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.
Other psychiatric morbidity reported
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should contact specialist travel clinics or visit the MASTA website (www.masta.org).
Schizophrenia
In Jerusalem each year, some 50 tourists are admitted to hospital for psychotic episodes. This may be linked to religious delusional experi-ences. A study of psychiatric morbidity in Heathrow Airport found admissions for schizophrenia from the airport accounted for one-fifth of the total number of schizophrenic patients admitted to the hospital.
Whether this reflects the restless mobility (voyages pathologiques) reported in schizophrenia is hard to tell.
Affective disorders
Abnormalities of circadian rhythm have been described in manic–
depressive disorder, unipolar depression and disturbances in the sleep–
wake cycle. It is not known whether these altered phase shifts in the circadian sleep–wake cycle have a role in inducing the illness or whether they are a secondary consequence of the psychiatric disorder.
Noradrenaline and serotonin are implicated in depressive illness, and dopamine in mania.
Jet lag
Crossing time zones is a consequence of rapid transmeridian travel. The body clock, which adapts to a 24-hour day/night cycle, is out of synchrony with the time of the destination and requires resetting by time cues, or Zeitgebers, at the destination. Jet lag describes the experience of this desynchronisation. The main disruption is to the sleep–wake cycle and the person experiences fatigue, irritability, poor
Table 15.2 Estimates of how long jet lag may last
Number of time zones crossed Number days required to adjust
Westward flights
0–3 0
4–6 1–3
7–9 2–5
10–12 2–6
Eastward flights
0–2 0
3–5 1–5
6–8 3–7
9–11 4–9
concentration and may feel hungry and want to defaecate at times inappropriate to the local time. Adaptation to one to two time zones when travelling east, or one to three time zones travelling west, is probably within most people’s range of adaptability. Internationally competing athletes usually require one day for every time zone crossed to regain form. Business executives with important meetings are advised to schedule these meetings several days after long flights. Table 15.2 provides estimates of how long jet lag may last.
It is interesting that sleep in patients with depression resembles sleep in normal subjects whose circadian rhythm of temperature and rapid eye movement (REM) sleep are phase advanced relative to their sleep schedule. Depression may therefore appear when travelling from east to west and hypomania when travelling from west to east.
It should be noted that the degree of disruption varies with individuals (Box 15.1) and that it tends to be more severe when travelling eastwards and the more time zones crossed.
Conclusion
Business travellers tend to be self-selected and they by and large enjoy business travel. They tend to have the travel eased for them in many ways – ticketing, check-in, baggage, fast-track facilities, restful lounge facilities, and the other benefits offered to those travelling business/
first class. They also tend to be confident travellers who, in the main, cope well with travelling. The frequent business traveller is usually cocooned by travel arrangements which deliver a sense of familiarity and security, with sufficient variation to make a trip interesting.
For the less experienced traveller, the pressures which exceed the individual’s coping strategies may be encountered at any transition Box 15.1 Factors which may affect a traveller’s coping capacity
(1) Type of traveller
• novice, timid, dependent traveller
• elderly
(2) Premorbid status (3) Reasons for travel
• business travel
• social events
• family reasons
• happy events/crises.
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phase in the round trip from preparation to travel, arrival at destination, and time spent away from home to return to home.
People’s lives are lived out in motifs, patterns, routines and lifestyles, which could be described as the sum functioning of coping strategies.
The less robust individual may operate from a rigid and sparse store of coping strategies. Air travel consists of rapid transitions. The traveller is in unfamiliar territory and, unless an accustomed traveller, the challenges of each transition may result in decompensation, especially in someone in delicate balance. These individuals may not be able to cope with the number, diversity and rapidity of challenges at each transition experienced in the process of travel, to which must be added time zone changes, jet lag, change in climate, different culture and language, different social systems and so on experienced on arrival.
Each challenge may be trivial in itself but may be daunting in the context of being in a foreign landscape of experience. For the vast majority, travel brings excitement, pleasure and new experiences. For some, the loss of moorings, being cut off from all that is familiar and secure, overwhelm their coping strategies. As more and more people travel, the travel industry may have a role in providing not only for the physical needs, but also smoother processes which recognise the emotional and psychological needs of the travelling population.
Further reading
Brown, D. (1996) Flying Without Fear. Oakland, CA: New Harbinger Publications.
Cook, G. C. (ed.) (1995) Travel-Associated Disease. London: Royal College of Physicians.
Cummings, C. T. & White, R. (1987) Freedom From Fear of Flying. London: Grafton Books.
Dawood, R. (1992) Travellers’ Health: How to Stay Healthy Abroad (3rd edn). Oxford:
Oxford University Press.
Moore-Ede, C., Sulzman, F. & Fuller, C. A. (1982) The Clock That Times Us. Cambridge, MA: Harvard University Press.
Swanson, V., McIntosh, I. & Power, K. (1998) Flight related anxieties and health problems. Travel Medicine International, 16, 83–86.
Waterhouse, J. M., Minors, D. S. & Waterhouse, M. E. (1990) Your Body Clock: How to Live With It, Not Against It. Oxford: Oxford University Press.
Yaffe, M. (1992) Taking the Fear Out of Flying. London: David & Charles.
Critical incidents and violence at work
Ian Palmer and Charles Baron
Introduction
Although anyone may be the victim of threatened or actual violence at work, certain occupations carry a higher risk of this. This is particularly true of those dealing with people who are potentially more violent.
Police officers, probation staff, prison officers and social workers may all fall into this category of occupation, but staff in the health care, teaching, retail and banking sectors, as well as those representing authority, have all been shown to be at risk, for a variety of different reasons.
Violence against one’s person is a particularly difficult form of trauma, which may give rise to stress reactions. Other types of critical or traumatic incident, not involving violence but where there is a serious threat to the safety either of the individual or of some third party, where the threat or actual harm is witnessed, may also be psychologically distressing. These are less easy to predict and can arise from major human disasters such as the fires at Hillsborough stadium and King’s Cross railway station. Certain occupations, however, may be at greater risk of experiencing or witnessing such incidents and these will generally include those in the emergency services and the armed forces.
Most individuals cope well under adversity. It is a mistake to overestimate the numbers who will react poorly to a critical incident and it is incorrect to assume that most people will be ‘traumatised’
by such events. All will, however, be changed by their experiences, and not infrequently for the better. It is important to avoid giving medical labels to normal reactions but it is equally important not to miss any post-trauma mental illness. Although distress and post-traumatic symptoms are common after exposure to traumatic events, most cases settle without professional intervention. However, some may lead to full-blown post-traumatic mental disorders, including post-traumatic stress disorder (PTSD).
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