectiveness, thereby differing from the primary concerns of clinical psychiatry with the diagnosis and treatment of mental disorders.
Flying is more than a means of transportation. Most writings of early aviators and the physicians who worked with them note that safe and effective flying involves more than simply having the desire and the physical capacity to fly. The terms used to describe the mental, emotional, and psychologic factors involved in aviation have varied considerably over the years, but the existence of these necessary qualities has never been in doubt. Three of the nine chapters in Anderson’s early book on aviation medicine discussed such matters as “the psychology of aviation,” and “the aeroneuroses.” “Nervous breakdowns have been noted since the early days of flying. In fact, they may be classed as an occupational neurosis [in] a comparatively new occupation, namely: aviation” (3).
Aircraft and their missions have changed since the days of wood, wires, and dope-covered linen, and the pilot population also has changed. Whereas our predecessors supported a homogeneous group of young men and a few young women, now we must consider people of all ages flying in general aviation, commercial aviation, peacetime or combat military aviation, and short- or long-duration space missions. Aeromedical practitioners still seek to select prospective fliers with healthy motivation, adequate innate physical and mental abilities, stable temperaments, and adaptive coping skills, but now we must maintain or enhance these characteristics throughout flying careers of 50 years or more.
Fliers writing about aviation may discuss matters that involve what we now call “human factors” (see Chapter 24)
but they also discuss, in some way or other, the pure joy of flying: the positive emotional factors that form an inescapable and essential part of the reasons that fliers love to fly. No other word will do. Fascination with the idea of flight is as old as the human race. Primal themes include the idea of the air as a living female entity. Air stimulates the imagination because it is invisible, unpredictable, and exists between heaven and earth. Invisible beings with the power of flight seem to inhabit this realm: angels, fairies, sylphs, winged demons, and the like. No religion or mythology fails to discuss or illustrate the existence of such creatures. The very concept of “up” involves becoming closer to heaven, as shown in the writings of St. Augustine, and the spirits of the air could move so speedily that they could appear to predict events (1). Armstrong (4) related the emotional aspects of aviation to a spiritual experience, noting that all religions portray flight as a divine gift. In the oft-quoted words of Magee’s sonnet “High Flight,” the ultimate act of the flier is to “Put out my hand and touch the face of God” (5). Military aviators, a traditionally unemotional group, give each other plaques inscribed with this poem. In short, psychologic factors are intrinsic to aviation.
but they also discuss, in some way or other, the pure joy of flying: the positive emotional factors that form an inescapable and essential part of the reasons that fliers love to fly. No other word will do. Fascination with the idea of flight is as old as the human race. Primal themes include the idea of the air as a living female entity. Air stimulates the imagination because it is invisible, unpredictable, and exists between heaven and earth. Invisible beings with the power of flight seem to inhabit this realm: angels, fairies, sylphs, winged demons, and the like. No religion or mythology fails to discuss or illustrate the existence of such creatures. The very concept of “up” involves becoming closer to heaven, as shown in the writings of St. Augustine, and the spirits of the air could move so speedily that they could appear to predict events (1). Armstrong (4) related the emotional aspects of aviation to a spiritual experience, noting that all religions portray flight as a divine gift. In the oft-quoted words of Magee’s sonnet “High Flight,” the ultimate act of the flier is to “Put out my hand and touch the face of God” (5). Military aviators, a traditionally unemotional group, give each other plaques inscribed with this poem. In short, psychologic factors are intrinsic to aviation.
Medical literature, by its nature, tends to discuss things that go wrong. The medical specialty of clinical psychiatry deals with mental disorders: their causes, diagnoses, and treatments, as well as their preventive aspects. Aerospace psychiatry differs from clinical psychiatry in several ways. Stated succinctly, not all mentally normal people are fit to fly, and not all mental disorders necessarily render a pilot unfit to fly. Aerospace psychiatry must deal with positive as well as negative mental health matters, for the absence of positive mental attributes, by no means definable as a mental disorder, may degrade safe and effective flying as surely as the presence of mental disease. Psychiatric disorders in fliers can affect flying safety and effectiveness at subclinical levels that do not warrant formal psychiatric diagnoses in nonfliers. Aerospace psychiatry also involves the system of physical examinations that certifies fliers for specified periods, examinations that include a prediction that the flier will remain mentally fit to fly at least until the next evaluation. In some military and commercial settings, the examiner may also be charged with selecting fliers who will be able to fly for a full career, that is, for 20 years or more, or until retirement age. This long-term requirement stands in stark contrast to the difficulty that clinical psychiatrists face in predicting whether a depressed patient will become suicidal in the next few weeks.
Operational aeromedical practitioners make psychiatric decisions about fliers in their offices. These practitioners may have varying levels of psychiatric experience and skill. Aerospace medicine describes the world of the aviator in ways that do not allow for easy translation into psychiatric terms, and so a flight surgeon and a clinical psychiatrist may describe the same phenomenon in quite different ways. Close coordination and cooperation is essential between the practitioners of aerospace medicine and their mental health consultants who may have varying knowledge of, or interest in, the aeromedical aspects of the matter in question. Flight surgeons’ decisions about fliers are not based on the usual clinical indications alone, but also on the aeromedical implications. Most psychiatrists would not understand the implications of “thinking ahead of the aircraft,” “get-homeitis,” or “poor situational awareness” without considerable explanation. Only a few physicians have trained and practiced in both fields to the extent that they may make aeromedical judgments about patients suffering from mental disorders without consultation.
Need for interdisciplinary cooperation arises in part because some fliers react quite differently to aviation stressors than they do to life stressors. Mental health factors that would be of little concern in everyday life—this defines subclinical—may compromise aviation safety and effectiveness in ways of which a non-aviation-oriented physician, psychologist, or counselor may simply be unaware. Human lives involve infinite circumstances of thought and behavior, which by definition may never all be included in a set of regulations. Therefore, knowing which problems are not compatible with safe and effective flight calls for a mature professional understanding of the principles underlying aeromedical decisions concerning mental health.
A textbook that is used by aeromedical practitioners in different countries should point out that cultural differences will affect some of the matters discussed in this chapter (e.g., attitudes toward women pilots or toward the treatment of symptoms of acute stress reactions in combat). In presenting the mental health aspects of selection, health maintenance for safe and effective flying, reactions to stressors of life and of aviation, and other aeromedical topics, we will discuss useful principles rather than explicit answers that may not fit the reader’s circumstances, or that may quickly become obsolete.
SELECTION OF FLIERS
Aeromedical mental health standards should pertain to flying safety and effectiveness, or to the health of the flier. Each criterion should be carefully justified because as more standards are used for selection less people can meet them all. Failing to meet a criterion may disqualify a person from employment, and so each standard must meet metastandards of fairness, validity, and equity. Valid standards should address safety, health, dependability, and competence, and the factors examined should be as objectively measurable and reproducible as possible. The ultimate validation of mental health in aviation is the flier’s career-long health, safety, and effectiveness. Researchers studying the effectiveness of various selection techniques have used different outcome criteria: solo flight, graduation from training, accident rates, and the career progression of graduates for up to 5 years. Any comparative assessment of this research must consider these different criteria. Some selection processes seek to identify those who are fully qualified to fly by disqualifying only those who have disorders (select-out), and some seek the best qualified among those who are not disqualified (select-in) (6).
Mental health standards continue to evolve as the mental health disciplines advance from their subjective historical roots toward objective measurements of mental function (psychologic and neuropsychologic testing), and toward an empirical foundation for classification of mental disorders, as described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) of the American Psychiatric Association (7, (p. xv). Advanced methods of examining the central nervous system [functional magnetic resonance imaging, positron-emission tomography, singleproton emission tomography, and technologically enhanced (quantitative) electroencephalography] offer diagnostic precision, and some may eventually become practical selection tools. Future genetic research may help identify the functional origins of the temperamental qualities of successful aviators. For now, though, most authorities depend on interviews and psychological tests for aeromedical qualification of prospective fliers and leave their operational selection to the intuition and experience of flight instructors. The selection process may be divided into matters involving motivation, aptitude for the job (ability), and sensitivity to self and others (stability) (6, (pp. 100-111).
Motivation to Fly
Motivation is the psychic force or energy that moves a person to satisfy a yearning or to achieve a goal. Healthy motivation to fly resembles a motivation for an artistic career or a career in medicine in its combination of emotional (limbic, irrational) and cognitive (cortical, rational) components. Many pilots will say, “I’ve wanted to fly for as long as I can remember,” which is evidence of the deep roots of their motivation. The proportion of emotional and cognitive elements in a specific flier changes with age, experience, and other life factors such as marriage, children, and normal events of life. A flier’s answer to the question “What do you tell yourself about the dangers of flying?” change after a crash, after marriage or the birth of a baby, or simply as the flier ages. Therefore, motivation to fly should be regarded as a dynamic process that may be reassessed when aeromedically necessary.
Motivation to fly may represent equilibrium between positive factors (e.g., joy, emotional meaning, and coping skills), and negative factors (e.g., fear, anxiety, and experienced or anticipated danger). The pure emotional joy of flying offsets a healthy fear of its true dangers. The subconscious “meaning” of flying (it represents power, freedom, independence, control, and other basic urges) can also give rise to anxiety if these primal elements are threatened. This may occur if the flier senses a loss of control over life situations (marital or family discord), resulting in a phobic fear of flying (FoF). Finally, the flier’s coping skills, necessary for basic resilience, hardiness, and stress tolerance, may be overcome by the actual dangers of flight as encountered in near collisions, accidents involving oneself or respected friends, or in combat situations where control is impossible (8,9).
Some fliers choose to fly not because of an emotional attraction, but because of a more rational attraction (e.g., financial rewards, social status, or travel). Because they do not have a strong emotional commitment to flying, these “rational choice” fliers may move on to other careers or activities without much internal struggle (symptoms) when their life circumstances change or when the real dangers of flight exceed their perception of the rewards of flying. A survey by McGlohn et al. (10) contrasted the mix of emotional and rational motivational elements in male and female U.S. Air Force aviators. The reasons most endorsed by the men (45%) emphasized the emotional elements that attracted them to aviation, whereas those most endorsed by the women (34%) emphasized the rational elements.
Any assessment of a person’s motivation to fly must deal with basic emotional issues involving “flying and dying.” Flying, a fascinating, dangerous activity, is both loved and feared—loved because of its power, grace, and beauty; feared because of the chance of catastrophe (11). Fliers who value their appearance of rationality and coolness may speak in unemotional terms about aviation matters that in fact have deep emotional roots. Because fliers by inclination and culture tend to downplay (suppress) emotional matters, or to compartmentalize (deny or even repress) them entirely, they may not recognize the strength of these issues in their own lives. Aeromedical practitioners must consider possible emotional factors whenever a flier’s response to a situation does not make sense (is irrational), or involves an inappropriate emotion, or seems disproportionate to the stressor involved. These three factors—irrationality, inappropriateness, and disproportionality—indicate underlying emotional components of aviation-related symptoms.
Some fliers have a flawed or pathologic motivation to fly. A need to compete with a fearful father figure through aggressive activity carries with it the unconscious fear of retribution should the effort succeed. Such individuals may become increasingly anxious as they move toward their goal of becoming an aviator. Others may be living out a parent’s own fantasy, or trying to prove that they are not afraid although no one said they were (counterphobic), or seeking risks in search of thrills (high stimulus threshold). A few would-be pilots do not wish to fly for its own sake, but wish to attain the role of pilot to compensate for feelings of inadequacy. Seeing themselves as alienated from others, inept, or weak, they wish to acquire the gregarious, competent, and powerful attributes they perceive to be those of fliers. Such pathologic motivations may underlie significant symptoms or downright dangerous flying behaviors in the absence of diagnosable psychiatric disorders. Weak or flawed motivation, or poor defenses against the real dangers of flying, may be recognized during flight training as “manifestations of apprehension,” or early in an active flying career as “FoF.”
Ability to Fly
“Ability” involves a flier’s physical, cognitive, autonomic, neurophysiologic, and psychologic traits. These include situational awareness, spatial perception, capacity for mental calculation, suppression of emotional responses during urgent
situations in favor of analysis and correct action, psychomotor skills (“good hands”), and alertness to a wide range of sensory inputs, along with the ability to screen out stimuli of no aeronautical importance. No one can excel in all these areas, but safe and effective flight requires a balance of such capabilities; flying requires more than clinical psychiatric normality.
situations in favor of analysis and correct action, psychomotor skills (“good hands”), and alertness to a wide range of sensory inputs, along with the ability to screen out stimuli of no aeronautical importance. No one can excel in all these areas, but safe and effective flight requires a balance of such capabilities; flying requires more than clinical psychiatric normality.
Abilities vary, and their assessment is not primarily aeromedical. Flight instructors can identify students with “good hands” during flight training, a crucial part of the select-in process that complements the medical process. They appraise the in vivo cockpit performance of applicants in matters involving intelligence, perception, attention, interpretation, and the speed and quality of decisions, based on variable sensory stimuli under flight training stress. These attributes are elemental to the ability to perform the mental and physical processes necessary for safe flight.
Aeromedical specialists and aviation psychologists have worked for decades to isolate these specific abilities and this process will undoubtedly continue for decades to come. Recent advances in flight simulator technology are challenging the conventional wisdom that only experience in actual flight can teach a person to fly. However, even the most sophisticated devices cannot duplicate fully the physical sensations and sensory inputs of actual flight (e.g., gravitational forces, pressure changes, total range of sound and vibration), nor can they overcome the student’s underlying knowledge that a mistake in simulated flight may be embarrassing, but will not result in sudden death. This surety means that the student does not experience the full effect of the powerful emotional, autonomic, and hormonal stimuli that may occur when the same situation occurs in a real aircraft, just as simulated combat training cannot entirely prepare anyone for the real thing (12).
Stability
“Stability” involves personality, temperament, and interpersonal relationships, including attitude toward authority. Even a lone private pilot must decide when and where to fly, must share airways, and must adhere to flying regulations and instructions. The aviator’s general attitude toward flying involves a way of thinking about weather, time of day or night, fatigue, circadian rhythm, readiness to deal with sudden inflight emergencies, and a host of other factors well known to pilots. Collectively, these are part of what the aviation community calls “human factors.” A pilot’s mistake in such matters can be as suddenly lethal as a midair collision, and skilled pilots have died from such avoidable choices as knowingly flying into thunderstorms or failing to perform complete preflight walk-around inspections because they were in a hurry.
Consideration of aviator stability includes an appraisal of personality (temperament). Probably no occupation has attracted as many studies of the personalities of its participants as has aviation. Beaven mentioned control of the imagination, patience, and a strong motivation to fly as important during World War I (13). Fine and Hartman emphasized above-average intelligence, a matter-of-fact view of life, and a preference for action over introspection; this latter characteristic explains why some fliers tend to act out their interpersonal frustrations rather than considering possible solutions (14). A study of 105 successful male military pilots noted their self-confidence, desire for challenge and success, and strong identification with their fathers. They tended to be eldest sons, to make life choices on a consciously rational basis, and to take risks only when their assessment of the odds led to a high chance of the desired outcome. They made friends easily, but avoided dependency and thereby maintained interpersonal distance (15). Christy described the balance between factors such as rigidity and flexibility, and the need for maturity, good motivation, and self-confidence, qualities that likely would assure success in any field of endeavor (16).
Modern research into the temperaments of successful aviators uses a more disciplined terminology. It does not depend on the clinical psychiatric literature for its vocabulary, nor does it follow the older aeromedical literature practice of describing fliers’ personalities by using everyday words rather than strictly defined and measurable terms. Helmreich et al., in their research into crew resource management (CRM), have identified two personality dimensions that affect aircrew performance: instrumentality, the work orientation, mastery of tasks, and desire to achieve; and expressivity, which includes interpersonal communications and sensitivity (17). They used interviews, questionnaires, and video techniques that allowed careful analysis by investigators, instructors, and the aircrew themselves. This research has produced information about effective and ineffective aviator personalities, although the investigators have not presented their results in clinical terms. Fliers may manifest instrumentality or expressivity either positively or negatively, and both factors are important in cockpit transactions.
The CRM approach has identified three categories of aviators. The first has positive elements in both dimensions. Positive instrumentality means a strong work orientation, drive to achieve, and drive to master the task. Positive expressivity includes low competitiveness and low verbal aggression. This combination seems the best for multicrew cockpits. During CRM training, such crews have the highest scores on coordination and communication skills, and best manifest the desirable attitude that responsibility rests with the entire crew rather than with the leader. They develop the most judgment and insight about their own reactions to stressors.
Crews demonstrating high instrumentality and low expressivity have the positive instrumentality characteristics of the first group, but are competitive and verbally aggressive (negative expressivity), are less skilled in communication and coordination, learn little about command responsibility, and show only modest recognition of stressor effects. A third group of aviators has both low instrumentality and low expressivity. This group does poorest in communication and coordination, actually regresses in appreciation of collective responsibility during training, and shows little recognition of personal stressor effects (17).
Helmreich’s research uses the methods of industrial or occupational psychology. The utility of the CRM concept has led to its application to other fields, such as the interactions of nuclear reactor control teams and the relationships between surgeons and anesthesiologists in operating rooms.
Selection Process
Mental health evaluations of aviators differ from usual clinical psychiatric interviews. Aeromedical examiners seek not only to affirm mental health in the ordinary sense, but also to determine when a normal person has the motivation, ability, stability, maturity, attentiveness, perception, anticipation, and judgment to make good decisions before and during a flight, and the hardiness and resilience to endure under prolonged stressors. The aeromedical practitioners responsible for physical examinations and the authorities that receive and evaluate the reports of these examinations must assess the possibility of aeromedically significant degradation of fliers during the interval until the next evaluation. In occupational selection of professional pilots, examiners must consider future fitness for a flying career of 20 years or more.
One approach to gauging the mental health of both prospective and trained aviators requires examiners to use a semistructured interview or a checklist. Flight surgeons perform formal assessments of adaptability in the U.S. Navy (Aeronautical Adaptability) (18,19) and U.S. Air Force (Adaptability Rating for Military Aviation) (20). The results vary in quality and usefulness because examiners’ psychiatric interviewing and observational skills differ, as well as their time for and personal interest in such evaluations. Although any practicing physician may recognize full-blown psychiatric disorders, lesser symptoms can be difficult to detect, especially if the flier conceals the difficulties (suppression, lying) or is unaware of them (denial, repression). The little formal research on this examination technique has not confirmed its predictive value (20). Difficulties in this endeavor include subtleties of the interview process (e.g., reverse malingering or “faking good,” resistances, experience of the examiner, the transference/countertransference interplay) and problems of recognizing significant symptoms and obtaining adequate and timely consultations when such symptoms are present (12).
Newly trained aeromedical practitioners soon develop professional and personal instincts about aviators, recognizing the bearing and behaviors of healthy fliers and forming useful preliminary impressions of their mental health. Some clues may be available as the examination begins: the reputation of the applicant in the community, or an examinee’s interaction with office staff. Flying candidates or experienced aviators who have mental health problems may behave differently with office staff than with the examiner, and so the staff should report any behavioral problems or eccentricities to the aeromedical practitioner.
Many examinations require that the examinee fills out a form before seeing the examiner. The examinee may mark carelessly, or omit, some answers. Examiners should obtain the correct or missing data and ask why the flier made this particular mistake; because a few fliers will not wish to lie directly, but will try to avoid reporting information they regard as negative. If the applicant does not live or work locally, the examiner may ask why he or she came so far; some will “shop around” for lax examiners, or will repeat examinations to learn how to conceal disqualifying information.
Examiners also should inquire carefully into any history of consultation with mental health professionals or para-professionals (lay counselors, company support programs) and ask about nonprescription medications, herbal remedies, and dietary supplements. Such information may be aeromedically significant because of the nature of these remedies, or because of the symptoms for which the pilot feels they are necessary. Be alert for illogical explanations about medical history or findings. If a flier’s explanation does not seem reasonable, ask for more details. If an examiner cannot understand a flier’s earnest efforts at explanation, benign possibilities include misunderstandings, communicating in the flier’s second language, educational deficiencies, cultural differences, or limited intelligence. However, the difficulty may be due to a neurologic or psychiatric problem.
Behaviors that caused body scars may represent patterns of personal recklessness. The scalp and skull should be palpated for evidence of head injury because these may have involved loss of consciousness or amnesia. Other pertinent physical findings bearing on mental status include unusual conduct, dress, grooming, tattoos or body piercings that suggest sociopathy, slash scars on wrists (possible suicide attempts), or stigmata of substance abuse such as odor of alcohol, needle tracks, or nasal septal scarring or perforations. The physician should talk with applicants before, during, and after the physical examination, inquiring about home, work, education, military experience, and flying activities. Again, examiners should trust their judgment that something may be amiss psychologically if they feel uneasy about the examinee.
At the end of the evaluation, the aeromedical practitioner should have enough information to decide whether a mental health disorder might be present, and whether outside medical data ought to be obtained. If anything raises clinical questions about the examinee’s mental status, or even if the examiner feels uncomfortable without knowing exactly why, a brief mental status evaluation (MSE) must be performed, using some or all of the items in Table 17-1. Note that this MSE extends beyond items considered in clinical “mini-MSEs” that are limited to evaluating the sensorium rather than assessing wider aspects of cortical function. Examiners who detect possible problems should defer certification and obtain formal mental health consultation to delineate these concerns more clearly. The certifying authority may have protocols to guide this process.
Selection for Space Flight
Evaluating the mental health and temperaments of individuals seeking to become astronauts includes several factors not considered for other types of flying. The United States National Aeronautics and Space Administration’s (NASA‘s)
intensely competitive biannual selection process may involve more than 3,000 initial applicants for 20 openings. The primary screening involves record reviews, but the final selection requires personal interviews and psychological testing. Almost any past or present psychiatric diagnosis will be grounds for disqualification, the binding select-out process. Mental health select-in is by no means binding because other medical and occupational standards will be applied to the applicants. However, the selection committee may consider identifiable positive personal qualities in its deliberations. Applicants are considered not only on the basis of their success in earth-bound occupations, but also in terms of their possible resilience or vulnerability to environmental stressors, prolonged isolation in small groups, and their interpersonal adaptive skills in groups of mixed gender, culture, ethnicity, occupation, and authority. Examiners must consider whether persons are self-sufficient or seem to require high personal maintenance from associates and authorities.
intensely competitive biannual selection process may involve more than 3,000 initial applicants for 20 openings. The primary screening involves record reviews, but the final selection requires personal interviews and psychological testing. Almost any past or present psychiatric diagnosis will be grounds for disqualification, the binding select-out process. Mental health select-in is by no means binding because other medical and occupational standards will be applied to the applicants. However, the selection committee may consider identifiable positive personal qualities in its deliberations. Applicants are considered not only on the basis of their success in earth-bound occupations, but also in terms of their possible resilience or vulnerability to environmental stressors, prolonged isolation in small groups, and their interpersonal adaptive skills in groups of mixed gender, culture, ethnicity, occupation, and authority. Examiners must consider whether persons are self-sufficient or seem to require high personal maintenance from associates and authorities.
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Because astronauts may undergo expensive training and service status for many years before actually flying in space, hereditary factors must also be considered in terms of expected future mental health. Some of these psychiatric and psychological factors go well beyond the usual definition of relative mental health: simultaneous success in work, personal relationships, and creativity, with the capacity to handle conflicts between instincts, conscience, important other people, and reality with maturity and flexibility (21, p. 127).
High standards of mental health for space crewmembers may seem intuitive, but are difficult to apply fairly and within legal and ethical limits. Although evidence-based standards would be ideal, clinical psychiatric literature, which usually concerns mentally ill individuals, seldom provides explicit data applicable to the early and subclinical conditions that space crew examiners must consider. NASA criteria generally follow the diagnostic formulations of DSM-IV (7), adding specific considerations for “traits” and subclinical manifestations. These criteria have been developed through a series of NASA-sponsored interdisciplinary meetings of operational flight surgeons, astronaut flight surgeons, aeromedical and clinical psychiatrists and psychologists, epidemiologists, and psychological testing experts.
During the selection process, psychological tests normed for the astronaut population add some objective data to the interviews, and all decisions are peer reviewed for possible individual bias. As with aircrew, anxiety disorders, mood disorders, and undesirable personality traits are the most common reasons for disqualification (22). Those responsible for developing and justifying selection and retention criteria have studied space-analogous circumstances such as Antarctic overwinter stays, nuclear submarine cruises, survival situations, and historic expeditions (6).
The subject of space crew mental fitness and collective interactions has been examined in the literature mainly, although crew questionnaires obtained before and after missions [for a summary of these data, see Kanas and Caldwell (23)]. Policies of the various space agencies, small size of space crew populations, intense public scrutiny, and difficulty in maintaining individual anonymity make case reports difficult. Still, with continued attention to the subject, and especially with the development of private individual onboard computerized questionnaires, data should accumulate over the next few years. As mission lengths increase and crews become even more heterogeneous, such data will be essential to mission safety and effectiveness and to the mental health of individual crewmembers.
Selection involves predictions of continuing health and especially of mental health, and is a difficult business indeed. Any system of aeromedical selection and certification depends not only on the examiners and the formal criteria, but also on the intelligence, insight, and integrity of the fliers to be forthcoming about medical matters, and to recognize and acknowledge when they are not fit to fly.
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