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Sixty-six subjects with severe fear of flying were recruited by advertisement and compared to 21 controls without flying fears. Subjects were interviewed and given several questionnaires to determine DSM-III-R diagnoses, history of flying, and development and course of flying phobia. Our phobic sample had a mean age of 46 and was 89% female. Diagnostically, 27% met criteria for current Panic Disorder with Agoraphobia, and 17% criteria for that diagnosis in the past. These two groups were more concerned with internal or social anxiety stimuli during flight than the group who had never had panic attacks but met criteria for Simple Phobia (flying). All three groups were equally concerned about external dangers. Traumatic flight events were common in phobics and controls, but phobics reported reacting to these events more strongly. Our results suggest a vulnerability-stress model with several vulnerability factors, including cognitive ones. Treatment implications are discussed. © 1997 Elsevier Science Ltd

Flying for business or personal reasons has become exceedingly common in developed countries like the USA, where other means of transportation are too slow to connect major population centers. But not all actual or intended passengers are happy to fly. Boeing estimates that 20% to 30% of the U.S. population are apprehensive about flying (Dean and Whitaker, 1980). Fear of flying can be a phobia with serious professional or personal consequences. In a recent survey in Sweden (Fredrikson et al., 1996), the point prevalence for DSM-III-R Simple Phobia (flying) ( American Psychiatric Association, 1987) was 2.6%. Flight phobics sometimes turn to mental health professionals for help, some of whom have begun to specialize in its treatment. At least five self-help books on this topic are currently available (Brown, 1996; Ellis, 1972; Greist and Greist, 1981; Remington and Remington, 1992; Stauffer and Petee, 1988). Unfortunately, the clinician has available only one systematic description of the psychological characteristics of these phobics. McNally and Louro (1992) conducted structured interviews with 17 applicants for treatment of fear of flying who met DSM-III-R criteria for Panic Disorder with Agoraphobia and 17 who met criteria for Simple Phobia. They found a clear distinction between the two groups: agoraphobics avoided flying because they feared panic attacks while simple phobics avoided flying because they feared crashing. From a clinical point of view, the existence of such subgroups implies that different treatments might be indicated for the two groups. Our own study (Ehlers et al., 1994) of another transportation phobia, driving phobia, found that our clients combined characteristics of Panic Disorder with Agoraphobia, Simple Phobia, and Social Phobia in that driving phobics typically had a mixture of fear of anxiety, fear of accidents, and embarrassment about driving. In addition, we were unable to determine when they reported panic attacks during driving whether the attacks were predominantly cued or uncued and to what extent they were unexpected. Of course, driving and flying have basic differences that might sharpen diagnostic distinction. In general, driving phobics come for treatment because of fear of being the driver, while flying phobics fear being passengers. It is not unreasonable for a driver with panic attacks to think that the extreme anxiety of an attack might impair his or her ability to drive and result in a crash, justifying mixed worries (Kuch and Swinson, 1989). On the other hand, the anxiety of an airplane passenger cannot be construed as jeopardizing the airplane. Another question is whether flying phobias are acquired by conditioning, vicariously, or through information (Rachman (1977) and Rachman (1990)). Previous studies have linked different phobias to different paths of acquisition (Ost, 1987; Ost and Hugdahl, 1983). Our driving phobics had not experienced the conditioning event of an automobile accident more frequently than nonphobic drivers; rather they tended to attribute their phobia to an excessive, usually unexplained rise in anxiety while driving. Vicarious or information learning was rated by the phobics as unimportant. This was not unlike the phobic origins endorsed by individuals in our study of public speaking anxiety (Hofmann et al., 1995). However, the situation could be quite different for flying phobia because of the extensive coverage of airplane disasters by newspapers and television. Images of a fragmented fuselage and sobbing relatives are not quickly forgotten. Conditioning could be involved in flying phobia in three ways. First, some stimuli occurring during flying can be unconditioned stimuli for classical conditioning. Watson (1924) regarded only three stimuli as inherently leading to fear or distress and serving as unconditional fear stimuli for classical conditioning of phobias, all of which can be present during flight: sudden loss of support (airplane drops during turbulence), loud noises (take-off), and under some circumstances pain (middle ear pain from air pressure changes). Second, some stimuli in the flying situation may be prepared stimuli easily linked to a fear response (Ohman, 1986; Seligman, 1971). Flying creates intense accelerating forces in three dimensions and tilting. Looking out of the window is like the visual cliff in experiments on toddlers (Walk and Gibson, 1961). These presumably prepared stimuli are more frequent in flying than in driving. Third, panic attacks in the airplane in people with panic disorder can lead to conditioned avoidance of typical agoraphobic stimuli present in flight: Quarters are cramped, and passengers gazing out the window to the ground miles away are reminded that they have no control over the flight and are now committed to remaining in the airplane until they are released, often hours later. In addition, panic attacks in themselves can be traumatic events (McNally and Lukach, 1992). The study reported here examined a group of 66 people selected solely on the basis of severe fear of flying. They underwent structured interviews and filled out questionnaires that were designed to parallel ones recently developed in our laboratory to study driving phobia (Ehlers et al., 1994) and speaking phobia (Hofmann et al., 1995) so that comparisons between these phobias could be readily made. We tried to address particularly whether flying phobics could be divided into subgroups on the basis of their fears being part of Panic Disorder with Agoraphobia or not. Since it was uncertain how “normal” flying fears are (cf. Hofmann and Roth, 1996), we also asked the same questions of an age and sex-matched nonphobic group.