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In addition to the listing of symptoms, the modules contain items for recording onset, severity and duration of the syndrome as well as the number of episodes where applicable. The modules also list symptoms and states which should be excluded before making a positive diagnosis. Clinicians are free to proceed with their assessments as they would in their usual clinical practice. They are encouraged to include information obtained from informants and other sources. For most disorders, diagnostic agreement was good to excellent, with kappas ranging above 0. Its initial application was in clinical studies where accurate diagnosis is essential to treatment evaluation. The interview was originally designed to meet the needs of both researchers and clinicians. It is published in two parts: a reusable administration booklet (with color-coded tabs) and one-time-use-only scoresheets. The biggest advantage of the research version is that it is much easier to modify for a particular study and its coverage is more complete. The organization of the modules is hierarchical, with explicit decision trees to show when to discontinue administration of each module. The interviewer scores individual symptoms in the following ways: ``inadequate information (fi Moreover, clinicians are requested to make several additional distinctions: ratings of both current and past episodes are required for mood disorders, judgements regarding aetiology (organic/not organic) are asked for psychotic symptoms and mood syndromes. Interviewers are encouraged to use all sources of clinical data when rating the interview. The range in reliability is enormous, depending on the nature of the sample and the research methodology. The Schedules comprise a set of instruments aimed at assessing, measuring and classifying the psychopathology and behavior associated with the major mental disorders of adult life. The structured clinical interview with semi-standardized probes is based on clinical ``cross-examination'. The trained clinical interviewer (a psychiatrist or clinical psychologist) decides whether a symptom has been present during the specified time and, if so, with which degree of severity. Part 2 covers the assessment of psychotic and cognitive disorders and abnormalities of behavior, speech and affect (Table 8. A round of painful thought which cannot be stopped and is out of proportion to the topic of worry. Rating is done on the basis of matching the answers of the respondent against the differential definitions of the symptoms and signs in the glossary, which is largely based on the phenomenology of Jaspers. The algorithms can be run at any time within the interview even with uncompleted data. This kind of information is important especially for testing and improving the diagnostic algorithms. It describes the rationale and development of the system and provides a valuable introduction to its uses. Other Semi-structured Diagnostic Interviews for Axis I Disorders A number of semi-structured diagnostic interviews have been developed for specific Axis I disorders, such as the Eating Disorders Examination [40] or the Yale Brown Obsessive Compulsive Schedule [41]. It has the following features: (a) polydiagnostic capacity; (b) a detailed assessment of the course of the illness, chronology of psychotic and mood syndromes, and comorbidity; (c) additional phenomenological assessments of symptoms; and (d) algorithmic scoring capability. The scores computed for each domain are added and the final, global score provides information on the presence or absence of borderline personality disorder. For a score of 3, the characteristics described in a criterion must be pathological, persistent, and pervasive. Decisions between a score of 2 or 3 are based on features such as the frequency or severity of a behavior, and the presence of distress or difficulties in social or occupational functioning. Results concerning concurrent validity (comparisons with clinical diagnosis and with other instruments) have been less satisfactory. The assessment of the three additional personality disorders is, however, relegated to the end of the interview, and as such can be easily omitted.

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In order to evaluate the duration of the effects, they examined several other functions following four days of isolation. On several occasions during isolation, they had subjects perform tasks such as mental multiplication, arithmetic catch problems, completing number series, anagrams, and wordmaking. Despite the fact that the decline in the twenty-two subjects of the experimental group was not statistically significant for all these tasks, the deterioration due to the experimental conditions was consistent. In a second series they found no change in digit span or analogies during isolation, whereas associative learning tended to decline, but not significantly. In a postisolation series they found significant deterioration in judgment of anomalies and in two block design tasks. Their general findings suggest that performance on intelligence test items grew progressively worse as length of stay in the cubicle increased. Starting with this observation, Vernon and Hoffman (76) used a procedure of sensory deprivation similar to that described above. They studied the ability of four paid volunteer male college students to learn lists of adjectives after twenty-four and forty-eight hours of confinement. Comparing their experimental subjects to an equivalent control group, they found that the ability at rate-learning improved with continued sensory deprivation. In a follow-up study, nine experimental and nine control subjects, who were all paid volunteer male college students, were compared for ability to learn a longer list of adjectives after twenty-four, forty-eight, and seventytwo hours of sensory deprivation (77). In this instance there were no significant differences between groups in errors or trials to criterion, although 64the experimental group made fewer overt errors and showed less variability. Thus, despite failure to confirm their own previous findings, this study did not support the deterioration finding of the McGill group. Goldberger and Holt (32) studied fourteen paid volunteer male college students under perceptual deprivation conditions similar to those of the McGill experiments. Subjects lay on a bed in a cubicie for eight hours and were encouraged to talk during their time in isolation. The following tests were administered at the end under the experimental conditions: arithmetic reasoning, digit span, and story recall. Subjects were then taken out of the isolation and a test of logical deductions was given. Comparison of the performance of the experimental subjects preand postconfinement (without a control group) showed that only the last of these, logical deductions, reflect significant impairment. Davis, McCourt, and Solomon (21) utilizing a modification of the polio tankrespirator procedure initially described by Wexler et al. Although they could talk to each other, they were confined separately and could not see each other. In comparing scores before and after isolation they found no change in performance on a block design task. These authors considered the possibility of procedural variables causing failure to confirm Bexton et al. Subjects were seated individually for one hour in an isolation chamber in a comfortable chair. They wore goggles which were either blacked out or else permitted diffuse light perception. Audition was minimized through car plugs, padded earphones, and the masking sound of a fan motor. Their fingers were wrapped in elastic bandages and they wore elbowlength gloves. Subjects were also told that they would perceive sensations ordinarily below conscious awareness. These experimenters report that there was no "gross cognitive deterioration" under these conditions as measured by the number of word associations produced in two minutes. The small sample size, the brief period of isolation, and the limited measure employed in this study suggests caution in interpreting this result. Cohen, Silverman, Bressler, and Shmavonian (18) reported an exploratory investigation on four subjects exposed singly to four hours of confinement and deprivation while seated in an anechoic chamber, with instructions to keep awake and to estimate the passage of successive thirty-minute intervals.

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It is often very difficult to define the boundaries between normality, eccentricity, and psychiatric disorder, and individuals, not uncommonly, cross over these boundaries from day to day. A basic requirement for that monitoring is that all flight crew members must know what should be happening with and to the aeroplane at all times. Ideally the actions of each crew member should continuously be monitored by his fellow crew member(s). Meaningful simulator training, reinforced with a suitable education programme, is a requirement. One of the basic fundamentals of this philosophy is that it is the inherent responsibility of every crew member, if he be unsure, unhappy or whatever, to question the pilot-in-command as to the nature of his concern. Indeed, it would not be going too far to say that if a pilot-in-command were to create an atmosphere whereby one of his crew members would be hesitant to comment on any action, then he would be failing in his duty as pilot-in-command. In smaller companies, procedures are less standardized and a greater degree of individuality is tolerated, so behavioural problems can be expected to be more common, and experience has shown that this is the case. This was dramatically demonstrated in the United Kingdom in 1989 when a flight crew shut down the wrong engine of a Boeing 737. Although the pilots believed their action was correct, the cabin crew had seen flames issuing from the other engine, but unfortunately this information was not communicated to the flight crew. In the ensuing crash several passengers and crew members were killed or severely injured. Interpersonal relationships are not particularly amenable to measurement, and there is much suspicion among pilots about any process which attempts, or seems to attempt, to measure personality. Based only on such an assessment can the authority objectively consider certification that is compatible with generally accepted flight safety standards. Figures for the risk of a future cardiac event in an individual recovering from a common cardiac problem such as myocardial infarction are available. Figures may also be available for certain other relatively common diseases, such as the risk of a cerebral metastasis from a recurrence of a surgically removed malignant melanoma, or the recurrence of an epileptic seizure after a first fit. It should be remembered that a medical condition in a pilot that might potentially result in only a loss of efficiency or a moderate decrease in safety in a multi-pilot aircraft might incur great risk in single-pilot operations. This might, paradoxically, have the opposite effect of that desired because it is possible that flight safety would suffer if older experienced pilots with minor health problems were replaced by younger and healthier, but less experienced pilots. At the same time, it seems reasonable to assume that uneventful flying experience may breed complacency and also that experience, obtained many years ago in aircraft types no longer flown and with navigational systems and other equipment no longer in use, may be of little value today. Unfortunately, the data relating pilot experience to risk of accident are sparse, although there is little evidence to suggest that the risk changes much between 60 and 65 years of age, and in 2006, 65 years became the upper age limit for professional pilots in multi-crew aircraft (increased from 60 years). Since the medical history is usually more important than the medical examination in eliciting conditions of flight safety concern, it is desirable that an applicant believes he will be treated fairly, should he volunteer that he has a particular medical problem. In cooperation with all stakeholders, including representative bodies of licence holders, States should strive to develop the appropriate culture to minimize this risk. Moreover, Contracting States which have their own reporting system are often hampered by the confidential nature of the information supplied. For example, a report following an incapacitation is often filed by another crew member who does not reveal the name of the incapacitated person, making follow-up difficult. The diagnosis might not be relevant at the time of incapacitation, but is important for monitoring medical standards and in determining where the maximum benefit for a given effort is achieved with respect to reducing the incidence of in-flight incapacitation. Attention needs to be given to devising a more accurate, preferably international, method of recording and classifying data on in-flight incapacitations. It is to be hoped that this development will provide the stimulus towards a more evidence-based application of aeromedical standards. Safety management principles as applied to the medical certification process are addressed in more detail in Part I, Chapter 1, of this Manual.

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One difference between cardiology (a topic that is well-suited to the application of objective risk assessment) and oncology is that with the former, once the risk has been defined and certification achieved, the pathological condition is not likely to go away. After treatment of malignancy, however, the prognosis improves with recurrence-free time after the original episode. Certification possibilities according to acceptable risks of incapacitation Incapacitation risk per year Acceptable level of certification Licence Less than 0. The second is the site of that recurrence, and this will depend on the primary tumour type. However, unless it is possible to cure many patients once their tumour has recurred (not a common situation) then the two curves will be very similar in shape. It includes figures along the curve showing the recurrence rates for each of the five years following treatment. These data, however, include a large spectrum of recurrence rates from very low (early stage disease) to very high (late stage disease). As would be expected, the more advanced stage tumours (stages 2 and 3) have a worse prognosis than early lesions. For instance, the risk of a recurrence between two and three years after surgery for a stage 2 tumour is nine per cent. Although metastases can occur in any part of the body, the majority are found in lymph nodes, lungs, bones, bone marrow and brain. For any particular tumour the risk of first recurrence at each of these sites can be determined from available data sources. Incidence of metastasis by site for a hypothetical tumour Site incidence Per cent Local and regional lymph nodes 60 Liver 20 Brain 10 Lung 5 Bone 5 Bone marrow 0 Defining the risk of a particular metastasis causing incapacitation 15. A brain metastasis, on the other hand, as the first indication of recurrent disease, can be assumed to carry a 100 per cent potential for sudden incapacitation in the form of a fit or seizure or another neurological event such as paresis, sensory loss or headache. Rarely metastases erode major vessels with catastrophic consequences (lungs and liver). In the first year, therefore, the average risk of incapacitation due to brain metastases ranges from 0. The combined risks of several sites of recurrence may need to be taken into account. Certification possibilities according to stage and time since completion of treatment Year since completion of primary treatment Stage 1 2 3 4 5 1 0. Chart indicating certification possibilities according to stage and time since completion of treatment Using certification assessment charts 15.

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