Treating fear of flying

[David Baxter PhD]

For Fear of Flying, Therapy Takes to the Skies
By TIM MURPHY, New York Times
July 24, 2007

For most of the 100 or so sleepy-eyed people boarding the U.S. Airways shuttle to Logan Airport in Boston from La Guardia in New York on a recent hazy Saturday morning, the 35-minute flight could not have been a bigger nonevent. But that was not the case for about 20 passengers clustered nervously near the gate. Many clutched puzzle books and bags of sour candy as though they held talismans. Some made nervous jokes, others sobbed quietly.

?I have pills with me just in case of an emergency,? said a teenage girl who planned to distract herself on the flight with celebrity magazines.

Mariasol Flouty, a 44-year-old software developer from White Plains, held fast to her Sudoku book. ?I had plane-crash nightmares,? she confessed. ?I woke up very tense.?

No one was more terrified than Beth Brenner, a 45-year-old mother of two teenagers from Somers, N. Y. ?I was hysterical last night,? she said, ?but my son said, ?You?re going to be O.K.? ? Ms. Brenner was crying quietly on the shoulder of a counselor and staying close to her designated seatmate, Richard Bracken, a retired pilot who had flown for American Airlines for 30 years. ?I?m trying to be a father figure here,? Mr. Bracken said.

Several studies have found that up to 40 percent of people have some degree of anxiety about flying, said Dr. Lucas van Gerwen, an aviation psychologist and professional pilot in the Netherlands and an organizer of an international fear-of-flying conference, sponsored by the International Civil Aviation Organization, that took place in early June in Montreal.

According to the National Institute of Mental Health, the percentage of Americans who have a fear of flying so intense that it qualifies as a phobia or anxiety disorder and keeps them off airplanes is closer to 6.5 percent. Those most paralyzed by their flying fear ? called aviophobia ? sometimes turn to programs like the one at Westchester County Airport in New York, run for 10 years by the Anxiety and Phobia Treatment Center at White Plains Hospital. The program culminates with the graduation flight to Logan from La Guardia.

?We have people who haven?t flown for 5, 10, 15 years,? said Dr. Martin Seif, a psychologist in Greenwich, Conn., who created the program, called Freedom to Fly. He himself used to be so scared of flying, he said, that he once arrived late at a conference in Atlanta because he insisted on taking a train, which got stuck in the snow.

People who suffer from phobias inhabit a world apart. ?Anxiety is an altered state of consciousness,? Dr. Seif said.

An anxiety or panic attack is often acutely physical, marked by sweating, numbness in the hands and feet, and a pounding heart, leading sufferers to think they are having a heart attack. In such an episode, ?the images in your mind feel like they can really happen,? Dr. Seif said.

Exposure-therapy programs like Dr. Seif?s, in which participants face their fear in small doses by meeting at an airport and boarding a stationary plane several times before taking an actual flight, have declined since the World Trade Center attacks of Sept. 11, 2001, as airport security has tightened, said several fear-of-flying experts.

As a result, virtual-reality programs ? high-tech simulations of the flight experience involving a helmet with built-in audiovisual components ? have replaced many more traditional treatment programs like Dr. Seif?s.

According to Dr. Barbara Rothbaum of Emory University in Atlanta, who has studied virtual-reality treatments for fear of flying, the success rate is comparable. Dr. Seif said his program?s success rate, defined as those who take the flight to Boston and back, was at least 90 percent. That is comparable to the success rate for similar programs, according to Jerilyn Ross, president and chief executive of the Anxiety Disorders Association of America.

The Sept. 11 attacks also shifted the equation for aviophobes in more subtle ways. With polls immediately after the attacks showing a spike in people who said they were anxious about or unwilling to fly, true aviophobes ?grabbed that as a reason for not flying anymore at all,? Dr. van Gerwen said.

In fact, when prodded by Dr. Seif during the program?s first session in mid-April, many participants conceded that their phobia was driven not by a rational fear of crashing but by their own anxiety, easily whipped into a frenzy by factors like a plane?s height, its enclosed atmosphere and wind turbulence, which can feel hazardous even to hardy fliers.

Together, Dr. Seif said, they would learn to ?stay in the situation and out-bluff anxiety.?

For the next five Mondays, group members practiced just that. They passed through airport security and met in one of the staff classrooms, where the program began with an outpouring of personal stories.

One man, a tall, broad-shouldered 37-year-old finance executive for an airline, divulged that he had not flown in 20 years, since having had a panic attack on board a flight after the death of his grandmother.

He was among several in the group to link the onset of their phobia to a major life change. That factor, Dr. Seif said, along with a genetic predisposition to anxiety disorders, appears to be a major contributor to a fear of flying.

Twice, the group was visited by Mr. Bracken, the veteran pilot, who patiently dispelled a wild array of fears. ?When I?m up there, I feel like the wings and tail are going to rip off,? one man said.

Mr. Bracken detailed the protections woven into building, maintaining and inspecting aircraft. He explained that turbulence was what occurred when, say, a plane hit a ripple of air left in the wake of another jet, and assured his listeners that radar kept planes miles away from truly dangerous weather.

Most group members found the explanations calming. Not Ms. Brenner. Told that the chance of a multiple engine failure was next to none, she insisted, ?But what would you do if they did??

Dr. Seif replied, ?That?s like asking what if you?re driving down the highway and your brakes go, your airbag?s not working and you?re approaching a big brick wall.?

The last half-hour of every session was spent aboard a stationary jet. The first time, many group members said their anxiety levels were high, raised by the enclosed space and the smell of the cabin. ?I feel like I?m going to throw up,? Ms. Brenner said.

But by the week before the actual flight, when airport staff members added another layer of reality by starting the plane?s engine, even she was relatively at ease.

That changed the next Saturday when the group members took their seats in the front of the plane to Boston. Tension filled the cabin. One young woman bolted from her seat, unpersuaded by entreaties to stay from Dr. Seif and others.

Once the flight was in the air, most participants coped well, as Dr. Seif had predicted they would, busying themselves with their magazines and puzzles or organizing an e-mail list so the group could stay in touch.

Ms. Brenner did not fare as well. She was nearly catatonic throughout the flight, clutching Mr. Bracken?s arm on one side and on the other, that of Cecilia Gschwind, 39, a homemaker from Harrison, N.Y.

?Why does it feel like we?re not going up?? Ms. Brenner asked as the plane made its unmistakable ascent. Halfway to Boston, when asked how she was doing, she said, ?I?m having a hard time focusing.?

Dr. Seif demanded that she talk with him to distract herself. He was only half-successful.

At Logan, with an hour or so to kill before the flight home, the participants were giddy and celebratory. Many spoke of their plans to fly again within the next few months. One woman, who had not flown in 10 years, said she was finally ready to take her children to Disney World. She lamented the places she had not flown in her 20s but said, ?I think my 30s will be good.?

Ms. Brenner, however, slipped away from the group and took a train back to New York, calling Dr. Seif to let him know.

?O.K., goodbye, see you Monday,? he said curtly into a cellphone.

He was softer, though, when the group reconvened Monday for a final session, and he told Ms. Brenner she did the right thing. ?It was such a trauma that you needed time to heal,? he said. For her part, Ms. Brenner said she was not ashamed of herself for running ? just frustrated. ?I thought I was going to feel this huge rush of relief and accomplishment after the flight,? she said. ?But I didn?t. I thought, ?This is not helping.? I was so unhappy.?

Ms. Brenner is not making any immediate plans to fly again. ?I?m going to try to figure out why it?s as bad as it is for me,? she said. ?I don?t think it?s about the planes.?

 

[David Baxter PhD]

You Are Cleared for Takeoff

You Are Cleared for Takeoff
By ALEX WILLIAMS, New York Times
September 17, 2006

A FEW days after the terror arrests in London last month, a small commuter plane with three tourists was banking off the coast of Costa Rica when a sudden sound, like a muffled explosion, shattered the calm. The rear door of the plane, improperly shut, had blown open.

There was a moment of panic for two of the passengers. But Roger Knox, a graphic designer making a connecting flight before boarding a jetliner home to San Francisco, was not worried. He had just doubled his usual preflight dose of Ativan, a prescription anti-anxiety drug, in anticipation of the ride on the small plane.

Mr. Knox, 46, said he is generally so drug-phobic that he doesn't take aspirin for a headache. But he is also a white-knuckle flier, and over the last few years, with advice from his doctor, he has experimented with drugs to massage his nerves before flying.

''My meds never give me a feeling of being high or stoned,'' Mr. Knox said. ''They can make me a bit drowsy, but for someone used to adrenaline-pumping, think-I'm-going-to-freak-out anxiety, that's a welcome change.''

Terror alerts. Long security lines. Overstuffed transcontinental jets. It's all more tolerable with a prescription drug to round off the edges, many people have found.

''I've kind of gotten over the stigma that I need to tough this out,'' Mr. Knox said.

As the era of populist anti-anxiety drugs has merged with the post-9/11 era of fraught air travel, nervous fliers increasingly turn to pills to make the hours of sealed confinement more bearable, according to therapists, flight-anxiety counselors and nervous fliers. For many stressed-out travelers, tossing back a prescription pill before a flight -- rather than a couple of bourbon and sodas, the old method -- is as routine as picking up a paperback on the way to the gate.

''Everybody personally and professionally that I know who is afraid to fly gets their hands on Xanax,'' said Jeanne Scala, a psychotherapist in Roxbury, N.J., adding that she has seen an increase in patients and friends talking about taking medication for flying jitters. ''They'll do anything to take the edge off the anxiety of sitting in a plane,'' she said. ''They just want to zone out, they want to sleep. So they'll take Ambien, Sonata, even pain medication like Soma, which is for back pain. People use whatever they have -- the pharmacy in their house.''

Tom Bunn, a licensed therapist and a former commercial pilot who started company called Soar in 1982 to counsel people with fears of flying, said he saw an increase in chatter about anti-anxiety medication on the message board of his company's Web site after 9/11. ''Everybody started saying, 'Take it like candy,' '' said Mr. Bunn, who is nevertheless skeptical about drugs' effectiveness and safety and does not recommend them in his program.

Ron Nielsen, a pilot for US Airways who also leads a flight-anxiety course, called Cleared 4 Takeoff, said scares like the London arrests of men accused of plotting to blow up planes with liquid explosives serve as a trigger for underlying fear, which leads many fliers to consider medication.

''That's one of the first things that come up every class,'' Mr. Nielsen said. ''The average fearful flier is more likely to say, 'Give me something, I gotta go to Boston.' I think every time you have a spike in collective anxiety in culture, people get to desperate places, people say 'O.K., I'm willing to do this, whereas yesterday I wasn't.' ''

There are plenty of options for the highly nervous flier. Xanax, Valium and Klonopin -- among the most popular -- are benzodiazepines, a class of anti-anxiety drugs often prescribed for use on an occasional basis. All have slightly different characteristics, times of duration and side effects, said Dr. Thomas R. Swift, president of the American Academy of Neurology in St. Paul. (Benzodiazepines are different from older sedatives like Seconal, a barbiturate, and from antidepressants like Zoloft and Prozac meant to be taken daily when used to treat panic disorders and other ongoing anxiety problems.)

Some fliers said they preferred a drug like Xanax to alcohol because its effects are typically mild. It does not make them spacey or fuzzy-headed, they said. They do not stumble off a plane as if their legs are filled with putty, making it appealing to business travelers who must attend meetings after landing.

''Benzodiazepines tend to be a relatively safe drug,'' Dr. Swift said, adding that the main side effect in small doses is sleepiness. The risk comes in, he said, when people borrow them from well-meaning friends.

''It's almost always a bad idea,'' said Dr. Swift, referring to pharmaceutical-swapping. ''The doctor that prescribed the medicine for the person had it knows the person's medical history. That's not true for person who borrowed it. There could be a contraindication to that drug.''

Doctors also caution against chasing an anti-anxiety pill with a drink, because alcohol functions as a ''powerful augmenter'' to benzodiazepines like Xanax, said Dr. William Rickles, an assistant clinical professor in the Department of Psychiatry at the University of California, Los Angeles. Unlike with powerful barbiturates, the mix ''doesn't drop your blood pressure and doesn't stop you breathing, so it doesn't kill you,'' Dr. Rickles said. ''But you might sleep for a long time.''

FOR some fliers, sleep is the goal. Dr. Neil B. Kavey, director of the Sleep Disorders Center at NewYork-Presbyterian Hospital/Columbia University Medical Center, said he has witnessed a dramatic increase in the number of patients who use these sleep drugs for flights -- most to combat jet lag, but some who simply knock themselves out to avoid anxiety -- over the last year or two. ''When I noticed the increase, I worried a bit if I would see people awakening on airplanes too heavily drugged,'' he said. ''But I don't think I've had any incidents.''

The new generation of prescription sleep drugs, which includes Sonata and Lunesta as well as the popular Ambien, is marketed as safer than an older generation of sleeping pills. (Ambien became a cocktail-party topic earlier this year, after reports that some users claimed they went on eating binges or driving excursions they didn't remember. And last summer, a London-bound plane was diverted after a passenger who later said that he had taken Ambien -- and drank two individual-serving bottles of wine -- tore off his shirt and made threatening remarks.)

Paul Taylor, a hair colorist in White Plains, was an unnerved air traveler who had to experiment with anti-anxiety drugs to find one that worked for him. Mr. Taylor, a native of South Africa who has been flying home routinely for years, said he developed a severe aversion to air travel after a trip in the late 1990's that required an emergency landing. Then a few years ago, a sympathetic acquaintance gave him a Valium for an upcoming trip to Seattle.

He tried it.

Nothing.

On the flight, Valium failed to ''shut down the little people in my brain, as I call them,'' said Mr. Taylor, 43, referring to his neuroses. ''I was literally grabbing onto the arm of my partner the whole way and freaking out.'' A year or so later he confessed his fears to a doctor, who prescribed Xanax. Thanks to that, combined with the cognitive therapy he learned from the Soar program, for him the skies have never been, well, quieter.

Although doctors and therapists confirm that drug use among jittery fliers is common, it is impossible to measure how common, because many people who pop the occasional pill do so without mentioning it to any professionals, especially if they received it from a friend.

Others just have a few Klonopin that they got from their general practitioner for anxiety issues in general, and decide to take them for a flight as needed.

There are nervous fliers who have drugs in their pocket but don't use them, said Marvin Aronson, a psychotherapist in Mount Vernon, N.Y., who treats flight anxiety. ''It's just having them that can make the difference,'' he said. (These fliers may want to bring the prescription bottle; the Transportation Security Administration requires that prescription drugs carried on board have a label matching the ticketholder's name.)

And drugs are certainly not the only option for jittery fliers.

''We have some people call up and want nothing but natural remedies,'' said Dr. Rickles, who uses techniques like biofeedback and virtual-reality therapy to help many patients combat their fear of flying. Some people with extreme phobias, he said, ''generally don't like to take drugs, because they are afraid that a drug might do something and then they can't get it out of them.''

Jerilyn Ross, president of the Anxiety Disorders Association of America, a nonprofit group of health care professionals in Silver Spring, Md., said that anxious fliers, like many people suffering anxiety, ''used to take Valium and hide it'' because they believed there was a stigma attached to self-medicating for anxieties like fear of flying. But now, she said, ''it's much less frightening'' and ''people are much more open about it,'' due in part to the torrent of information -- and pills -- available on the Internet.

Certainly, some people, particularly those suffering an acute fear of flying, have turned to pills since the heyday of barbiturates like Seconal and Nembutal in the 60's and 70's, doctors said. But these days, there are even more reasons why tremulous fliers may want to indulge.

For Kermit Morse, a computer systems analyst at a bank in Columbus, Ohio, going through security lines at airports is an added psychological hurdle as he tries to find a new peace with flying. He flew routinely until a few years ago, when a growing sense of fear due in part to the post-9/11 jitters stopped him in his tracks at the gate at the Columbus airport just as he was about to board a flight to Dallas.

''I was at the gate and I could not walk down the jetway,'' Mr. Morse, 48, recalled. ''So I went home.''

He saw a doctor, who for a time put him on a daily regimen of Paxil, a drug often prescribed for acute anxiety disorders. For his first flight after that, it worked. Sort of. While on a plane flight, the fear ''didn't seem to be as he intense,'' he said, though he still found himself ''looking for anything that might indicate there's a problem with the plane.''

At least, Mr. Morse added, ''I could actually get on the plane.''