The psychology of fear of flying (part II): A critical evaluation of current perspectives on approaches to treatment

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Summary

This is the second of a two part review which critically evaluates research published in disparate sources into the psychological treatment of fear of flying. Part I established fear of flying as a complex heterogeneous clinical phenomenon. This paper discusses the way in which evidence from clinical trials translates to best practice in treating fear of flying. Published research on psychological interventions uses terminology which bears a close resemblance to cognitive behavioural therapy. It is, however, questionable whether some treatment approaches reflect the implementation of the cognitive behavioural model as it is described in the wider literature on the treatment of anxiety disorders. This review evaluates a synthesis of published research which considers fear of flying and related anxiety disorders with the aim of deriving best practice. It concludes that the most effective psychological interventions will be those based on an accurate functional assessment of an individual and their social context relevant to fear of flying and not merely a set of standard and invariant protocols. Most published research has been carried out on participants who self refer or volunteer for treatment and it is probable that this is a biased clinical group which may distort reported efficacy and treatment outcomes. It concludes by highlighting directions for future research and the development of psychological treatments for fear of flying.

Introduction

Part I of this review1 evaluated published research which examined the nature, prevalence and etiology of fear of flying. It demonstrated that fear of flying demands attention because it has undesirable consequences for the personal and professional lives of those affected and is responsible for an identifiable loss of revenue to the airline industry. It concluded by describing the etiology and nature of fear of flying.

In summary, fear of flying emerges from an individual’s unique background and characteristics. Psychological influences will include co-morbidity such as low mood or existing psychological disorders and traits such as anxiety sensitivity. Indeed, fear of flying may often be a symptom of a psychological diagnosis such as General Anxiety Disorder (GAD) or Panic Disorder. Social factors such as anxious flyers among friends or family or experiences such as turbulent flights may contribute to a fear of flying. Physiological characteristics such as sub-clinical vestibular dysfunction or undetected hypoxia may also play a part. The result of even identical learning history and social influences is likely to be different for each individual and may range from sub-clinical anxiety to an incapacitating clinical phobia, panic disorder or similar anxiety disorder. This is likely to include a number of behavioural, emotional, cognitive and physiological symptoms which will, again, vary among individuals.

The complex etiology and nature of fear of flying would lead one to expect that the most effective interventions are those which consider the distinct aspects of fear of flying. It is, however, also the case that fear of flying is either a symptom or presentation of an anxiety disorder even at sub-clinical levels. Effective interventions should therefore be those which are known to be effective for similar anxiety disorders. The challenge to those providing treatment is to blend the complex demands of fear of flying with the known efficacy of interventions for similar anxiety disorders.

Studies which evaluate interventions to reduce fear and anxiety associated with air travel have been published in disparate sources which include medical, aviation and psychology journals. There has been no previous attempt to provide a systematic critical evaluation of published research in this area, although there have been published overviews, and it is therefore possible that those who provide psychological treatment to fearful flyers may be unaware of some of the findings reviewed here. The primary aim of this review is to undertake such an evaluation. It has been constructed as a systematic review rather than meta-analysis because, as this review will demonstrate, variations in outcome measure, statistical analysis and methodology would make a formal statistical meta-analysis meaningless.

This paper critically evaluates the literature which examines psychological interventions for fear of flying. It also identifies some recent developments in psychological interventions for anxiety disorders which are likely to improve the effectiveness of therapies for fear of flying. Furthermore it highlights conceptual and methodological vagaries in research which has evaluated interventions for fear of flying which so that clinicians may can compare ‘like with like’ and not be misled by the seemingly high success rates reported. This is important to address as there are a plethora of published studies on the efficacy of various fear of flying treatment. There has been one review of 15 multi-component group programmes which suggested that such interventions were effective and presented guidelines for best practice based on the views of participants in a conference on fear of flying.2 No existing review, however, has established guidance for best practice based on a synthesis of studies which consider fear of flying and current perspectives on anxiety disorders in general. This is the aim of the critical evaluation presented here.

Section snippets

Method

The initial selection of literature to be included in the review was achieved by database searches. The databases used were PUBMED, PsycINFO, PsycARTICLES and Science Direct. Each of these databases was searched using the criteria described below. Relevant full text articles were then retrieved as required. Literature retrieved in this way was then also scrutinised for further references as described in the following sections. An initial search was conducted in October 2007 and repeated in

Review

The review identified 43 published studies which met the selection criteria. It also identified one review of the efficacy of virtual reality treatments and two summaries of group programmes.2, 4, 5 The majority of studies consider only psychological approaches to treating fear of flying, although two clinical trials6, 7 and two case study reports8, 9 evaluate the efficacy of medication. Medication has not proven to be effective in resolving fear of flying or anxiety disorders generally in the

Directions for future research

The main limitation of research which evaluates interventions for fear of flying is the tendency to use participants who are unlikely to adequately represent the population of fearful flyers and to consider them to be a homogeneous group who meet one definition of a clinical diagnosis. The assessment of interventions is based on changes in the mean of assessment measures of experimental conditions and disguises individual differences. Few studies have attempted to identify reasons for or

Conflict of interest

None declared.

References (72)

  • S. Kim et al.

    Use of skills learned in CBT for fear of flying: managing flying anxiety after September 11th

    J Anxiety Disord

    (2008)
  • L.-G. Ost et al.

    One versus five sessions of exposure in the treatment of flying phobia

    Behav Res Ther

    (1997)
  • J.I. Capafons et al.

    A reattributional training program as a therapeutic strategy for fear of flying

    J Behav Ther Exp Psychiatry

    (1999 Dec)
  • T. Haug et al.

    A three-systems analysis of fear of flying: a comparison of a consonant vs a non-consonant treatment method

    Behav Res Ther

    (1987)
  • A. Muhlberger et al.

    Repeated exposure of flight phobics to flight in virtual reality

    Behav Res Ther

    (2001)
  • N.S. Jacobson et al.

    Psychotherapy outcome research: methods for reporting variability and evaluating clinical significance

    Behav Ther

    (1984 Sep)
  • D.M. Clark

    Anxiety disorders: why they persist and how to treat them

    Behav Res Ther

    (1999)
  • S. Rachman et al.

    Safety behaviour: a reconsideration

    Behav Res Ther

    (2008)
  • D.M. Clark

    Developing new treatments: on the interplay between theories, experimental science and clinical innovation

    Behav Res Ther

    (2004 Sep)
  • J.C. Beckham et al.

    Emotional processing and fear measurement synchrony as indicators of treatment outcome in fear of flying

    J Behav Ther Exp Psychiatry

    (1990 Sep)
  • P. Anderson et al.

    Cognitive behavior therapy for fear of flying: sustainability of treatment gains after September 11

    Behav Ther

    (2006 Mar)
  • J.M. Armfield

    Cognitive vulnerability: a model of the etiology of fear

    Clin Psychol Rev

    (2006)
  • M. Oakes et al.

    The psychology of fear of flying (part I): a critical evaluation of current perspectives on the nature, prevalance and etiology of fear of flying

    Submitted for Review

    (2010)
  • L.J. Van Gerwen et al.

    Fear of flying treatment programs for passengers: an international review

    Aviat Space Environ Med

    (2000)
  • D. Moher et al.

    The CONSORT Statement: revised recommendations for improving the quality of reports of parallel-group randomized trials

    Ann Intern Med

    (2001 Apr 17)
  • R.T. Da Costa et al.

    Virtual reality exposure in the treatment of fear of flying

    Aviat Space Environ Med

    (2008)
  • O. Ekeberg et al.

    Effects of beta 1- and beta 2-blockade on blood pressure and sympathetic responses to flight phobia stress

    Clin Pharmacol Ther

    (1990 May)
  • D.O. Lewis

    Serendipitous relief with disopyramide of phobia of flying

    Am J Psychiatry

    (1983)
  • H.G. Anderson

    The psychology of aviation

  • D.C. Bond

    The love and fear of flying

    (1952)
  • D.H. Barlow

    Anxiety and its disorders: the nature and treatment of anxiety and panic

    (2002)
  • J.E. Carr

    Behavior therapy and the treatment of flight phobia

    Aviat Space Environ Med

    (1978)
  • O. Ekeberg et al.

    Plasma catecholamines in some airline passengers

    Scand J Clin Lab Invest

    (1989 Apr)
  • B.O. Rothbaum et al.

    A controlled study of virtual reality exposure therapy for the fear of flying

    J Consulting Clin Psychol

    (2000)
  • B.K. Wiederhold et al.

    The treatment of fear of flying: a controlled study of imaginal and virtual reality graded exposure therapy

    IEEE Trans Inf Technol Biomed

    (2002 Sep)
  • R.J. Roberts

    Passenger fear of flying: behavioural treatment with extensive in-vivo exposure and group support

    Aviat Space Environ Med

    (1989 Apr)
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