Flying Phobia

Although fear of flying is very common, affecting up to 40 % of airline passengers, so that many airlines offer treatment programmes (Van Gerwen, Lucas & Diekstra, 2000), there are few studies of the experience of flying phobia. These include lists of preoccupations associated with the fear: for example fear of the aircraft crashing and of losing control of one's reactions (Van Gerwen et al., 1997; Wilhelm & Roth, 1997). It is not difficult, therefore, to imagine catastrophic predictions that people might make: the confusion and disorder prior to a crash, being crushed and torn apart by the impact and being identified by one's dental records. The triggers for these fears and elaborations probably occur most often and most intensely during takeoff, landing and turbulence (Girodo & Roehl, 1978; Van Gerwen et al., 1997) and this may be seen in the interoceptive feedback from one's body during these phases. However, studies have paid no attention to cognitive processing that might be influenced by sensational reports of flying disasters. Instead they have concentrated on diagnostic issues (Aitken etal., 1981; Van Gerwen etal., 1997; Wilhelm & Roth, 1997).

Nevertheless, studies of comorbid disorders in people with flying phobia, claustrophobia, agoraphobia with panic and social phobia, suggest imaginings (McNally & Louro, 1992; Van Gerwen et al., 1997; Wilhelm, 1997) such as suffocating and dying of a heart attack during a panic or causing a visible commotion and provoking ridicule. Those who report agoraphobia express little concern about the occurrence and consequences of the aircraft crashing (McNally & Louro, 1992). Although there have been descriptions of passengers using alcohol to excess and losing control, so that airlines now enforce prosecution, there appear to be no surveys of alcohol use and fear of flying. In civilians, quality of life may be impaired by flying phobia. For example, it might prevent them from flying when it is essential in their employment. In military personnel, whose training entails great expense, the phobia may require aircrew to be retrained or taken off flying duties.

All but two studies of treatment have exposed subjects to some experience of flying (Table 20.3). Many airlines have treatment programmes (Van Gerwen et al., 1997). These could use flight simulators, which reproduce aircraft movement in flight, such as roll, for training aircrew. Computer-driven virtual reality displays, although very expensive, are

Table 20.2 Outcome studies for treatment of claustrophobia

Comorbidity

Design (including repeated measures)

Booth & RachmanO 992)

Excluded Four groups: all had three sessions: exposure to external stimuli, exposure to anxiety symptoms, cognitive therapy, control group

Botella et al. (2000)

Not clearly addressed but two Ss were asked to discontinue psychotropic medication. One S had fear of storms

Four Ss in controlled multiple-baseline design: baseline then virtual reality

Excluded Four groups:

claustrophobies and spider/snake phobies given in vivo exposure and relaxation (ER) or in vivo exposure and disconfirmation of misappraisals of bodily sensation (ESF)

Outcome measures Statistical outcome Clinical significance

Anxiety Sensitivity Index (ASI), Behavioural Test (BAT), pulse rate in BAT, ad hoc rating scales of predicted and experienced fear, checking of negative cognitions and physical symptoms

Behavioural Avoidance Test, four self-report measures

Exposure group better than control group on 6 of 7 measures (+ tests) but a multivariate analysis of variance showed no significant differences among the treatment groups

Improvement in all measures but no statistical tests

Not clearly addressed

Not clearly addressed

Behavioural Tests Twenty-six per cent of Not addressed

(BATS), anxiety rating Ss failed to complete in BATS Anxiety treatment. ESF

Sensitivity Index (ASI), reduced four

Self Analysis Q (SAQ). measures of fear to

Fear Generalisation greater extent than

Q (FGQ); Heart rate ER. ASI reduced by before BATS both

Design (including

Comorbidity repeated measures) Outcome measures Statistical outcome Clinical significance

Design (including

Comorbidity repeated measures) Outcome measures Statistical outcome Clinical significance

Ost etal. (1982)

Excluded

Five groups: Ss assessed as 'behavioural' or 'physiological' reactors; both groups divided to receive exposure or applied relaxation over eight sessions. Waiting-list control

Fear Survey Schedule (FSS); Automatic Perception Q (APQ); Claustrophobia Scale (CS); Behavioural Avoidance Test (BAT)

All groups improved on all measures but greater improvement on all measures in 'behavioural reactors' given exposure and in 'physiological reactors' given relaxation

These results confirmed by statistical criteria of clinical significance

Ost etal. (2001)

Excluded but anxiety, agoraphobia and depression measured

Four groups: one session exposure, five sessions exposure, five sessions cognitive therapy, waiting list

Behavioural tests (BATS); blood pressure, heart rate; Claustrophobia Scale (CS); Agoraphobia Scale (AS), Fear Survey Schedule (FSS); Anxiety Sensitivity Index (ASP) etc.

Four Ss dropped out; the three treatment groups combined were better than the waiting-list Ss on almost all measures but differences among treatment groups not consistent

No clinically significant difference among treatment groups according to statistical criteria

Table 20.3 Outcome studies for treatment of flying phobia

Design (including Comorbidity repeated measures)

Study

Denholtz & Mann (1975) and Denholtz etal. (1978)

Excluded according to MMPI but undisclosed number reported improvement in claustrophobic symptoms

Four groups: systematic desensitisation to film; similar procedure without grading of exposure, similar without relaxation, relaxation only and placebo

Girodo & Roe h I (1 978) Not addressed

Eight groups: preparatory information, self-statement training, those combined, pseudo treatment. These divided into flying with cockpit door open/closed

Haug etal. (1987)

Not addressed

1 0 Ss in four groups: stress inoculation, applied relaxation. 'Cognitive' and 'physiological' responders

Outcome measures Statistical outcome Clinical significance

Subsequent flight, according to self-report; Taylor Manifest Anxiety Scale (TMAS)

SR Anxiety Inventory, ad hoc Treatment Effectiveness Questionnaire

Seventy-eight per cent of Ss flew on free flight. Number of Ss flying being greater in Ss given full systematic desensitisation (SD) than in others. However Ss were transferred into SD from others

Self-talk Ss less anxious than pseudo treatment. Differences among other groups not clear

Not clearly addressed. Numbers of Ss unable to fly pre-treatment not given. Therefore, extent of improvement is unclear. 23 of 26 Ss reported having flown in 3-5 years subsequently

Not addressed. All Ss were able to fly as part of treatment

Fear Survey Schedule (FSS), Fear of Flying Scale (ad hoc for present study) rating scales for expected anxiety, negative thoughts rating scale, Behavioural Test (BT), heart rate

Both groups improved on all measures but inconsistent differences between groups

All Ss took part in arranged flight post-treatment but pre-treatment behavioural assessment not clear

Study

Design (including Comorbidity repeated measures)

Howard ef al. (1983) Excluded Five groups: eight sessions imaginal desensitisation, flooding, implosion, relaxation and no treatment

Maltby etal. (2002)

Some Ss had agoraphobia or panic disorder with agoraphobia

Two groups Virtual Reality (VR) exposure of 'attention-placebo' group treatment

Muhlberger etal. (2001)

Self-medication by alcohol etc. recorded but impact not assessed

Two groups: extensive virtual reality (VR) and relaxation

Outcome measures Statistical outcome Clinical significance

Fear Survey Schedule (FSS) and ad hoc Q on Attitudes to Flying (QAF) self-report rating scales, pulse rate, observer check list

All groups improved on QAF comparing pre-treatment and follow-up after a flight. Improvement pre- to post-treatment only in four treatment groups

Flight Anxiety Situations Q (FAS); Flight Anxiety, Modality Q (FAM); Flight History; Subjective Units of Discomfort (SUDS)

Fear of Flying Scale (FFS); General Fear of Flying Scale (GFFS), Danger Expectancy Scale (DES), Anxiety Expectance Scale (AES), Anxiety Sensitivity Index (ASI); heart rate (HR); skin conductance level (SCL)

On four of six measures, VR showed greater improvement immediately post-treatment; on only one measure at six months was VR superior

No significant differences between groups for FFS, GFPS, DES, AES or ASI. 'Avoidance of flying rating' favoured VR only group, but both groups improved on all measures

Most Ss flew on test flight after intervention, including no treatment group. In subsequent three months. No treatment and systematic desensitisation Ss both flew less than others

Assessed by standard statistical test: improvement mean cf 2 SDs above population. No in vivo test of outcome

None mentioned. No record of subsequent in vivo flying

(continued)

Table 20.3 (continued)

Study

Comorbidity

Design (including repeated measures)

Outcome measures

Statistical outcome

Clinical significance

Rothbaum etal. (2000)

Depression and anxiety both minimal, assessed by questionnaire

Two groups: one session or five sessions of exposure and 'cognitive restructuring' and information

Included Ss with agoraphobia with/ without panic disorder. Ss with psychosis or drug/alcohol abuse excluded

Three groups: virtual reality exposure (VRE), in vivo exposure up to sitting in stationary aircraft all for eight sessions, waiting-list

Fear of Flying Scale (FFS); Fear Survey Schedule (FSS), State-Trait Anxiety Inventory (STAI); Beck Depression Inventory (BDI; Beck Anxiety Inventory (BAI); Credibility and Expected Success Scales: Behavioural Test (in vivo flight-extent accomplished)

Attitudes to Flying Q (QAF), Fear of Flying Inventory, (FFI), Clinical Global Improvement (CGI)

Both groups improved on all measures but there was a deterioration on the Behavioural Test one year later

VRE superior to waiting-list control on all measures after treatment and on two of three measures at six months. VRE no better than Exposure

Not addressed but 93 % and 79 % had flown once after treatment

VRE Ss (11 of 14) and Exposure Ss (14 of 1 5) groups more likely than waiting-list Ss to complete a flight arranged by the Experimenter after treatment

Walder etal.

Excluded? But includes Ss described as 'claustrophobic'

Two groups: information, graded exposure in vivo in groups and no treatment

State Anxiety Inventory, Self rating anxiety scales. Self-report of flying experience

Improvement on ratings of anxiety in treatment group. Flying experience post-treatment unclear. Differences between treatment and control groups unclear

Unclear now being exploited. No study has addressed catastrophic imaginings explicitly. One study (Girodo & Roehl, 1978) instructed subjects to recite encouragement to themselves but they had selected subjects who were not too afraid to fly.

Two studies included subjects who had other anxiety disorders that could have contributed to their fear of flying (Maltby et al., 2002; Rothbaum et al., 2000) but these were not addressed directly. No study determined if subjects flew more than once after treatment although most showed improvement on measures of fear greater than baseline and in comparison with control groups. Two studies examined military aircrew but they used no valid or reliable measures or experimental design (Aitken et al., 1971; McCarthy & Craig, 1995).

In conclusion, relaxation training or exposure to the experience of simulated flying can reduce the fear of flying. However, the effect of these interventions on the capacity of subjects to undertake flights is not clear. Moreover, there has been no test of the effect of comorbid anxiety disorders, common in flying phobia, or the effect of treatment on the quality of life.

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