A fear of flying is common. In general, this fear is irrational and can constitute a phobic anxiety state. Recent estimates indicate that one in six adults avoid flying altogether on account of fear and only 6% of people who fly are completely free of anxiety.
If fearful flyers are able to board an aeroplane, very often they experience intense anxiety and panic during the trip, and during their holiday or business stay considerable anticipatory anxiety will almost certainly develop concerning the return journey.
Many people with a fear of flying use alcohol or medication in an attempt to relieve their intense anxiety. Straw polls of people attending fear-of-flying courses indicate that, of those who are able to fly at all, more than 50% will use alcohol or medication before a flight.
Causative factors
For people who have never flown, there may be fears about the unknown, compounded by misinformation about the aviation industry, safety factors, training of pilots and how aircraft fly. Also, a psychological process called personalisation may come into operation: some people have a tendency to take external events (especially negative ones) and apply them to themselves when there is no rational basis for doing so.
Messages from the news media which may suggest that flying is unsafe
are internalised, thereby creating anxiety and possibly avoidance behaviour. Some people who have a fear of flying may be suffering from a pre-existing panic disorder, possibly accompanied by agoraphobia;
these people worry about what would happen, and how they would cope, if they were to get a panic attack while on board; unfortunately, panic attacks are more likely to arise under conditions of restriction and confinement. People with claustrophobic tendencies may also feel very uncomfortable on aeroplanes, whether small commuter ones or larger crowded ones. Other factors which may create fear include concerns about turbulence (which in reality is uncomfortable but not dangerous) and that they will fall out of the plane (i.e. that the floor of the plane will give way). Actual traumatic incidents involving accidents (such as the Manchester Airport aircraft fire of a few years ago) may result in the development of a phobic reaction.
Clinical presentation
People who have panic attacks suffer intense fear and usually have a large range of symptoms, which include increased heart rate, palpi-tations, trembling, disrupted patterns of breathing, light-headedness,
‘butterflies’ in the stomach, mental confusion, feelings of derealisation (unreality) or depersonalisation (qualitative changes within oneself) and fears of dying or losing control. There may be a fear of showing oneself up during a panic attack. Often there is hypervigilance (being selectively attuned to pick up every happening onboard the aircraft) and catastrophic thinking related to innocuous small incidents. The self-esteem or morale of fearful flyers is often poor.
Individuals with intense anxiety may, of course, show avoidance or opting-out behaviour; flights have been delayed after a panicking passenger has boarded the aircraft.
Table 15.1 Annual medical in-flight incidents recorded by one international airline (further details available from the author upon request)
Number
Passengers 33 537 158
Incidents 3 026
Incidents related to the central nervous system (CNS) 375 Examples of CNS cases
Anxiety 86
Drugs/alcohol 11
Unspecified psychiatric disorders 3
Fewer than a third of the CNS cases could be classified as relating to mental health.
WANG & BURNS
Prognosis
Provided individuals are motivated to overcome the fear of flying, the outlook is very good, assuming they receive appropriate cognitive–
behavioural therapy (CBT); counselling by itself is not likely to be effective in most cases. Many people who have been grounded have overcome their fears; with appropriate assistance, the anticipatory anxiety they have experienced has turned into anticipatory pleasure.
Effect on work
An inability to fly can have serious repercussions for businesspeople whose work may involve overseas travel. Sometimes they will conceal the problem for as long as possible by sending subordinates overseas, but sooner or later the problem comes to light, often to the embarrassment of the individual concerned. Careers may be hindered by the phobia;
people may avoid applying for high-level jobs which involve flying.
Management
The key issue is often to get the fearful flyer to admit to the problem.
Unfortunately, some people believe that such a fear is a sign of weakness and that they would be ridiculed by their colleagues at work. Such beliefs tend to lead to a failure to address the problem unless the fear of losing one’s job becomes sufficient to overcome the reluctance. If an occupational physician is approached by a sufferer, it is important to create a climate of understanding and to communicate that the individual has a recognised clinical anxiety state. Reassurance can be provided that the problem is quite common and that with appropriate clinical assistance, regardless of the aetiology, it can be overcome. Unless the occupational physician is well versed in CBT approaches, referral to a clinical psychologist, psychiatrist, or cognitive–behavioural therapist is required. It is probably best to advise the individual to refrain from flying until coping skills have been acquired in order to deal with the phobia.
If it is essential that the person flies, anxiolytic medication should be considered.
Therapy
Many research studies show that CBT is the method of choice in helping people overcome panic disorder and phobic anxiety states. The cognitive part of the therapy is concerned with helping the patient think rationally (not positively) about the fears. Catastrophic thinking involves cognition about the worst possible outcome. As emotion (fear, etc.) can follow the (irrational) thinking, it is important that this type of thinking be challenged and become more reality based. Irrational patterns of
thinking are detected and modified, thereby leading to a reduction in anxiety. The behavioural therapy may be concerned with training the person to relax deeply and the use of systematic desensitisation. Graded exposure to fear-arousing situations (visits to different parts of airports, control towers, boarding a plane, etc.), while using the newly acquired CBT coping skills, is often an essential part of the therapeutic process.
Thus, therapy has multiple components – compiling an accurate database about all aspects of flying, graded exposure to a variety of potentially fear-arousing situations and coping with anticipatory anxiety and any fear which may arise by using the cognitive and behavioural techniques.
Avia Tours runs a number of courses involving the CBT approaches, including a flight at Heathrow, Manchester, Birmingham and Glasgow Airports for people with a fear of flying. British Airways captains and cabin staff, psychologists, psychiatrists and others are involved in the courses. Details may be obtained by telephoning 01252 793 250.
Prevention
Why are so many people afraid to fly? Partly the answer lies in the frequent, often faulty and biased messages from the news media that flying is unsafe. Sometimes the news media appear to make a drama out of an incident. Such reporting can create anxiety-generating thinking in susceptible individuals – individuals who may magnify and internalise such reports. Thinking rationally about media-reported incidents involving flying or about personal experiences while flying, and having a range of anxiety-reducing coping skills are the best ways of preventing the onset of a phobic anxiety state. Where the individual has been subjected to a traumatic experience while flying, an early debriefing session with an experienced clinician may help to allay future fears.