Flying phobia

Types of Psychology: Clinical; Counseling; Psychopathology; Psychotherapy.

An intense fear of flying can have many impacts on one's life, from accepting jobs or promotions in the airline industry to visiting family and friends and going on vacations. Flying phobia hinders lifestyle. The phobia has four components: possibility of a crash (although, statistically, flying on commercial airlines is safer than nearly every other mode of transportation), confinement, heights, and turbulence. Evidenced-based psychotherapy offers short-term treatment to overcome fear of flying.

Introduction

Specific phobias are among the most common psychological problems. Estimates claim that 10 to 30 percent of the population experience some form of phobia, with rates varying with individuals' learning history and exposure to sources of fear.

Fear of flying, or aerophobia, is a situational phobia. It is an emotional and mental anxiety, worry, or preoccupation which is out of proportion to the rational, objective danger of taking an airplane. This can involve extreme anxiety any time before a flight (even before arriving at the airport) or during a flight, and it may not abate until after landing. This fear leads to maladaptive behaviors subject to the autonomous nervous system and treatment requires regulation of these responses.

According to the fifth edition of the Diagnostic and Statistical Manual (DSM-5), fear of flying is characterized by three symptoms: 1) marked fear of airplanes, 2) avoidance of airplanes, and 3) impairment in flying.

The fear reaction occurs upon encountering the feared stimulus—fixed or rotary wing aircraft—and may escalate the anxiety into a full-fledged panic attack. Psychologists and allied health professionals who treat flying phobia distinguish when the anxiety is excessive and irrational and whether sufferers' anxiety is rooted in a fear of crashing while flying or anticipated fear of having a panic attack during a flight.

Causes and Treatment

Past personal experiences, as well as a learning history that includes observations of others' anxiety over the same situation or informational learning after reading or hearing about dangerous situations in flying, are among the most common reasons flying phobia develops. Often, those who suffer with flying phobia have histories of struggling with anxiety which predate their fear of flying. Aerophobia frequently exists with other anxiety disorders. Competent treatment requires a thorough understanding of diagnostic criteria and potential sources of diagnostic error are required to establish an accurate assessment and focused treatment plan.

Psychotherapy based on empirical evidence suggests that behavioral and cognitive psychotherapy, or some variation of them, are the most effective approaches. They are common sense procedures that usually make immediate sense to those in treatment. These approaches prioritize results, demystify the patient-therapist relationship, assign homework, and usually include these basic areas of evaluation:

List of urgent and realistic problems. A structured interview evaluates the biographic history and thereon remains in the here and now using charts which are individualized using specific questionnaires.

Strategies for intervention. Even though psychologists use manuals, intervention is tailored for each symptom and each individual.

Progress evaluation. Every session records progress made. Sub-goals are useful to accelerate behavior change. Efficacy is more important than etiology; effectiveness and relief are more important than causes and explanations.

Behavior and cognitive psychotherapy are both approaches that utilize case formulation based in hypotheses about the patients' problems. The formulation aids in the development of a plan in order to treat this emotionally painful and socially embarrassing psychological disorder. It is mandatory to monitor the psychotherapeutic process on a regular basis.

A Case Example

A case of flying phobia might be treated as follows: a forty-year-old woman describes her problem as "every time I am going to fly I stay at home with my suitcase." She related that when she last booked travel to Europe with her husband some years ago, she had to return home from the airport. The following year, she tried again, this time planning to fly to Mexico, but was unable to surmount her fear. Her aerophobia started twenty years earlier during her honeymoon. Last year, when her husband was flying to Europe for business and invited her to come along, she remained too anxious, and she knew that if she declined, he would simply travel alone.

Behavioral Analysis: In a structured interview, factors that may facilitate or complicate treatment are identified. In this case the patient was prompted to travel as soon as possible. She embraced the belief that she must insist to herself that she has to travel and that she will be successful this time. A positive and hopeful belief helps deal with her specific fears, and unlearning the maladaptive fear is the main focus behavioral and cognitive behavioral approaches take.

Questionnaires: Frequently, questionnaires are used to engage patients or clients in this treatment while helping the psychologist better assess the source, frequency, and intensity of the fear. The Fear Survey Schedule of two researchers, Wolpe and Lang, asks clients to rate the intensity of their distress associated with fear using 108 items. Huag and colleagues developed their Fear of Flying Scale which uses 21 items to assess levels of fear associated with different aspects of flying. In 1966, researchers produced the widely used Subjective Units of Distress Scale, commonly referred to as SUDS. This scale asks people to subjectively rate the intensity of their fear using a verbal rating on a 10-point scale, where 10 represents the worst fear one can imagine, and 0 represents no fear at all.

Assessment: Assessment begins by emphasizing that the goal is not to completely eliminate anxiety but rather to minimize the distress and avoidance of the source of the anxiety through systematically confronting the fear of flying.

The result of the structured interview might be an anxiety hierarchy that looks something like this:

• Fear of boarding the airplane 10 SUDS
• Walking up the steps to the aircraft 9 SUDS
• Taking the bus to the airplane 8 SUDS
• Standing in the line for the flight check-in 7 SUDS
• Seeing the airplanes from a terrace 4 SUDS

Exposure Therapy

Systematic desensitization is a form of behavior therapy which has evolved into what is today called exposure therapy and is based on the theory that maladaptive emotional responses are learned and can also be unlearned through re-education. The treating clinician gradually exposes the person in small, incremental steps that must be taken in order to fly: thinking about taking a flight, purchasing tickets, driving to the airport, checking in, waiting for boarding, boarding itself, settling in and buckling the seat belt, take-off, achieving cruising altitude, flying, descent, and landing.

(The numbers are SUDS from 0 to 10)

Session I (45 minutes) Exposure in Imagination

Scene 1: "Imagine driving to the airport and observing airplanes in the sky flying over the ocean," might be presented three times, with the patient reporting SUDS ratings of 3 on the first presentation, 2 on the second, and 1 on the third.

Scene 2: "Look at these four photos of airplanes," is the presentation of external visual stimuli, again presented three times. The patient might report an initial SUDS of 9. After exposure to the pictures of the anxiety-provoking stimulus (airplanes) in the safe environment of a psychologist's office, the patient may report gradually lessened anxiety, ending with a SUDS of 6 on the third presentation.

Session II (45 minutes) Exposure in Imagination

Scene 1: "Imagine that the flight is being announced for departure." The patient is asked to hold that image imaging themselves present in the airport. They might be given the same instruction two additional times with a resulting decrease in her anxiety reaction. It would be common for a patient to begin with a SUDS of 7 and end with a SUDS of 4 or 5 by the third presentation.

Session III (45 minutes) Exposure in Vivo

Scene 1: "Imagine yourself traveling to just visit the airport; you are not going to try to board a flight. You are simply and safely going to visit the airport." This session might end with the homework assignment of actually traveling to the airport and spending an hour there while practicing a relaxed breathing technique. Commonly, aerophobic patients will end this exposure with a SUDS rating of 3 or 4.

Session IV (45-minutes) Exposure in Imagination

Scene 1: "Imagine that you are flying in fifteen days." This image might be presented three or four times, with the patient visualizing what their life would really be like if she were actually flying in fifteen days. SUDS scores of 4 and 3 would be usual.

Scene 2: (If session time allows.) "Imagine that you are flying tomorrow," would be followed by at least two presentations. The typical patient might have an initial SUDS of 4 or 5 at that prospect with gradual reduction in anxiety as the presentations continued.

Session V (45 minutes) Instructions for Self-monitoring

At this point in treatment, the patient would be given a list to record their SUDS ratings while traveling: traveling to airport, checking in at the airline counter, arriving and waiting at the gate, going on the entryway ramp, entering the airplane, finding her seat, going through the preflight checklist, taxiing, taking off, reaching cruising altitude, assessing each hour during the flight, and landing.

Discussion of Treatment

The goal of psychotherapy in this situation is to monitor the progress of each session and, if progress is made, continue stepwise until the problem, here debilitating anxiety, is resolved. When progress is insufficient to move forward, the psychologist will reevaluate the patient's anxiety hierarchy, develop an alternative hypothesis, and offer another plan of treatment. The psychologist usually does not push the patient beyond her level of comfort, and pacing and time until resolution will vary with each patient.

Generally, except for short-term, occasional use, pharmacotherapy is not necessary for the treatment of specific phobias. Also, when there is more than one problem, the clinician-patient collaboration will address the more urgent problem first. The method described here utilized patients' precise conceptualization of what and which characteristics of flying are anxiety triggers for them. Patients' conceptualization includes knowing the triggers and cues, anticipating the consequences of their avoidance, and recognizing objective safety behaviors.

Fear of flying may include physical symptoms such as changes in brain activity, the release of cortisol, insulin, and growth hormone, and increases in blood pressure and heart rate. Among other symptoms are unsteadiness, dizziness and lightheadedness, nausea, sweating, shortness of breath, trembling or shaking, upset stomach, and irregular bowel movements.

Applied relaxation: For therapy to work, it was believed for many years that patients had to be relaxed, and many psychologists and allied behavioral health professionals utilized a technique known as progressive muscle relaxation to promote a physically relaxed state. However, empirical evidence has shown that while effective, attaining deep relaxation is not necessary. It is sufficient for patients to simply be calm through diaphragmatic breathing and visualization of pleasing scenes. Being in a calm state is neuropsychologically antagonistic to being in an anxious state. Human neurology and more specifically the autonomic nervous system does not permit being anxious and breathing slowly to coexist at the same time.

Progressive muscle relaxation is directed to five group of muscles, arms and shoulders, face (forehead, eyes, nose, tongue, and neck), thorax and lower back, diaphragmatic breathing, and legs and feet. Patients are instructed to practice these exercises at a minimum of twice a week. Progressive muscle relaxation is an auxiliary tool for reducing discomfort and stress. Its goal is not to promote relaxation per se, but for the patient to let go of physiological tensions in the body.

Virtual reality (VR) and Computer-Assisted Exposure Therapy: Other forms of treatment are a variation of exposure therapy. To counteract the physiological symptoms associated with the fear of flying, VR software has been produced that includes four sessions of anxiety management training followed by exposure to a virtual airplane or an actual airplane at the airport. This treatment protocol involves follow-up at six and twelve months and boasts a 70 percent success rate.

Conclusion

Patient confidence in psychological treatments and their benefit is enhanced by promoting the scientific value of existing and future empirical research guides for treatment decisions. Scientific understanding, assessment, prevention, and treatment of human problems are the road to advance public health. Psychological clinical science is an applied science. As such, it is concerned with generating new knowledge regarding the nature of psychological problems, and with translating that knowledge into applications that improve the human condition.

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