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Effectiveness of Cognitive Behavioral Therapy Integrated with Systematic Journal name: Neuropsychiatric Disease and Treatment Article Designation: Original Research Year: 2015 Volume: 11 Neuropsychiatric Disease and Treatment Dovepress Running head verso: Triscari et al Running head recto: The treatment of flight anxiety: a randomized trial open access to scientific and medical research DOI: http://dx.doi.org/10.2147/NDT.S93401 Open Access Full Text Article ORIGINAL RESEARCH Effectiveness of cognitive behavioral therapy integrated with systematic desensitization, cognitive behavioral therapy combined with eye movement desensitization and reprocessing therapy, and cognitive behavioral therapy combined with virtual reality exposure therapy methods in the treatment of flight anxiety: a randomized trial Maria Teresa Triscari1 Abstract: The purpose of the research was to compare the effectiveness of the following Palmira Faraci2 treatment methods for fear of flying: cognitive behavioral therapy (CBT) integrated with sys- Dario Catalisano3 tematic desensitization, CBT combined with eye movement desensitization and reprocessing Valerio D’Angelo1 therapy, and CBT combined with virtual reality exposure therapy. Overall, our findings have Viviana Urso1 proven the efficacy of all interventions in reducing fear of flying in a pre- to post-treatment comparison. All groups showed a decrease in flight anxiety, suggesting the efficiency of all three 1Laboratory for Psychosomatic treatments in reducing self-report measures of fear of flying. In particular, our results indicated Disorders, Local Health Trust, Palermo, Italy; 2Faculty of Human and significant improvements for the treated patients using all the treatment programs, as shown not Social Sciences, University of Enna only by test scores but also by participation in the post-treatment flight. Nevertheless, outcome “Kore”, Enna, Italy; 3Italian Flight Safety Committee, Aeroporto di measures maintained a significant effect at a 1-year follow-up. In conclusion, combining CBT Fiumicino, Fiumicino (RM), Italy with both the application of eye movement desensitization and reprocessing treatment and the virtual stimuli used to expose patients with aerophobia seemed as efficient as traditional cogni- tive behavioral treatments integrated with systematic desensitization. Keywords: flight anxiety, fear of flying, aerophobia, cognitive behavioral therapy, EMDR, VRET Introduction Although commercial air travels have become one of the safest forms of transport, many people are still affected by aerophobia. In fact, the last years have been charac- terized by a growing request for fear of flying intervention programs. Nevertheless, rather few controlled studies on the compared effectiveness of different treatments Correspondence: Palmira Faraci 1,2 Faculty of Human and Social Sciences, for flight anxiety were conducted. Phobias are the experiences of an unreasonable University of Enna “Kore”, Cittadella amount of anxiety regarding a particular object or situation, causing the stimulus to Universitaria, Viale delle Olimpiadi, 1 be completely avoided or endured with intense anxiety, which interferes with one’s 94100 Enna, Italy Tel +39 0935 536 536 normal functioning.3 Specific phobias are set apart from ordinary fears by their impact Fax +39 0935 536 943 on daily functioning: distress may lead to impairments, such as being unable to maintain Email [email protected]; [email protected] a job or social relations.4 As regards their etiology, phobias result from an interaction submit your manuscript | www.dovepress.com Neuropsychiatric Disease and Treatment 2015:11 2591–2598 2591 Dovepress © 2015 Triscari et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further http://dx.doi.org/10.2147/NDT.S93401 permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on how to request permission may be found at: http://www.dovepress.com/permissions.php Triscari et al Dovepress between a disposition to physiologically experienced fear encouraging results in treating anxiety disorders and a wide and a psychological vulnerability to experience anxiety.5 range of specific phobias,16 including claustrophobia,17 The flying phobia appears as a heterogeneous phenomenon, acrophobia,18–20 agoraphobia,21,22 and flying phobia.17,23–25 with many components, not all of which are specific to flight The aim of the present paper was to compare the effective- itself, characterized by three different kinds of symptoms: ness of the following treatment methods for fear of flying: physiological, psychological, and behavioral reactions. Fear cognitive behavioral therapy integrated with systematic of flying can interfere with one’s personal and work life, and desensitization (CBT-SD), cognitive behavioral therapy it can range from moderate apprehension, to considerable combined with eye movement desensitization and reprocess- discomfort, to a disabling phobia. ing therapy (CBT-EMDR), and cognitive behavioral therapy As flying has become a more frequently integrated part combined with virtual reality exposure therapy (CBT- of our industrialized society, several treatment programs – VRET). Sequence of the design included a pre-treatment concerning anxiety management approaches, provision of assessment, an intervention phase consisting of 10 weekly accurate information regarding airplanes and flying, and treatment sessions, a post-treatment assessment 1 week after exposure techniques – have been developed to treat patients the last treatment session, and a 1-year follow-up assessment. who suffer from fear of flying and are now available to those It was hypothesized that CBT-SD, CBT-EMDR, and CBT- who are motivated to overcome their problem. Most of the VRET would similarly reduce flying anxiety and avoidance treatment protocols usually include exposure in vivo or between pre- and post-treatment assessments based on out- in-flight simulators, stress inoculation training, systematic come measures, which included self-report instruments and desensitization, and relaxing training.6 flying avoidance. Fear of flying levels were derived from While cognitive behavioral therapy (CBT) is considered the participants’ mean scores obtained at pre-treatment and to be the first-line therapy for fear of flying, there are limited post-treatment assessment phases. It was expected that the data on whether other psychotherapeutic techniques are also analyses would reveal statistically significant changes in effective in treating aerophobia. Eye movement desensitiza- fear of flying measures with a decreasing trend from pre- to tion and reprocessing (EMDR) is a relatively new technique post-treatment assessments. To reduce measurement error, of treatment based on the theory that disturbing experiences self-report measures with adequate psychometric properties are stored in the brain and the associated negative emotions and sensitivity to treatment effects were included. become trapped in the body, preventing the person from processing them during periods of rapid eye movement. Methods EMDR may aid to unlock these thoughts, helping the brain Participants to process them without experiencing the negativity that was Participants were 65 flight phobics self-referred to the Labora- once associated, therefore reducing anxiety. Specifically, tory for Psychosomatic Disorders of the Local Health Trust the therapist helps the person to recall events, images, or of Palermo, asking for a training program aimed to reduce thoughts and gently couples rapid eye movements to each or eliminate fear of flying. They were 30.8% males and event by careful observation and then redirects the eye 69.2% females, with a mean age of 43.52 (standard deviation movements using a stimulant or distraction such as a light, [SD] =10.42; range =24–70). All participants were involved in object, or music. the assessment phase before and after the treatment program. The effectiveness of CBT for fear of flying has been They were interviewed with the Millon Clinical Multiaxial scientifically well established,2 whereas the effectiveness Inventory (MCMI-III26,27), conducted by a trained psycholo- of EMDR in the treatment of a specific phobia has not gist and met the Diagnostic and Statistical Manual of Mental been long since investigated.7–9 This method is still lacking Disorders (DSM-V) criteria for neurotic diseases, phobia, empirical evidence supporting its efficacy with complex anxiety, and panic attacks. Exclusion criteria were neuro- or trauma-related phobias.10–13 Therefore, the application logical disorders, posttraumatic stress disorder or acute stress of EMDR with specific phobias merits further clinical and disorder not related to fear of flying, severe agoraphobia, and research attention. a comorbid psychiatric diagnosis. Subjects were also excluded Virtual reality exposure therapy (VRET14,15) provides if they had suicidal tendencies or did not want to stabilize their a controlled environment for people who are exposed to antidepressant medication during the course of treatment. a computer-generated virtual world that simulates a real The first group received the CBT-SD program. It con- experience with the feared object or situation. Some experi- sisted of 22 patients
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