Virtual reality
Introduction
Fear of flying (FOF) or Aviophobia, classified in the DSM 5 as a Specific ( situational) Phobia, is characterized by “excessive and persistent fear of air travel”. Although there are multiple pathways to fear of air travel, most cases are accounted for by two but very different clinical phenomena:
- Fear of aviation accident
- Fear of panic.
Aviation Accident- Fear of Flying
Fear of mechanical failure and/or accident causing the plane to crash is the number one reason for fear of flying. Individuals with this fear so embed themselves in the possibility of a fatal outcome that the flight becomes contaminated with idea of premature death. This perspective colors the person’s entire reaction to the idea of flying. Individuals in this group focus on every and anything related to the functioning of the aircraft and accident. Common fears seen in this group are:
As a result, they have biased scanning for and memory of aviation accidents, reports of pilot error or irresponsible behavior. Aviation statistics mean nothing to them: 2.5 incidents per million aviation hours ? 8% of passengers in such accidents fatally injured ? “Someone has to go down, why not me”. “ It is unnatural for this much metal to be in the air”. As with many fears that steer away from what is real or plausible, the relationship with possibility, in the fear of aviation accidents is selective and cherry-picked.
- Mechanical failure
- Accidents in the air
- Crashing during take-off or landing
- Birds being sucked into the engine
- Weather conditions
- Lightening strikes
- Turbulence loss of control of aircraft
- Electrical failture
- Wind sheer
- Pilot error
- Pilot mental health crisis
- Pilot medical emergency
Behavioral Responses To Fear of Flying
As with other anxiety disorders, fear elicits a reaction to "protect" oneself from perceived "threat". If there is no clear threat, the experience of fear can activate scanning to find one. The responses in fear of flying all line up according to the classic survival imperative, but adapted to the context at hand: flying. As described throughout this website, there is always a human uniqueness in how we respond to fear. Nonetheless, the most common (apologies) frequent flyers are:
- Avoidance: “I am not flying”. “I’ll drive, take the train, bus or even walk”.
- Safety Seeking Behaviors:
For those who must remain conscious and functional and who can’t avoid flying-whether it be for business or certain life circumstances, safety seeking behaviors are the premier behavioral coping responses. As described in specific phobias, safety behaviors help you get through the feared situation but they ultimately reinforce fear. Safety behaviors are limitless and they are unique to the person but they are always organized around the relevant context. Some common examples in the context of fear of flying are:
- Seeking reassurance
- inquiring about the type of aircraft
- praying
- mastering the science of meteorology
- Tracking the time until landing
- Scanning for noises and sounds
- Fidgeting
- Tapping with feet or hands
- Excessive use of alcohol
- Excessive use of sedating medication-sometimes dangerously mixed with alcohol
- Studying what flight crew announcements for signs of concern
- Gripping the seat
- Squeezing the hand of travel companion -if available
- studying the reactions of other passengers and flight attendants during turbulence.
Fear Panic During of Air Travel
This form of air travel anxiety is experienced by those who suffer from panic disorder. Consequently, the clinical characteristics in general Panic Disorder-described elsewhere on this site- are present when flying. It is important to understand that this group of travelers is not afraid of the plane crashing, as in fear of flying; rather, the fear is having a panic attack while "trapped" on an airplane where escape is not a viable option. As is alway the case in anxiety, the nature of the situation shapes the specific ways anxiety is expressed. Thus certain nuances of panic fears and the specific safety behaviors used are contoured to the context of flying.
Other Fears
- Fear of closed in spaces (claustrophobia), such as that of an aircraft cabin
- Fear of heights (acrophobia)
- Fear of vomiting (emetophobia) or being near someone who is vomiting
- Fear of hijacking or terrorism
Treatment
Cognitive-Behavioral Therapy
CBT is the treatment of choice for both fear of panic and fear of accident during air travel. The core fears of each is different, and, consequently, the focus of cognitive methods varies accordingly. Nonetheless, the fundamentals of CBT are applicable to the treatment of both. Briefly, steps in the approach I use, by category, are listed below:
Fear of Flying Treatment
- Identifying the specific catastrophic fears and ALL the safety behaviors unique to the individual
- Defusing catastrophic fears is necessary to gain and to is the cognitive and narrative foundations of this fear is therefore essential . the is viewed of a fatal crash the expectation of a catastrophic away from the expectation of a catastrophic acc of Cognitive therapy techniques with some blending of reframing to de-catastrohize these fears (essentially the Beckian, “what is the evidence for and against?)
- Identifying the specific justifications that maintain the “construction” of the fear- a technique used in Inferential-Based Treatment (IBT)
- Creating a reality-based counter perspective and narrative of flying
- Writing out in detail a narrative of an imagined flight, that includes fears, urges to act on safety behaviors, responses to the fears, calming strategies and measurable, clear behaviors in line with story of not crashing.
- Repeated rehearsal of the narrative, together with youtube videos
- Rating fear responses during imaginal exposure
- Setting up a flight
- Mapping of the imaginal exposure onto the real flight
- Rehearsal and preparation for the real flight.
- The flight with strict no-safety behavior contract along with use of all strategies practiced
- Rating the flight
- Debriefing the flight and adjusting strategies
- Setting up at least two more flights over a 4-6 month period
- Repeating all the steps above
Fear of Panic During Air Travel
Treatment of fear of panic while flying blends the technique of scripted imaginal rehearsal used for fear of flying with the methods of panic control therapy. The safety behaviors panickers rely on when flying are very similar to those used elsewhere, but adapted to the agoraphobic context of air travel. Below I have listed treatment steps for fear of panic when flying:
- Reference the counter non-panic, narrative that has been developed during the Panic Control Therapy phase of treatment
- Identify safety behaviors that occur specifically while flying
- Follow all of the steps imagined rehearsal for fear of flying, listed above, moving forward from the first narrative step in the bullet point example below:
- Write out a detailed narrative of an imagined flight that includes fears [of panic], urges to act on safety behaviors [related to panic], responses to these fears, calming strategies and measurable, clear behaviors in line with story of not [dying of panic].
Virtual Reality Exposure Treatment
Both fear of panic and fear of accident require exposure air travel. This does present both logistic and financial obstacles, as many do not have the resources or time to fly often.To overcome this limitation and enhance imaginal exposure, very recently, I have introduced Virtual Reality technology as a proxy for exposure. Thus far, VR clearly adds significant value to the overall treatment package. I chose the Ovrcome VR software as it has an extensive library of simulations and is very affordable. Ovrcome was created at the start of the pandemic with tele therapy in mind. It allows the therapist to view and audio into the client's VR simulation. Additional information about the use of this technology will be added to this site over the next several months
Treatment of Obsessional Spectrum Anxiety
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