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circumstances, persons with personality disorders should not be allowed to work in the aviation
environment.
Persons with impulse control disorders are particularly unsuitable for careers in aviation. The inability to
control an impulse when the adverse consequences are obvious is a major concern in someone accepting
the responsibilities of a safety-sensitive function within aviation. Moreover, persons with these disorders
are also usually at odds with their environment, which is an added stressor and may lead to further
inability to focus on the task at hand and detract from the attention required in aviation.
Applicants with disorders of behaviour (for example regarding habit, gender identity, sexuality) should be
assessed on the basis of their ability to put aside the disorder (or any conflicts related to the disorder) in
ICAO Preliminary Unedited Version — October 2008 III-9-6
order to attend to the aviation task at hand. These persons may have significant conflicts with their
environment, leading to further difficulties, which may become an impediment for them to hold an
aviation licence.
ORGANIC MENTAL DISORDERS
A wide range of agents can cause organic disturbances of the brain. The resultant symptoms depend on
the causal agent, the part(s) of the brain affected, the previous health of the brain, and the current
environment of the person. The causal agent may be external (alcohol, drugs, medication, injury, etc.) or
internal (tumours, endocrine disorders, degeneration, etc.). An organic mental disorder may present with a
wide array of psychiatric symptoms. The examiner may not always detect such a disorder unless he is
aware of the possibility that the disorder may be present. The most common result of an organic insult to
the brain is delirium or dementia, but anxiety, depression and behavioural changes may also have organic
causes. An organic insult to the brain may result in reduced functioning, and once the insult is removed,
there may still be concern about the continued optimal functioning of the brain.
The presenting symptoms of delirium are disturbed consciousness and a change in cognitive ability,
developing over a short period of time. Return to the previous level of functioning may be swift once the
causal agent is removed. A history of a delirium need not be a bar to licensing. If the delirium was caused
by the use of alcohol or another psychoactive substance, a more intensive investigation should be
undertaken. The operational aspects of cognitive incapacitation are further considered in Part I, Chapter
3.
Dementias are the result of progressive and irreversible brain damage, leading to impairment of memory
and other cognitive disturbances. The most common dementia is Alzheimer’s Disease, which usually has
a slow, insidious onset after age 65 to 70. It is not unusual that older persons with disturbed cognition are
given a diagnosis of Alzheimer’s Disease without the benefit of a full psychiatric examination. It is
imperative to rule out the presence of a depressive illness or indeed any reversible medical conditions,
which may present with symptoms of dementia before deciding on a diagnosis. With older aircrew, the
medical examiner should be aware of the possible presence of early dementia and at least carry out some
rudimentary tests of cognition (e.g., The Mini-Mental Status Examination, Appendix 1). If this
examination gives any evidence of deterioration, there would be reason to embark on more extensive
medical and psychological investigations (e.g., neuropsychological testing, basic biochemistry, EEG,
CAT scan, etc.).
SLEEP DISORDERS
Insomnia affects up to one-third of the adult population, and large numbers of people complain of
intermittent sleep difficulties. Individuals with insomnia become tense, anxious, preoccupied with sleep,
and frequently complain of poor concentration and poor ability to focus on tasks. Persistent insomnia
requires a complete history and thorough physical examination as the presence of organic causes must be
ruled out (e.g. chronic pain, narcolepsy, sleep apnoea, episodic movement disorders).
Disturbed sleep is commonly associated with alcohol or substance abuse and with a host of psychiatric
conditions including mood disorders, psychosis, and anxiety disorders. At times the sleep disturbance
may be one of the presenting complaints and when further history is obtained, the other symptoms of the
psychiatric disorder will be revealed. The sleep disorder may consist of initial insomnia (commonly
associated with anxiety), interrupted sleep (commonly associated with substance abuse, in particular
alcohol), and early awakening (commonly associated with depression).
Insomniacs will frequently self-medicate with prescription or non-prescription medicines or with readily
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Manual of Civil Aviation Medicine 2(16)
