Clinical characteristics of flight phobia

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.

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.

High place phenomenon: prevalence and clinical correlates in two German samples

BACKGROUND

The high place phenomenon, that is, a sudden urge to jump when in a high place, is an experience known to many people, that has rarely been studied. The present study aimed to assess the prevalence of the high place phenomenon in a non-clinical and a clinical German sample. Furthermore, clinical correlates of the experience were assessed.

METHODS

The study sample comprised 276 participants (67% female; Mage = 32.08, SDage = 10.73) who took part in an online assessment and 94 patients (73.4% female; Mage = 49.26, SDage = 13.32) suffering from clinically relevant fear of flying. Participants filled out questionnaires on experiences with the high place phenomenon, depression, anxiety, suicide ideation and anxiety sensitivity.

RESULTS

The high place phenomenon was known to nearly 60% of the online sample and to 45% of the patient sample. Suicide ideation as well as anxiety sensitivity were positively associated with experiences with the high place phenomenon in the online sample. Depression, anxiety and suicide ideation were unrelated to experiences with the phenomenon in the patient sample.

CONCLUSION

The high place phenomenon is commonly reported by (lifetime/current) suicide ideators. However, it is also a common experience in individuals who have never suffered from suicide ideation. It is therefore cautioned not to interpret such experiences as an expression of a hidden death wish.

[CME: Fear of Flying and Flying Phobia]

CME: Fear of Flying and Flying Phobia Abstract. Fear of flying and flying phobia are very common in the general population and can lead to substantial distress. Symptoms and diagnosis of fear of flying and flying phobia will be described. Severe fear of flying can be diagnosed as specific phobia or alternatively as agoraphobia. Cognitive behavioral therapy with exposure in vivo has been shown to be the most effective treatment. The treatment with benzodiazepines is the main priority for the general practitioner and will be subsequently discussed. The treatment of flying phobia and agoraphobia will be described based on two examples.

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.

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

Flying phobia is a highly prevalent anxiety disorder, which causes sufferers significant distress and life interference. The processes which maintain flying phobia remain poorly understood. A systematic search of the literature was performed to identify what research has been conducted into the processes which may be involved in the fear of flying and whether processes which are believed to maintain other anxiety disorder diagnoses have been investigated in flying phobia. The results of the literature review are presented and related to existing cognitive behavioral theory and research. The results indicate that little research has been conducted into a number of areas considered important in the wider cognitive behavioral literature on anxiety disorders: namely attention, mental imagery, memory, worry, and safety-seeking behaviors. The review proposes a hypothetical model, derived from cognitive behavioral theory, for the processes which may be involved in maintaining flying phobia, and considers a number of areas for future research.

WAYS OF ACQUIRING FLYING PHOBIA

BACKGROUND

The few studies that have explored how flying phobia is acquired have produced contradictory results. We hypothesized that classical conditioning plays a role in acquiring flying phobia and investigated if vicarious (model) learning, informational learning through media, and experiencing stressful life events at the time of onset of phobia also play a role.

METHOD

Thirty patients with flying phobia and thirty healthy controls matched on age, sex, and education were interviewed with the Mini-DIPS, the short German version of the Anxiety Disorders Interview Schedule (DSM-IV diagnostic criteria) and the Fear-of-Flying History Interview.

RESULTS

Fifty Percent of patients with flying phobia and 53% of healthy controls reported frightening events in the air. There was no significant difference between the two samples. Thus there were not more classical conditioning events for patients with flying phobia. There also was no significant difference between the two samples for vicarious (model) learning: 37% of flying phobia patients and 23% of healthy controls felt influenced by model learning. The influence of informational learning through media was significantly higher for the clinical sample (70%) than for the control group (37%). Patients with flying phobia experienced significantly more stressful life events in the period of their frightening flight experience (60%) than healthy controls (19%).

CONCLUSIONS

Frightening experiences while flying are quite common, but not everybody develops a flying phobia. Stressful life events and other factors might enhance conditionability. Informational learning through negative media reports probably reinforces the development of flying phobia. Clinical implications are discussed.

Norwegian airline passengers are not more afraid of flying after the terror act of September 11. The flight anxiety, however, is significantly attributed to acts of terrorism

The aim of this paper is to study: (1) the prevalence of flight anxiety among Norwegian airline passengers; (2) situations that may be of concern during flights and situations not related to flying; (3) whether passengers feel more afraid after the terror act of September 11, 2001; and (4) whether passengers were more afraid in 2002 than in 1986.A questionnaire was distributed during domestic flights in Norway in 1986 and 2002. To asses flight anxiety, a six point scale was used, from 0 = not afraid at all, to 5 = always very afraid, and sometimes avoid flying because of that. A 10-cm visual analogue scale (VAS) was used to measure the degree of anxiety. There were 50.8% who were not afraid at all. There were 12 women (5.2%) and one man (0.4%) with flight phobia. However, 22 (4.5%) had cancelled flights because of anxiety during the last two years. Situations that caused most concern during flights were turbulence and fear of terrorism and highjacking. After September 11, 48% were not more afraid, 38% a little more, 10% moderately, 3% rather much and 2% very much. The passengers, however, were not more afraid of flying in 2002 than in 1986. About 3% of Norwegian airline passengers have a flight phobia. Women are significantly more concerned than men. The impact of the terror act September 11, 2001 was rather moderate. The level of flight anxiety among Norwegian airline passengers was not significantly different in 2002 and 1986.

Prevalence and Behavioral Styles of Fear of Flying

According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), fear of flying is a specific situational phobia, but it has a heterogeneous character because it can be influenced by many other fears. Attention toward (monitoring) or away from (blunting) threatening information is influenced by people’s control of voluntary attention. In our online questionnaire study, 9,166 subjects (age 17–70 years) were selected for participation. The Flight Anxiety Modality (FAM) questionnaire and Miller Behavioral Style Scale (MBSS) were used to measure fear of flying and behavioral style. Also, demographic information was collected. Women reported a higher FAM sum score than men, as predicted. Participants who scored higher on the MBSS were found to have also scored higher on the FAM. Participants who had never flown before scored higher on the FAM than participants who had flown before. In this sample, monitoring can be associated with an increase in fear of flying. Future research should focus on gaining a more multicultural picture of fear of flying.

Aviophobia assessment: validating the Flight Anxiety Situations Questionnaire as a clinical identification measure

An Internet survey was conducted to validate the Flight Anxiety Situations Questionnaire (FAS; Van Gerwen, Spinhoven, Van Dyck, & Diekstra, 1999) as a clinical identification measure for aviophobia. Nine hundred and seventy six people completed the survey. Using further criteria, the total pool was reduced to 98 aviophobics and 474 non-phobics. Receiver operating characteristic analysis and chi-square tests of associations indicated that minimal scores of 56 (as previously reported in research) and 70 on the FAS were useful predictors of being a flying phobic. However, the empirically derived cut-off score of 70 on the FAS had the best overall balance of Type I and Type II error, such that the diagnostic standard for flying phobia was set neither too low nor too high. Given that 60.3% of participants were university students, results may not be generalizable to the general population but may be particularly useful for researchers at these settings.

Anxiety sensitivity moderates the relationship of changes in physiological arousal with flight anxiety during in vivo exposure therapy

Physiological sensations and discomfort constitute the major symptoms reported by aviophobics. Anxiety sensitivity (AS) seems to moderate the relationship between self-reported somatic sensations and flight anxiety, and AS has been identified as a vulnerability factor for flight phobia. In this study we examined whether AS moderates the effects of somatic sensations and autonomic nervous system reactivity on flight anxiety induced by real flight. In fifty aviophobics participating in Cognitive Behaviour Group Therapy (CBGT), flight anxiety, somatic sensations and autonomic nervous system reactivity were assessed during a guided return flight. Results indicate that physiological reactivity interacted with AS. Changes in heart rate and parasympathetic activity were more strongly associated with changes in reported flight anxiety for high AS participants, and less for participants low on AS. Results did not indicate a moderating effect of AS on the relationship between self-reported somatic sensations and flight anxiety. Our results suggest that therapy for flight phobia might benefit from addressing the physical effect of anxiety, by means of cognitive restructuring and exposure to interoceptive stimuli, particularly in aviophobics high in AS.

Associative learning in flying phobia

BACKGROUND AND OBJECTIVES

Modern learning theories suggest that particularly strong associative learning contributes to the etiology and maintenance of anxiety disorders, thus explaining why some individuals develop an anxiety disorder after a frightening (conditioning) event, whereas others do not. However, associative learning has rarely been investigated experimentally in specific phobias. The current study investigated associative learning in patients with flying phobia and healthy controls using a modified version of Olson and Fazio's associative learning paradigm (Olson & Fazio, 2001).

METHODS

Under the guise of an attention task, patients with flying phobia (n = 33), and healthy controls (n = 39) viewed a series of distracters interspersed with pairings of novel objects (counterbalanced conditioned stimuli, CSs) with frightening and pleasant stimuli (unconditioned stimuli, USs).

RESULTS

After the conditioning procedure patients with flying phobia rated both CSs more frightening and showed stronger discrimination between the CSs for valence compared to healthy controls.

CONCLUSIONS

Our findings indicate a particularly stronger conditioning effect in flying phobia. These results contribute to the understanding of the etiology of specific phobia and may help to explain why only some individuals develop a flying phobia after an aversive event associated with flying.

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

Fear of flying, its nature, prevalence, etiology and treatment, has been the subject of a substantial quantity of research over the past 30 years. With the exception of a dated review of treatment methods however, there has been no evaluation of this expanding body of evidence, its contribution to theory and influence on clinical practice. Published research has also generally failed to apply developments in the understanding and treatment of anxiety disorders generally to fear of flying. This review provides a critical evaluation of the existing literature and what it reveals about theory and practice. It does this from the perspective of Cognitive Behavioural Therapy. The evidence reviewed demonstrates that fear of flying is a heterogeneous phenomenon which is acquired under the influence of complex psychological, social and physiological factors unique to each affected individual. Effective psychological interventions must therefore be founded on a comprehensive functional assessment of each individual, a finding which is considered in detail in the second part of this review.

Cognitive vulnerability in fear of flying: the role of anxiety sensitivity

Previous research has indicated that more than 50% of air travel passengers experience hypoxia above clinical threshold. This condition produces a number of aversive somatic sensations such as difficulty breathing, elevated heart rate, dizziness, etc. Because these symptoms closely resemble the somatic symptoms of anxiety, it is interesting to look into a possible relationship between hypoxia-related symptoms and fear of flying. More specifically, the aim of this study is to clarify the role of anxiety sensitivity as a cognitive vulnerability marker in this relationship. Anxiety sensitivity is the specific tendency to interpret bodily sensations as threatening or harmful. Our hypothesis is that anxiety sensitivity moderates the relationship between hypoxia-related symptoms and fear of flying. When people with high anxiety sensitivity fly and experience somatic symptoms, they will make threatening interpretations causing fear and as a possible consequence avoidance behaviour leading to flight anxiety. About 160 participants were asked to complete the Flight Anxiety Situations Questionnaire, the Flight Anxiety Modality Questionnaire and the Anxiety Sensitivity Index. Results of a moderator analysis indicated that the relationship between somatic sensations and in-flight anxiety is stronger for people with high anxiety sensitivity than for people with low anxiety sensitivity. So it seems that anxiety sensitivity does indeed function as a moderator between the experience of somatic sensations while flying and in-flight anxiety. Clinical implications are discussed, as well as suggestions for further research.

The Flight Anxiety Situations Questionnaire and the Flight Anxiety Modality Questionnaire: norms for people with fear of flying

BACKGROUND

The Flight Anxiety Situations Questionnaire (FAS) and the Flight Anxiety Modality Questionnaire (FAM) are widely used in clinical practice and research studies. The aim of this study was to derive norms for people suffering from fear of flying completing the FAS and FAM.

METHODS

The sample is composed of 2072 individuals suffering from fear of flying and 1012 non-patients. Means, standard deviations and percentile ranks for raw FAS and FAM subscale scores will be presented. Normative data are provided enabling the comparison of individual scores.

RESULTS

The results showed a conspicuous difference between the patient and non-patient samples. As a whole the patient group scored higher on the scale assessing the level of anxiety experienced in different flight or flight-related situations and on the scale measuring the symptoms of anxiety or anticipatory anxiety in flight situations than the normal controls.

CONCLUSIONS

The findings of this study suggest that the FAS and FAM questionnaires can be applied in the investigation of fearful flyers and the normal population. A considerable number of flying phobics obtained scores in the clinically significant range on the subscales assessing anticipatory anxiety, in-flight anxiety, generalized flight anxiety, somatic complaints and cognitive complaints.

Vagally mediated heart rate variability and heart rate entropy as predictors of treatment outcome in flight phobia

In the present study a computer-assisted exposure-based treatment was applied to 54 flight phobics and the predictive role of vagally mediated heart rate (HR) variability (high frequency, 0.15-0.4 Hz band power) and heart rate entropy (HR time series sample entropy) on treatment outcome was investigated. Both physiological measures were taken under controlled breathing at 0.2 Hz and during exposure to a fearful sequence of audiovisual stimuli. Hierarchical regression analyses were conducted to assess the predictive power of these variables in these conditions on treatment self-report measures at the end of treatment and at 6 months follow-up, as well as on the behavioral treatment outcome (i.e. flying at the end of treatment). Regression models predicting significant amounts of outcome variance could be built only when HR entropy was added to the HR variability measure in a second step of the regression analyses. HR variability alone was not found to be a good predictor of neither self-reported nor behavioral treatment outcomes.

Psychological factors in airline passenger and crew behaviour: a clinical overview

Air travel places unique physical and psychological demands on the traveller and air crew. This paper presents a general overview of the psychological aspects of air travel and specifically how air travel affects airline passenger and crew behaviour. It covers travel and stress, the effects of travel on behaviour, fear of flying, disruptive passenger behaviour and crew mental health, highlighting what insights clinical psychology can offer in relation to these.

Biocyberpsychologie:

Zusammenfassung. Eine erfolgreiche Angsttherapie (Exposition) geht einher mit der Aktivierung und Umstrukturierung von Furchtnetzwerken ( Foa & Kozak, 1986 ). Aktivierung und Umstrukturierung zeigen sich in subjektiven und physiologischen Angstreaktionen, die im Verlauf der Exposition abnehmen. Um die Angstexpositionsbehandlung in der virtuellen Realität (VR) zu untersuchen, wurden in der vorliegenden Studie subjektive Angst sowie Herzraten- und Hautleitfähigkeitsreaktionen von Flugphobikern und Kontrollpersonen während vier virtueller Flüge hinsichtlich Aktivierungs- und Habituationseffekten analysiert. Flugphobiker zeigten erhöhte subjektive und physiologische Reaktionen. Zusätzlich wurden bei Flugphobikern und Kontrollpersonen differenzielle Reaktionen in spezifischen Flugphasen sowie eine Habituation der Angst und der Herzratenreaktion während der vier VR-Flüge gefunden. Virtuelle Flüge aktivieren also die Furchtnetzwerke bei Flugphobikern und sind daher als Test für die Diagnose von Flugphobie sowie zur Expositionsbehandlung anwendbar. Durch die subjektive Angstreaktion und die Herzratenreaktion scheint eine Prognose des Therapieerfolgs möglich.

Personality pathology and cognitive-behavioral treatment of fear of flying

Studies have been inconclusive about the influence of personality pathology on treatment outcome in anxiety disorders. In general, it has been presumed that treatment outcome is negatively influenced by the presence of personality pathology. This is a study of the prevalence of personality pathology among persons who were seeking help for fear of flying. Moreover, the effects of personality pathology on the results of a multimodal, standardized, cognitive-behavioral fear of flying treatment program employed by an agency that specializes in treating people with fear of flying were studied. Personality pathology was determined with a self-report questionnaire, which provides ICD-10 diagnoses of personality disorders and dimensional severity scores for personality pathology. Treatment outcome was assessed with three different fear of flying questionnaires. Based on clinical judgment after individual-case conceptualization, participants (N=922) were assigned to a particular treatment for fear of flying. Self-report data for fear of flying were collected at pretreatment and at 3, 6 and 12-month follow-ups in 659 participants who followed the 2-day treatment program. Moreover, the number of flights made in the year following treatment was determined.The results of this study showed that participants with personality pathology, mainly from cluster C (anxiety), report greater fear of flying before treatment than participants without personality pathology. After treatment fear of flying was significantly reduced. Presence of personality pathology was not predictive of the number of flights after treatment and scores on the VAFAS scale at short or long term. Only on two questionnaires for fear of flying collected at short-term participants with personality pathology obtained significantly higher scores, although the size of the differences was relatively small. It was concluded that participants with personality pathology also benefited from fear of flying treatment and that the presence of personality pathology although cannot be regarded as a contra indication for a standardized, cognitive-behavioral group treatment.

High altitudes, anxiety, and panic attacks: is there a relationship?

People exposed to high altitudes often experience somatic symptoms triggered by hypoxia, such as breathlessness, palpitations, dizziness, headache, and insomnia. Most of the symptoms are identical to those reported in panic attacks or severe anxiety. Potential causal links between adaptation to altitude and anxiety are apparent in all three leading models of panic, namely, hyperventilation (hypoxia leads to hypocapnia), suffocation false alarms (hypoxia counteracted to some extent by hypocapnia), and cognitive misinterpretations (symptoms from hypoxia and hypocapnia interpreted as dangerous). Furthermore, exposure to high altitudes produces respiratory disturbances during sleep in normals similar to those in panic disorder at low altitudes. In spite of these connections and their clinical importance, evidence for precipitation of panic attacks or more gradual increases in anxiety during altitude exposure is meager. We suggest some improvements that could be made in the design of future studies, possible tests of some of the theoretical causal links, and possible treatment applications, such as systematic exposure of panic patients to high altitude.

Virtual reality exposure therapy for the treatment of fear of flying: a controlled investigation

Forty-five participants who refused to fly during a screening test and who also met Diagnostic and Statistical Manual of Mental Disorders criteria for specific phobia, agoraphobia, or panic disorder with agoraphobia were randomly assigned to 5 sessions of either virtual reality exposure (VRE) or attention-placebo group treatment (GT). At posttreatment, 65% of VRE participants and 57% of GT participants flew during a test flight. Both groups showed significant improvement following treatment on standardized self-report measures of flight anxiety, with a better outcome for the VRE group on 4 of 5 of these measures. At 6-month follow-up, however, most group differences had disappeared; VRE resulted in a better outcome on only 1 of 5 standardized flight anxiety measures.

Driving-related fear: a review

This article reviews the research on driving-related fear (DRF). Until recently, research has concentrated almost exclusively on the effect of motor vehicle accidents (MVAs) on subsequent levels of DRF. However, recent findings have suggested that MVAs are not solely responsible for this fear reaction, and that non-MVA driving fear can be just as strong. Studies of the broader driving-fearful population have encountered difficulty with diagnostic conceptualisation of DRF, although some have investigated a possible typology of DRF. Driving skill has been a neglected issue in the DRF research, and may prove to be a useful part of assessment and remediation of this potentially debilitating problem. Issues of definitional inconsistency are highlighted, and suggestions are made for several directions that future research might profitably take.

Repeated exposure of flight phobics to flights in virtual reality

The present study examined the effects of repeated exposure of flight phobics to flights in virtual reality (VR). Flight phobics were randomly assigned either to complete one VR test flight followed by four VR exposure flights (VR group; N=15) in one lengthy session or to complete one VR test flight followed by a lengthy relaxation training session (relaxation group; N=15). All participants completed a second VR test flight at the end of the session. Fear reports and physiological fear reactions (heart rate, skin conductance level) during VR exposures were registered, and fear of flying was assessed psychometrically from 3 weeks before to 3 months after exposure. Exposure to VR flights elicited subjective and physiological fear responses in flight phobics, and these responses attenuated within and across VR flights. Fear reduction associated with repeated VR exposure was greater than fear reduction caused by relaxation training. Fear of flying improved in both treatment groups, but several outcome measures indicated greater effects in the VR treated group than in the relaxation group. These findings indicate that exposure in virtual reality may offer a new and promising approach for the treatment of fear of flying.

The somatic symptom paradox in DSM-IV anxiety disorders: suggestions for a clinical focus in psychophysiology

Although DSM-IV criteria for anxiety disorders include physiological symptoms, these symptoms are evaluated exclusively by verbal report. The current review explores the background for this paradox and tries to demonstrate on theoretical and empirical grounds how it could be resolved, providing new insights about the role of psychophysiological measures in the clinic. The three-systems approach to evaluating anxiety argues that somatic measures as well as verbal and behavioral ones are indispensable. However, the low concordance between these domains of measurement impugns their reliability and validity. We argue that concordance can be improved by examining the relationship of variables less global than anxiety and by restriction to specific anxiety disorders. For example, recent evidence from our and other laboratories indicate a prominent role of self-reported and physiologically measured breathing irregularities in panic disorder. Nonetheless, even within a diagnosis, anxiety patients vary radically in which somatic variables are deviant. Thus, in clinical practice, individual profiles of psychological and physiological anxiety responses may be essential to indicate distinct therapeutic approaches and ways of tracking improvement. Laboratory provocations specific to certain anxiety disorders and advances in ambulatory monitoring vastly expand the scope of self-report and physiological measurement and will likely contribute to a refined assessment of anxiety disorders.

Determining the focus of driving fears

Fear of driving has been recognized as a complex diagnostic entity. Studies on flying phobia have drawn similar conclusions, although increasing clarity has been gained through research that indicates that there may be subtypes of flying phobia based on the focus of fear. However, it is unclear if similar subtypes exist for fear of driving. The aim of the present study was to conduct a preliminary investigation of driving fear subtypes and to clarify further whether there were differences between driving-fearful respondents who had been in a motor vehicle accident (MVA) and those who had not. Eighty-five driving-fearful, media-recruited respondents completed a questionnaire that assessed anxiety, avoidance, and concerns related to their driving fears. The sample had high expectations of negative events while driving. There were no significant differences between those who had experienced an MVA and those who had not on various measures of fear severity. Cluster analysis revealed two main foci of fear, one characterized by danger expectancies and the other based on anxiety expectancies and unpleasant driving situations. This emphasizes the importance of assessing both internal and external foci of fear. Although this finding is consistent with the results obtained for flying phobia, more research is required to replicate and extend these results and to develop and evaluate differential treatment programs.

Psychiatric diagnoses among self-referred dental injection phobics

In order to determine the psychiatric characteristics of people with dental injection phobia. 118 dental injection phobics were systematically assessed using a structured clinical interview and a written questionnaire. Fifty-four percent of subjects had a current Axis I diagnosis other than dental injection phobia, mainly anxiety, mood or adjustment disorder, and 68.6% of subjects had an additional lifetime Axis I diagnosis. Subjects with additional current Axis I diagnoses reported higher dental anxiety, greater severity of injection fear cognitions, and poorer relationships with dental professionals, than did subjects without any or with past Axis I diagnoses. Further investigation is needed to explore the treatment possibilities for patients with and without additional current diagnoses.