Martin N. Seif, PH.D. Clinical Psychologist Anxiety Disorders Treatment

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Typologies for the Fear of Flying: Implications for Flight Personnel and Therapists

Ronald M. Doctor, Ph.D.
California State University, Northridge, California
Director, Freedom to Fly, Los Angeles
Martin Seif, Ph.D.
Associate Director, Anxiety Disorders Program,
White Plains Hospital and Medical Center
Director, Freedom to Fly, New York

Introduction

The purpose of this presentation is to provide a clinical picture of fearful fliers so that in-cabin personnel, therapists and airline staff can better help them to understand and manage their fears.
We use the term “fearful flier” as a general label. In fact, "fearful flier" is a confluence of a number of different phobias, each of which may be triggered during various aspects of the flying experience.
Each phobia may result in similar intense anxiety, but the acquisition and maintenance processes of these anxieties can be quite different.
These differences have implications for management and treatment.

The Categories of Fearful Fliers

We currently include the following types of fearful fliers as representing the majority of the population. Other lesser types could be included, but we have chosen to limit our discussion to the following:

The Avoidant-Flier
The Phobic Flier
The Panic Flier
The Socially Phobic Flier
The Agoraphobic Flier
The Specific Phobia Flier
The Paranoid Flier--this is tentatively characterized as a sub-group of "fearful fliers," although there are significant differences from all the other groups.

Similarities among Fearful Fliers in Flight

Experience of high anticipatory anxiety. Anxiety experienced while planning and preparing for flight, including packing, passing through security, entering and seating themselves on the aircraft. The closer to the flight experience, the higher anticipatory anxiety will build. Anticipatory anxiety gradually diminishes along with flight anxiety.
High autonomic arousal. Activation in the body that may fluctuate but generally stays high in preparation and throughout the flight--furrowed brow, noticeable muscle tension, frequent movements and discomfort; or, in the opposite case, a freeze or frozen position, perspiration, vigilance, startle responses at noises or changes in sensations (including the movement of turbulence), difficulty attending to written material or conversations.
A consistent tendency to become involved with catastrophic mental imagery that is usually not communicated to others (except trusted others)
An "altered state" of consciousness while flying which makes catastrophic thoughts feel like they are highly likely to occur (often with vivid imagery)
A state of "disconnect" from comforting realities in their environment while flying, along with an unshakable preoccupation with terrifying anticipations.
Have often survived previous traumas, either in airplanes or other sources, and re-experience them in the flying situation. Fears associated with turbulence can represent trauma for some travelers. Previous panic in airplanes can traumatize individuals and arouse anxiety or panic in the present. Others experienced a loss or rejection or other painful experiences and associate them with flying. Also, painful memories (such as abuse as children) may arise while traveling toward or away from home.
An extremely low likelihood of violent or unruly behavior. (*We cannot make this statement with regard to the Paranoid Flier.)

Differences Between Fearful Fliers

The Phobic Flier displays the typical fear reactions seen by therapists and flight personnel in airplanes. The phobic flier is afraid of crashing and dying, and these concerns permeate their experience. They are hyper-vigilant, and constantly listen for noises and other cues in anticipation of severe problems. They imagine plummeting from the sky, gasping for air, and screaming in morbid terror on their way to disintegration. While on the flight, they live in a future of terrifying expectations of catastrophe. Their fantasies began weeks before the flight and they are frozen in fear by the time they reach the airport. They feel like they are going to their execution.

The Panic Flier is quite different from the Phobic Flier. The Panic Flier's fear of crashing and dying is often quite mild and manageable, and secondary to another type of fear. The Panic Flier is primarily afraid of having a panic attack in the airplane and feeling trapped and unable to exit or get out. Thus, the Panic Flier's greatest fear is being trapped in what appears to be a claustrophobic cabin filled with other people. Often they will show similar claustrophobic reactions in elevators, back seats of cars, and other closed or closed and crowded spaces. The fear of panic in enclosed situations is frequently complicated by social fears involving embarrassment, humiliation and helplessness. This Group would feel comfortable flying if they could open the window and get some fresh air, or ask the pilot to land the plane whenever they felt discomfort. Another group of Panic Fliers fear panicking in high places, and would have no problem flying if they could cruise at tree-top altitudes. Panic Fliers often exhibit high anticipatory anxiety and are very likely to cancel flights or avoid flying. They often have social fears as well as claustrophobia, acrophobia and fear of panic attacks.

The Agoraphobic Flier is similar to the Panic Flier in that they feel trapped in the airplane and are afraid of having a panic attack during the flight. However, they also have the added fear of being away from a safe place. Agoraphobics feel intense anxiety when outside of their safe area (often a home, neighborhood or area around their home) and feel unable to return to their safety zone. Their feelings of helplessness are contained and subsequent anxiety is reduced, if there is a safe person available to them. The Agoraphobic Flier feels particularly anxious on an airplane, since air travel swiftly separates them from their "safety zone." The feelings of separation, aloneness and helplessness add to their fear state in flying.

The Socially Phobic Flier constitutes up to 30% of Fearful Fliers (often in combination with the Phobic and Panic reactions) and is more prone to freezing in their seat. They are an aspect of the classic “white knuckle” fliers of lore. These are people locked in a prison of immobility and traumatized by their own reactions. They do not want to call attention to themselves or stand out in any way lest people realize they are afraid and embarrass them. Social reactions are crippling and viewed as aversive and personally threatening. These are the "invisible" phobics, often ignored by helping personnel.

Specific Phobic Fliers are not afraid of airplanes or the experience of flying per sé. Instead, these fliers suffer from fears or phobias whose triggers may be encountered during aspects of ordinary flight. Such triggers include flying over deep water, night flying, fear of germs and illness, and a general lack of control over one's environment. As with most phobics, their thoughts are focused on these triggers which cause intense fear reactions. It is the contact with these phobic stimuli that frightens Specific Phobic Fliers.

The Paranoid Flier is a newly emerging class of fearful flier probably derived from stories and news accounts of terrorism and plane hijackings. These are suspicious, distrusting individuals who feel vulnerable in many social situations. They are vigilant and scan their environment for possible threats, ready to over react at any time. Their vigilance creates the conditions for startle and quick anxiety responses to almost any change in stimulation. This can be combined with rage responses as well in this age of unruly passenger problems. We believe that a large percentage of these fliers have significant traumatic experiences in their past, and that the events of 9/11 serve as reminders of prior traumatic events. We hypothesize that this type will become more prevalent as additional traumatized fliers return to the sky.

The Avoidant-flier is one who rarely flies and usually only under extreme pressure from others. This distinction is important from the point of view of motivation, self esteem, and the effect on significant others. Those who don't fly will need medication, short trips and a lot of support in order to eventually be regular passengers. They are usually not motivated, see the problem as incurable and/or want someone else to solve it for them. They are a burden to their families and friends and often have low self esteem, partly because they are limited. They fall short of their dreams and this pattern is often seen in other parts of their lives. Once the Avoidant Flier does fly (usually under extreme circumstances) they present a management problem because of their obvious distress and often demanding ways of coping. They usually continue to avoid flying even after completing a graduation flight for a fear of flying course.

How to Help the Fearful Flier in the Airplane

General Principles for In-flight Personnel

We note that observing and responding correctly to distressed passengers will generally calm them and give them an emotional anchor. Feeling that their fears are understood has profound anxiety-reducing benefits to the Fearful Flier. Reducing their anxiety will also make the flight easier for everyone aboard the plane.

Tell Fearful Fliers that:

Flying is safe.
They are in a safe place.
It is all right to feel anxious.
Anxiety is uncomfortable, but not dangerous.
They won't suffer any harm from anxiety.
That their thoughts are frightening them, not the airplane. They have control over their thoughts even though they are not controlling the airplane
Try to stay in the here and now. Touch and feel things, look around, smell and taste and activate the senses
Try to stay with "what is," as opposed to "what if."
Flying may feel dangerous, but it is not dangerous.

Try not to tell them:

Calm down! Relax! Control yourself!
Don't be anxious.
Don't make a spectacle of yourself.
Don't embarrass me or my crew.
You are being ridiculous.
What's the big deal A lot of people get anxious all the time.
Take pill.
Shut up!

Suggestions for Helping each Type of Fearful Flier

ThePhobic Flierwill be concerned about safety related aspects of flight. Remember that this flier is obsessively locked into a continuous re-run of terrifying thoughts about flight catastrophes.

Reassure them that flying is very safe-- movement of the airplane as it flies is just as safe and normal as cars bouncing a bit on the road.
Point out that their thoughts are making them afraid, and not the airplane or the flying experience.
Remind them that feelings are not facts, and, while they may feel like the flying experience is dangerous, the facts show that flying is safe.
Suggest that they pay more attention to comforting realities of the flight, and focus on manageable tasks in the present.
Reiterate that they have control of their thoughts even though they have chosen to give control of the airplane to the pilots.
Remember that it does no good to try to talk someone out of their fear.

Panic Fliers are frightened that they will experience a panic attack on the flight. They may complain of physical symptoms, seem overly concerned with possible flight delays, or talk directly about feeling panicky

Ask what they need to feel more comfortable.
Re-assure them that it is okay to feel anxious.
Explain that the energy used in trying to fight the anxiety goes right into making the anxiety worse.
Tell them that they don't have to exit the plane in order to feel comfortable. They can recover in the phobic situation if they can reduce their "what if" thoughts.
Let them know that panics cannot hurt them, although they are very uncomfortable.
Inform them that panics are self-limiting--they cannot panic forever. (As they sometimes fear.)
Tell them that you will make an effort to monitor them and to talk when possible.

The Agoraphobic Flier, who is fearful of panicking away from their "safe place," will often be accompanied by a safety person.

Ask whether it is best to talk with the safety person or the Agoraphobic Flier. Sometimes it is best to speak with both.
Re-assure both the safety person and the Agoraphobic Flier that they are not alone and there are people around who can be helpful to them.
Remind the Agoraphobic Flier that he can carry his own safe space, no matter where he is physically located.
Encourage the safety person to engage the Agoraphobic Flier on breathing (long, slow out-breaths), distractions, and safe self-talk (i.e., the plane is flying straight and level.).
Give support to the safety person, especially if that person begins to feel frustrated, exhausted, or overwhelmed.
Encourage the safety person to reinforce the recommendations discussed under helping the Panic Flier.

Specific Phobias Fliers have pre-existing fears or phobias that are encountered during ordinary flight. They are not afraid of flying, but rather the triggers they might encounter while in flight.

This type of Fearful Flier will usually be able to identify their particular trigger. The most common are heights, deep water, darkness and lack of control.
Give accurate information in a neutral voice about the triggers they fear. (i.e., "We are cruising at 37,000 feet", or "We will be flying over water for the next 2 hours," or "Our Captain is a highly trained, highly experienced flight specialist.")
Encourage them to find a safe place in their body that they can move to find some calming.
Then ask them to create a safe place in their mind around that area of the body and to visualize it.
Encourage them to go between the "unsafe," anxious areas of the body and the safe place--the anxiety will then often recede.
Many techniques are helpful in reducing the anxiety of specific phobias.Relaxation, distraction (counting backwards from 100 by three's, doing work or number puzzles, listening to favorite music), diaphragmatic breathing.

Socially Phobic Fliersare approached differently from other types of fearful fliers, since the attention of flight personnel and other passengers can accentuate their phobic concerns and result in increased anxiety.

These anxious fliers are hypersensitive to real or imagined criticism.
They are sometimes identified by facial flushing or remaining frozen in their seat for the entire flight.
Before proceeding, ask if they would like attention, since they dread exposing their fear to others.
Keep questions away from describing their internal experience. Instead, ask—if possible--if they would like to move to a more comfortable (less visible or separated from another passenger) place.

Remind them that they are far less visible then they think, and that they might imagine themselves in a protective bubble that no one else can penetrate.
Tell them that others are self involved and neither focused on, nor concerned about them.
Ask them to focus on how other people appear to them, as opposed to how they imagine they appear to others.

Paranoid Fliers are difficult and agitated fliers since they feel they are in a vulnerable situation. They therefore require great care.

Ask them if they are concerned about safety on the plane.
Remind them that every passenger has been screened for dangerous materials.
Tell them that cargo has been X-rayed and examined carefully.
Remind her that the flight crew strives to provide a safe flight.
Your role is to provide safety first, and then comfort.
Rules and delays are in the service of flight safety: coping with them require flexibility and patience.

Therapeutic Approaches Outside of the Flying Situation

We emphasize the need to work outside of the airplane flight in controlled situations where exposure, cognitive rehearsal and desensitization can be practiced. For example, the Panic Flier is often helped with containment exercises like relaxation exercises, distraction cues, and cognitive restructuring to help them see that while they don't have control of the airplane they can exert some control over their own bodily reactions. Practice in enclosed situations where there are other people is helpful (ride in buses, back seat of cars, elevators, boarding stationary planes, etc.). The Phobic Flier can benefit from cognitive work to shift fear thoughts and reduce the superstitious assumption that their own tension is preventing an accident. Agoraphobic Fliers benefit from exposure work aimed at extending their safe area, towards the goal of feeling safer within themselves.

Vagal tone reduction can have a significant therapeutic effect. Vagal tone refers to parasympathetic activation (since sympathetic activity is mediated by reduction of vagal tone). Breathing synchronized with heart beats can have a significant calming effect that can then facilitate cognitive changes and restructuring. Twelve (12) breaths per minute is an good breath rate and will generally slow heart rate. This should be combined with visualization and the experience of something they appreciate. The combination of breath rate and experiencing something or someone they truly appreciate will slow and calm the arousal. The goal is to separate the inner experience from the experience of the airplane. Control is more possible over the inner experience. Fearful Fliers feel the airplane controls their experience. Separating the two is extremely important.

Wiggling in turbulence. Turbulence creates an unsettling shaky state in the body that is caused by movement of the airplane. To separate the airplane from the individual, have them wiggle in their seat, or have a companion shake their seat, so they override the sensation of turbulence. You can tell them that no one will notice their movement and it will give them some control over the movement they feel is out of their control. Remind them that airplanes are built to withstand much more turbulence than what they experience.

Medications are usually misused. Knowledgeable physicians recommend that fearful fliers take anxiolytic medications and not antidepressants as the most effective means of combating anticipatory anxiety and reducing the intensity of anxiety reactions during flight. The benzodiazepines are best. They should be started at a lower dose at least a week before to the flight so as to help with rising anticipatory anxiety, and a full dose should be taken at least 2 hours prior to flight. SSRI's (or SNRI’S) are useful in reducing panic feelings, but these medications need to be started months prior to the flight, increased gradually to a therapeutic dosage, and taken everyday thereafter. Additionally, SSRI’S have little or no effect on anticipatory anxiety. Fearful Fliers who are flying frequently to overcome their phobias usually need to gradually reduce their medications as they increase confidence in managing flight anxiety.

Frequent fliers can often benefit from consistent in-flight practice of internal-control techniques such as vagal tone breathing, cognitive modification and techniques to reduce bodily sensation while fly