Medicine Planet: Conquering Fear of Flying

— -- When Mary Eiff is forced to get on an airplane, the usual stresses of business life takes on a whole new dimension.

The 30-year-old entertainment industry professional is afraid to fly, and like many who suffer from this particular phobia, the fear expresses itself in the most graphic of images: “My fear of flying started with TWA Flight 800 — I was obsessed,” she recounts. “All I recall is the fuselage floating in the Atlantic. My intense fear is being at the bottom of the ocean, in my seatbelt, and I know I’m drowning.”

Mary is not alone. Approximately 10 percent to 25 percent of the population are afraid to fly. One in eight Americans deliberately avoids commercial air travel due to their fear. What many people do not know is that fear of flying is an eminently treatable condition. For most people, a few simple steps will eventually enable them to get on an airplane without getting into a panic. And for those whose fear is more intractable, a variety of new treatments are starting to show promising results.

What Is Fear of Flying

Fear of flying is what is known as a simple phobia; other simple phobias include fear of dogs, spiders and heights. Phobias are a type of anxiety disorder. They are generally provoked by exposure to the feared object or situation, and characterized by avoidance of it. Distressed endurance of a feared situation can also put you in the phobic category.

In many situations, what appears to be fear of flying is actually a somewhat different disorder, and distinguishing correctly between the two is important when considering treatment.

Michael Tompkins, director of Professional Training at the Center for Cognitive Behavioral Therapy in Oakland, Calif., notes that for some, the real problem underlying their fear of flying is agoraphobia. Agoraphobia is a type of panic disorder that leads to extreme anxiety, excessive fear or even terror of being in a situation where one is not in control and from which one is unable to escape. People who suffer from agoraphobia often go to great extremes to avoid the kinds of people, places or situations that can precipitate their panic attacks.

In Mary’s case, for example, her fear of drowning while trapped in her seatbelt at the bottom of the ocean, as unlikely a scenario as it is, may in fact be the central trigger for her anxiety around flying.

The Treatments

The treatment for phobias is the same as treatments for most anxiety spectrum disorders — exposure to that which is feared. Simply flying a lot will eventually cure many people of their fear of flying, and for others, the phobia will gradually recede on its own.

But that, of course, is easier said than done. “The reason fear of flying is so difficult to treat is that people who are afraid to fly organize their life around not flying, thereby avoiding the very experience that could heal them,” says Lynn Martin, a psychotherapist who specializes in the treatment of anxiety disorders at the University of California San Francisco.

More advanced treatments for fear of flying are based on a psychological model known as Cognitive Behavioral Therapy. CBT aims to retrain or recondition the irrational thinking patterns and habits that cause the phobic person’s life-crippling anxieties and baseless fears. Based on its results, CBT is considered to be the most effective treatment for many anxiety disorders.

Anxiety in a situation of actual danger is normal and in fact useful for keeping us out of trouble. We become more alert, aware, and ready to take action — fight or flight — to save ourselves. But air travel is not actually a dangerous situation. Commercial airline crashes are in fact extremely rare occurrences, and the reality is that one is in much greater danger when traveling in a car than on a plane. Airline safety records notwithstanding, a person who is afraid to fly might have a strong belief that the plane will crash.

Once the person’s fight-or-flight mechanism has been activated by his or her belief in the imminence of danger, something called “cognitive spiraling” takes place. Terrifying thoughts spin out of control, and logic takes a back seat.

Mary, for example, had a number of scenarios, one more terrible than the next, which become more exaggerated and less realistic as her anxiety grew. The basis of the “cognitive” part of CBT, according to Tompkins, is to help people challenge their faulty thinking processes, to get between the irrational beliefs and the panicky reaction to them so they can, in effect, reprogram their mind’s responses. Changes in behavior are then possible.

But this is only half the battle, particularly since some of the thoughts fear-of-flyers have about crashing aren’t entirely irrational. As they are keen on explaining, “Planes do crash!” In fact, one of the unfortunate aspects of this phobia is that people who suffer from it become veritable experts on such details as the structural challenges of engines, stories from the black box, the exact speed at which 50 tons of aluminum free-falls, and other terrifying tidbits gleaned from flights gone wrong.

What You Can Do On Your Own

Finding out that you’re not in fact crazy or cowardly, but that you suffer from the simple phobia known as fear of flying is an important first step. Questions you might ask yourself to get a full picture of the nature of your phobia include:

What exactly are my symptoms? When do they begin? What exactly triggers my anxiety? What helps the anxiety to subside?

Once you become aware of the “anatomy” of your phobic reaction and what its triggers are, you can experiment with managing your responses on your own. Start with what are known as self-control strategies. These include techniques such as progressive muscle relaxation, deep breathing, and visualization, all of which are described in most books on cognitive therapy or anxiety disorders.

Many who fear the out-of-control nature of flying take steps that work to establish aspects of mastery for them. They bring familiar items, handwork, paperwork, or self-soothing products such as hand creams or herbal tea with them on the flight. Anything that evokes the familiar rhythms of ordinary life can help to redirect your focus away from your anxiety.

Sometimes confiding in a flight attendant and asking him or her to check in with you during particularly stressful parts of the flight (at takeoff and landing for example) can be soothing as well. Most important, don’t avoid flying. Evidence shows that the more people fly, the easier it becomes for them to manage their anxiety.

Therapies

If none of these strategies work, the next stage would be to enlist the help of a therapist. Most people with anxiety disorders tend to overestimate the probability of negative events and focus too intently on the emotion, rather than on coping. This is known as “catastrophizing.“ Part of the treatment is to challenge these dysfunctional, exaggerated beliefs and to replace them with more realistic ones. If Mary were in cognitive behavioral therapy, a session might go like this:

Mary: I’m terrified that the flight will go down.Therapist: What is the likelihood of this happening?Mary: Look at all the people on commercial planes who have plummeted to their deaths. Not to mention those 12-seaters. Swish, it’s over.Therapist: While you begin to relax your muscles and breathe more deeply, I want you to consider the fact that, in actuality, it’s more dangerous to drive your car to the mall than it is to fly.

“The therapist might also have the client listen to the radio, watch TV, and read the newspaper for a week, and note the number of planes versus auto accidents,” notes Tompkins. Then, Mary and her therapist might estimate what that means nationally in terms of the probability that a plane would crash.

At this point Mary would most likely be unconvinced, as her phobic mind counters the therapist with endless examples of horrifying ways people have died. She breathes, practices relaxing her muscles, perhaps visualizes a soothing scene, and remembers the reasoning that invalidates her fears-rational thoughts (“disconfirmations”) that are beginning to replace her formerly automatic, hysterical cognitive spiraling.

Mary would be likely then to move through more attempts to find data of which she is utterly terrified. The therapist would help her to generate her own more reality-based responses while also helping her to relax. They are practicing for when she’s on the plane as well. She will need to implement these cognitive (“thinking”) and behavioral (“doing”) strategies before the cognitive spiraling begins and she becomes too anxious. This is why learning to identify the triggers to anxiety is so important; once the anxiety has been spiked and the catastrophic thoughts begin, it is very difficult to arrest the consequent rush to terror with self-control methods. Being able to prevent anxiety reactions also adds to a phobic person’s experience of having some control (mastery), contributing to the eventual dramatic reduction in both the severity and the occurrence of these episodes. With repeated coupling of relaxation techniques and the replacement of negative, terrifying thoughts with more realistic and reassuring ones, the phobic person begins to rewire his or her mind-body pathways.

Exposure Therapy

The next step in treatment is called “exposure therapy” — prolonged exposure, increasing in degree and intensity, to the feared object or situation. Exposure therapy can be either “in vivo” (in life) or “imaginal” (in imagination).

In vivo therapy involves actually exposing clients in real life to the objects or situations that they fear. For fear of flying, this would mean: going to the airport while practicing relaxation during the whole experience with the therapist’s help; gradually becoming more comfortable with airplanes by boarding, for example, an empty plane, sitting in the seats, and taxiing on the ground; and eventually even taking roundtrip flights for true exposure to all the various potential triggers.

Although in vivo therapy is very effective in most cases, it tends to be time-consuming and, when done with a professional (the most effective means of treatment), may be costly.

In imaginal therapy, the “exposure” can be done in the client’s imagination in the therapist’s office, where he or she might be asked to listen to sounds, see sights, feel tactile sensations that would be experienced in an actual phobic situation. The client must rely on his or her imagination to continue creating the “exposure” to the frightening scenes.

One challenge to imaginal therapy is that it can sometimes be difficult for patients to imagine the situation with sufficient intensity to have the effect of exposure, and consequently they may not receive any reduction in their anxiety.

According to Rhonda Adessky, an expert in the cognitive behavioral treatment of anxiety disorders, “most simple phobias remit in between six to eight sessions, that is if there isn’t an underlying panic disorder, in which case treatment may take up to 15 sessions.”

Virtual Reality Exposure

And now there’s cyberspace therapy. “Virtual reality exposure” (VRE) is based on principles of exposure similar to the in vivo and imaginal modes already described. It was developed by Barbara Rothbaum, from the Emory University School of Medicine, and Larry Hodges, of the Georgia Institute of Technology, and their colleagues.

A PC, operated by the therapist, processes visual imagery and displays scenes that simulate flying in an airplane for the patient, who wears a headset. Most people feel as though they are in the virtual environment within 30 to 60 seconds.

The patient works through different aspects of flying beginning with just sitting in the plane with the engines off and progressing on through the entire flight “experience”: engines on, taxiing on the runway, takeoff, flying in smooth and then turbulent weather, and landing. The sights and sounds are true to those actually seen and heard in flight, and people experience their anxiety triggers as if they were on a real plane. Some VRE experiences include seats that bump and lean in synchronicity with all the other computer-generated sensations of flying.

Tompkins believes that virtual therapies can be effective. One advantage of virtual exposures is that they can simulate turbulence on demand, and can offer the patient repeated takeoff and landing practice. Eight sessions of virtual treatment cost approximately $1,200. “People respond with as much anxiety to the image of something feared as to the real thing” he notes. With VRE, a person striving to overcome the fear of flying can benefit from repeated exposure to his or her phobic stimuli in a short space of time.

If you are one of the many people whose fear of flying shapes their lives, you now have a choice of treatments that can help you change your life. You have the power to overcome your fear of flying.

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