Clinical Practice Guideline
Developed for the
Aerospace Medical Association
by their constituent organization
Overview: Adjustment disorders are characterized by the development of clinically significant emotional or behavioral symptoms in response to an identifiable psychosocial stressor or stressors. These symptoms are clinically significant if marked distress is in excess of what would be expected from exposure to the stressor or there is significant impairment in social or occupational functioning. The symptoms should not represent bereavement for the death of a loved one but, may be considered as an adjustment disorder if the reaction is in excess of, or more prolonged than, would be expected. Adjustment disorders can be viewed as a function based disorder (inability to maintain role function) whereas, major depression is seen as a symptom-based diagnosis (5 of 9 specific symptoms for more than two weeks) (3). An adjustment disorder must begin within three months of the onset of a stressor and resolve within six months of the termination of the stressor or its consequences. Adjustment disorders may be either acute or chronic. Chronic adjustment disorders are characterized by the persistence of symptoms for six months or longer in response to an enduring stressor or its consequences. Stressors may be a single event or there may be multiple stressors. Stressors may be recurrent or continuous. If the disturbance meets the criteria for another Axis I disorder or is an exacerbation of a preexisting Axis I or II disorder, the diagnosis of adjustment disorder should not be used.
Adjustment disorders are classified by the subtype that best characterizes the predominate symptoms:
A) With depressed mood - when the symptoms are depressed mood, tearfulness, or feelings of hopelessness.
B) With anxiety – with symptoms such as nervousness, worry, or jitteriness.
C) With mixed anxiety and depressed mood – when symptoms are a combination of depression and anxiety.
D) With disturbance of conduct – with conduct disturbance involving the violation of the rights of others or of major societal norms and rules.
E) With mixed disturbance of emotions and conduct – involving both emotional symptoms and a disturbance of conduct.
F) Unspecified – for maladaptive reactions to stressors that are not classifiable as a specific subtype.
Aeromedical Concerns: Adjustment disorders are one of the most common psychiatric diagnoses among aviators. These disorders are commonly associated with functional impairment resulting from decreased concentration, depression, anxiety, inattention, insomnia, fatigue, temporary changes in social relationships and problems with decision making. These impairments are all incompatible with aviation duties.
Medical Work-up: If the adjustment disorder appears mild and improves in the first few weeks the flight surgeon may choose to manage the case with consultation from mental health. Early interventions with psychotherapy to strengthen coping mechanisms and short-term pharmacotherapy have been shown to ameliorate recovery (4,5). If the patient is not responding to stress reduction and coping skills an initial trial of benzodiazepines may calm the patient and induce needed sleep. If the patient continues to be symptomatic and overly distressed, antidepressants and continued psychotherapy should be of benefit. However, if the disorder is more severe and/or fails to improve in 1-2 weeks consider referring the case to mental health. Early mental health treatment can lead to early symptom resolution and possible return to flying status without the need for a waiver. Delay in treatment can lead to progression of symptoms to a more severe Axis I diagnosis (6). Adjustment disorders tend to resolve and only 21% ever develop into a diagnosis of depression (2).
Aeromedical Disposition (military): Air Force: If the DSM-IV-TR diagnostic criteria for adjustment disorder are met, then aviators should be placed DNIF until the disturbance is resolved. If the disorder resolves within 60 days the aviator is placed back on flying status and no waiver is required. If the disorder persists beyond 60 days the aviator is disqualified and a waiver is required. An evaluation by a qualified mental health professional is required prior to waiver consideration. There is no mandated recovery period before waiver application. The period of remission should be of such length that the flight surgeon and mental health consultant feel confident that the aviator will not suffer a recurrence.
The aeromedical summary should include:
A) Copies of mental health evaluation and treatment summary (evaluation within three months of submission).
B) An aeromedical summary outlining any social, occupational, administrative or legal problems associated with the case.
C) Letters from the aviator’s supervisor and treating psychiatrist or psychologist supporting a return to flying status.
Navy: No requirement for waiver. Once the aviator has symptom resolution, has discontinued all meds and clearance from mental health, approval for flight status is granted.
Army: Requirement for waiver after 90 days of symptoms requires resolution of symptoms with no meds and same guidelines required by Air Force. New Army regulations are allowing flight status using SSRIs. When medication is required for stabilization and will be continued, require 90 days usage with stability and flight evaluation for waiver.
Aeromedical Disposition (civilian): No antidepressants, antipsychotic or anxiolytics are presently permitted in civil aviation. Adjustment disorders are granted medical certification once they have resolved. Depending on the length of time medication was used, the airman may be asked to discontinue all psychotropic medications for 90 days before consideration for return to flying. A current status of the medical condition is required at that time.
Waiver Experience (military): Review of a large military waiver database from 2001 through mid-August 2007 showed 269 cases of adjustment disorder; 13 were pilot candidates (5%), 87 were pilots or navigators (32%) and 169 were non-pilot aircrew (63%). Of the 269 cases, 104 (39%) were disqualified and 165 (61%) were granted waivers. A random review of 76 waivers (48 qualified/28 disqualified) revealed that all the disqualifications were due to aviators with ongoing adjustment disorders. Of these disqualifications six were prior approvals with subsequent recurrence. Of the approved waivers the minimal time of remission was 5 months and the average was one year or more.
Waiver Experience (civilian): There is no single pathology code for adjustment disorder in the FAA’s Aeromedical Certification system so civil aviation experience with this condition cannot be determined at this time.
1. Adjustment Disorders. Diagnostic and Statistical Manual of Mental
Disorders, Fourth edition, Text Revision. DSM-IV-TR. American
2. Andreasen N, Hoeuk P. The Predictive Value of Adjustment Disorder. American Journal of Psychiatry. 1982: 139; 584-590.
3. Kirch KL, et al. Difficulties in Screening for Adjustment Disorder. Palliative and Supportive Care. 2004: 2123-2131.
4. McGlynn TJ, et al. Diagnosis and Treatment of Anxiety Disorders,
A Physicians Handbook. American Psychiatric Press,
5. Stewart JW, et al. The Pharmacotherapy of Minor Depression. American Journal of Psychotherapy. 1992; 46: 23-36.
6. Strain J. Adjustment Disorders, Psychooncology.
7. USAF. Aircrew Medical Waiver Guide, Adjustment Disorder, revised Sept. 2007.
9. US Federal Aviation Administration.
Guide for Aviation Medical Examiners.
10. US Navy. Aeromedical Reference and Waiver Guide. Adjustment Disorder, Update March 2007.
Update: January 18, 2008