Panic with a twist: an unusual presentation of combined psychiatric and neurologic symptoms in a tactical jet aviator.

A 28-yr-old Naval F-14 aviator presented with complaints of flight-related anxiety occurring intermittently over an 18-mo period. Symptoms included sensation of strangeness, concern over the welfare of his radar intercept officer, flushing, nausea, and intense need to immediately land the aircraft. He also described a 6-mo history of episodes wherein he would see "shooting stars" in the periphery of his vision, accompanied by dizziness and disorientation. These latter attacks were always precipitated by head turning, usually in combination with positive Gz maneuvers, and were relieved by head straightening. The anxiety symptoms were consistent with a form of panic attack, but the neurological symptoms provoked further workup. Magnetic resonance cerebral angiogram demonstrated a dominant right vertebral artery and hypoplastic left vertebral artery. All symptoms resolved once the aviator was removed from flying the aircraft. After a year of follow-up with an aviation psychiatrist, he remained asymptomatic and was reassigned to maritime patrol aircraft. This case illustrates a difficult diagnostic, therapeutic, and disposition challenge. This aviator suffered from a complex interaction of neurologic and psychiatric manifestations having a common inciting stimulus, namely flying the F-14 Tomcat. A promising aviation career was preserved upon removal of that stimulus.