Processes Contributing to the Maintenance of Flying Phobia: A Narrative Review

Fear of Flying, Stress and Epileptic-Like Symptoms

Background

Intense fear of flying, called aviophobia, is a highly prevalent psychological phenomenon, afflicting (in some estimates) up to 40% of the population of industrialized countries and although aviophobia is a highly prevalent mental health problem, published studies about its epidemiology and treatment are rare.

Methods

In this study, including 61 participants (28 males and 33 females; mean age 26.85) engaged in business related travels in the last two years, we assessed relationships of fear of flying problems with symptoms of stress also reflecting childhood traumatic stress experiences and its influences on brain sensitization and epileptic-like symptoms. In this assessment we also studied fear of flying symptoms and work related psychological problems described as burnout.

Results

The results show that the participants who manifest higher levels of stress symptoms have higher levels of aviophobic experiences. Stress symptoms measured by TSC-40 manifested significant correlations with aviophobic experiences measured by Flight Anxiety Modality Questionnaire (FAS) (Spearman R=0.46, p<0.01). Other correlations were found between FAS and Limbic System Checklist (LSCL-33) (Spearman R=0.39, p<0.01) and FAS and Burnout Measure (BM) (Spearman R=0.30, p<0.01).

Conclusion

The results of this study indicate that the experience of fear of flying is related to past and recent stressful events and also to levels of work related problems described and experienced as burnout.

Virtual reality exposure with vibrotactile stimulation for the treatment of fear of flying: A pilot study

BACKGROUND AND OBJECTIVES

Virtual reality (VR) interventions are becoming more prevalent in treating fear of flying (FoF). Since multisensory stimulation can enhance the sense of presence in a virtual environment, the present study compared virtual reality exposure with and without vibrotactile cues to determine its contribution to the realism of the virtual experience.

METHODS

A repeated measures design was used. Thirty-one participants were exposed to two experimental conditions with a minimum of a one-week interval between them: one in which participants were exposed to the virtual environment with vibrotactile cues (smart chair, SC), and another in which participants were exposed to the virtual environment without vibrotactile cues (ordinary chair, OC). The administration order of both conditions was counterbalanced to avoid possible order effects.

RESULTS

Participants felt higher levels of sense of presence when using the SC than the OC. However, the addition of vibrotactile stimulation partially influenced experienced anxiety. Some personality traits were also associated with participants' sense of presence and anxiety responses during the exposure.

LIMITATIONS

The sample size was smaller than required. Moreover, only self-reported measures were used. Finally, a roller coaster instead of an airplane scenario was used for the exposure, which might not have been suitable enough for provoking anxiety in participants with FoF.

CONCLUSIONS

Vibrotactile cues enhanced the sense of presence. However, the addition of vibrotactile stimulation did not have a consistent effect on anxiety experienced during exposure. Therefore, the benefits of incorporating vibrotactile cues in virtual reality environments for exposure therapy are not clear.

Key factors behind various specific phobia subtypes

While it has been suggested that more than a quarter of the whole population is at risk of developing some form of specific phobia (SP) during their lives, we still know little about the various risk and protective factors and underlying mechanisms. Moreover, although SPs are distinct mental disorder categories, most studies do not distinguish between them, or stress their differences. Thus, our study was manifold. We examined the psychometric properties of the Specific Phobia Questionnaire (SPQ) and assessed whether it can be used for screening in the general population in a large sample (N = 685). Then, using general linear modeling on a second sample (N = 432), we tested how potential socio-demographic, cognitive emotion regulatory, and personality variables were associated with the five SP subtypes. Our results show that the SPQ is a reliable screening tool. More importantly, we identified transdiagnostic (e.g., younger age, female gender, rumination, catastrophizing, positive refocusing) as well as phobia-specific factors that may contribute to the development and maintenance of SPs. Our results support previous claims that phobias are more different than previously thought, and, consequently, should be separately studied, instead of collapsing into one category. Our findings could be pertinent for both prevention and intervention strategies.

Overcoming Fear of Flying: A Combined Approach of Psychopharmacology and Gradual Exposure Therapy

Aviophobia, the fear of flying, is a prevalent type of situational-specific phobia categorized under anxiety disorders in The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Patients with aviophobia experience intense, irrational fear when traveling by air. Active avoidance of the phobic stimulus is a diagnostic feature that affects one's quality of life and commonly leads to significant functional limitations. Virtual reality based gradual exposure therapy is a treatment option for aviophobia due to its easy accessibility and low cost, but it may not be very effective. This case reports the effectiveness of using psychopharmacologic treatment in combination with real-life gradual exposure therapy to successfully treat a patient with aviophobia. Written consent from the patient was obtained prior to the writing and submission of this case report.

Relationships between fear of flying, loudness dependence of auditory evoked potentials and frontal alpha asymmetry

Previous research has suggested that fear of flying, which is defined as a situational, specific phobia, could overlap with depressive and anxiety disorders. Whether the neuronal dysfunctions including altered serotonergic activity in the brain and altered neural oscillations observed for depressive and anxiety disorders also overlap with alterations in fear of flying is unclear. Here, thirty-six participants with self-reported fear of flying (FF) and forty-one unaffected participants (NFF) were recruited. The participants completed the Beck Depression Inventory (BDI-II), the State-trait Anxiety Inventory (STAI) and the Fear of Flying Scale (FFS). EEG-recording was conducted during resting-state and during presentation of auditory stimuli with varying loudness levels for analysis of the Loudness Dependence of Auditory Evoked Potentials (LDAEP), which is suggested to be inversely related to central serotonergic activity. Participants with fear of flying did not differ from the control group with regard to BDI-II and STAI data. The LDAEP was higher over F4 electrode in the FF group compared to controls, whereas exploratory analysis suggest that differences between groups were conveyed by female participants. Moreover, the FF group showed relatively higher right frontal alpha activity compared to the control group, whereas no difference in frequency power (alpha, beta and theta) was observed. Thus, this study brought the first hint for reduced serotonergic activity in individuals with fear of flying and relatively higher right frontal activity. Thus, based on the preliminary findings, future research should aim to examine the boundaries with anxiety and depressive disorders and to clarify the distinct neural mechanisms.

An internet-based treatment for flying phobia using 360° images: A feasibility pilot study

BACKGROUND

More research is needed in the field of Internet-delivered Cognitive Behavioral Treatments (ICBTs) for specific phobia in order to understand which characteristics are important in online exposure scenarios. The aim of the present work was to conduct a feasibility pilot study to explore participants' opinions, preferences, and acceptability ratings of two types of images (still images vs 360° navigable images) in an ICBT for Flying Phobia (FP). A secondary aim was to test the potential effectiveness of the two active treatment arms compared to a waiting list control group. An exploratory aim was to compare the role of navigable images vs. still images in the level of sense of presence and reality judgment and explore their possible mediation in treatment effectiveness.

METHODS

Participants were randomly allocated to three conditions: NO-FEAR Airlines with still images (n = 26), NO-FEAR Airlines with still and navigable images (n = 26), and a waiting list group (n = 26). Primary outcome measures were participants' opinions, preferences, satisfaction, and acceptance regarding the images used in the exposure scenarios. Secondary outcome measures included FP symptomatology outcomes and measures of sense of presence and reality judgment.

RESULTS

Participants in the study preferred navigable images over still images before and after treatment (over 84%), and they considered them more effective and logical for the treatment of their problem. However, adherence in the experimental conditions was low (42.3% dropout rate), and more participants withdrew from the group that included navigable images compared to the group that only included still images (14 vs. 8), with no statistical differences in attrition between the two conditions. NO-FEAR Airlines proved to be effective in reducing FP symptomatology compared to the control group, with large between-group effect sizes on all FP measures (ranging from 0.76 to 2.79). No significant mediation effect was found for sense of presence or reality judgment in treatment effectiveness.

DISCUSSION

The results of the current study suggest that participants prefer more immersive images in exposure scenarios, providing data that can help to design useful exposure scenarios to treat specific phobias in the future. They also provide evidence supporting the effectiveness of an ICBT for FP.

TRIAL REGISTRATION

Registered at Clinicaltrials.gov (NCT03900559) on April 9, 2019. Retrospectively registered.

Individual differences in the temporal progression of motion sickness and anxiety: the role of passengers' trait anxiety and motion sickness history

The objective of the study is to show that trait anxiety and motion sickness history are responsible for different temporal progressions of sickness in passengers. The level of inflight anxiety and inflight sickness severity was monitored for 124 passengers in a full-motion cabin simulator during a short-haul flight with four different flight segments. Four groups with different characteristics in trait anxiety and motion sickness susceptibility showed different profiles of inflight sickness development. High trait anxiety was responsible for high inflight anxiety and a constantly high level of motion sickness, while passengers with just a motion sickness history showed an increase in motion sickness severity over time. We suggest that trait anxiety and motion sickness susceptibility interact and have an impact on the temporal progression of inflight sickness severity. The analysis of temporal developments of anxiety and sickness are fruitful for understanding the origins of motion sickness, research and individual treatments. Practitioner summary: In a full-motion cabin simulator study with 124 passengers the level of inflight anxiety and inflight sickness severity was monitored. Trait anxiety and motion sickness history were found to have different impacts on the temporal progression of individual sickness severity. Abbreviations: ANOVA: analysis of variance; AVES: air vehicle simulator; hiA/hiM: group with high anxiety and high motion sickness susceptibility; hiA/loM: group with high anxiety and low motion sickness susceptibility;MSSQ: motion sickness susceptibility scale; loA/hiM: group with low anxiety and high motion sickness susceptibility; loA/loM: group with low anxiety and low motion sickness susceptibility; SPSS: statistical package for the social sciences; SSQ-TS: total score from the simulator sickness questionaire; STAI: state trait anxiety inventory.

Are patients with cognitive impairment fit to fly? Current evidence and practical recommendations

BACKGROUND

The worldwide prevalence of dementia is increasing and represents a major public health concern. In the last decades, air travel services have undergone an impressive expansion and one of ten passengers is aged 65 years and older. While air travel can be stressful at all ages and health conditions, older individuals with cognitive impairment carry a greater risk for air-travel-related complications. Consequently, demands to general practitioners for assessing their older patient's fitness to fly are increasing.

METHODS

We conducted a search of the literature in PubMed on the impact of in-flight environmental changes on passengers with cognitive impairment and possible resulting complications. This set the base for a discussion on pharmacological and non-pharmacological interventions aimed at preventing in-flight complications in this vulnerable population.

RESULTS

While our research strategy identified a total of 11 articles related to older age and air travel, only three focused on passengers with cognitive impairment. Our literature review showed that the airplane environment may lead to a large spectrum of symptoms in passengers of all age groups. However, passengers with cognitive impairment due to neurodegenerative diseases are at increased risk for experiencing the most extreme symptoms such as acute confusional state. Non-pharmacological and pharmacological interventions at different stages of the travel process (before, during and after) can help prevent complications in this vulnerable population.

CONCLUSION

The decision to let a patient with cognitive impairment fly requires a solid understanding of the in-flight environmental changes and their impact on older patients with cognitive impairment. Moreover, a sound weighing of the risks and benefits while considering different aspects of the patient's history is demanded. In this regard, the role of the treating physicians and caregivers is essential along with the support of the medical department of the airline.

The impact of affect labelling on responses to aversive flying-cues

Individuals with flying phobia experience increases in subjective anxiety in response to flying-related cues. However, the cognitive processes that contribute to cue-reactive anxiety in individuals with flying-related anxiety remain poorly understood. Preliminary research suggests that changes in visual imagery and volitional control may contribute to this cue-reactive anxiety. Engaging in affect labelling during exposure therapy has been shown to reduce cue-reactive anxiety in individuals with fears relating to a variety of stimuli but has not been investigated in the fear of flying. The present study recruited 110 participants with a range of flying-related anxiety scores to complete an online cue-reactivity experiment. The study sought to evaluate whether an aversive flying cue triggered changes in imagery, volitional control and anxiety, and whether changes in imagery and volitional control predicted level of cue-reactive anxiety. Participants were randomly allocated to an affect labelling or non-affect labelling condition to additionally assess whether engaging in labelling one's emotion following exposure to an aversive flying cue would attenuate cue-reactive changes in anxiety relative to a group who did not. Significant cue-reactive changes in anxiety, and volitional control were observed from neutral to aversive flying cue were observed. After accounting for the effects of flying anxiety severity, only volitional control significantly improved the prediction of cue-reactive anxiety. Participants in the affect labelling condition reported significantly smaller increases in anxiety than the non-affect labelling group following exposure to the aversive flight cue. This is the first study to indicate affect labelling may help to regulate aspects of cue-reactive anxiety in response to aversive flying stimuli.

Evaluating Perceived Probability of Threat-Relevant Outcomes and Temporal Orientation in Flying Phobia

Probability bias regarding threat-relevant outcomes has been demonstrated across anxiety disorders but has not been investigated in flying phobia. Individual temporal orientation (time perspective) may be hypothesised to influence estimates of negative outcomes occurring. The present study investigated whether probability bias could be demonstrated in flying phobia and whether probability estimates of negative flying events was predicted by time perspective. Sixty flying phobic and fifty-five non-flying-phobic adults were recruited to complete an online questionnaire. Participants completed the Flight Anxiety Scale, Probability Scale (measuring perceived probability of flying-negative events, general-negative and general positive events) and the Past-Negative, Future and Present-Hedonistic subscales of the Zimbardo Time Perspective Inventory (variables argued to predict mental travel forward and backward in time). The flying phobic group estimated the probability of flying negative and general negative events occurring as significantly higher than non-flying phobics. Past-Negative scores (positively) and Present-Hedonistic scores (negatively) predicted probability estimates of flying negative events. The Future Orientation subscale did not significantly predict probability estimates. This study is the first to demonstrate probability bias for threat-relevant outcomes in flying phobia. Results suggest that time perspective may influence perceived probability of threat-relevant outcomes but the nature of this relationship remains to be determined.