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Open access Full Text article

http://dx.doi.org/10.2147/NDT.S93401

effectiveness of cognitive behavioral therapy
integrated with systematic desensitization, cognitive
behavioral therapy combined with eye movement
desensitization and reprocess ing therapy, and
cognitive behavioral therapy combined with virtual
reality exposure therapy methods in the treatment
of flight anxiety: a randomized trial

correspondence: Palmira Faraci
Faculty of human and social sciences,
University of enna ?Kore?, cittadella
Universitaria, Viale delle Olimpiadi, 1
94100 enna, italy
Tel +39 0935 536 536
Fax +39 0935 536 943
email [email?protected];
[email?protected]

Journal name: Neuropsychiatric Disease and Treatment
Article Designation: Original Research
Year: 2015
Volume: 11
Running head verso: Triscari et al
Running head recto: The treatment of flight anxiety: a randomized trial
DOI: http://dx.doi.org/10.2147/NDT.S93401

Maria Teresa Triscari1

Palmira Faraci2

Dario catalisano3

Valerio D?angelo1

Viviana Urso1

1laboratory for Psychosomatic
Disorders, local health Trust,
Palermo, italy; 2Faculty of human and
social sciences, University of enna
?Kore?, enna, italy; 3italian Flight
safety committee, aeroporto di
Fiumicino, Fiumicino (rM), italy

Abstract: The purpose of the research was to compare the effectiveness of the following
treatment methods for fear of flying: cognitive behavioral therapy (CBT) integrated with sys-

tematic desensitization, CBT combined with eye movement desensitization and reprocessing

therapy, and CBT combined with virtual reality exposure therapy. Overall, our findings have

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

treatments in reducing self-report measures of fear of flying. In particular, our results indicated

significant improvements for the treated patients using all the treatment programs, as shown not

only by test scores but also by participation in the post-treatment flight. Nevertheless, outcome

measures maintained a significant effect at a 1-year follow-up. In conclusion, combining CBT

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

for flight anxiety were conducted.1,2 Phobias are the experiences of an unreasonable

amount of anxiety regarding a particular object or situation, causing the stimulus to

be completely avoided or endured with intense anxiety, which interferes with one?s

normal functioning.3 Specific phobias are set apart from ordinary fears by their impact

on daily functioning: distress may lead to impairments, such as being unable to maintain

a job or social relations.4 As regards their etiology, phobias result from an interaction

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between a disposition to physiologically experienced fear

and a psychological vulnerability to experience anxiety.5

The flying phobia appears as a heterogeneous phenomenon,

with many components, not all of which are specific to flight

itself, characterized by three different kinds of symptoms:

physiological, psychological, and behavioral reactions. Fear

of flying can interfere with one?s personal and work life, and

it can range from moderate apprehension, to considerable

discomfort, to a disabling phobia.

As flying has become a more frequently integrated part

of our industrialized society, several treatment programs ?

concerning anxiety management approaches, provision of

accurate information regarding airplanes and flying, and

exposure techniques ? have been developed to treat patients

who suffer from fear of flying and are now available to those

who are motivated to overcome their problem. Most of the

treatment protocols usually include exposure in vivo or

in-flight simulators, stress inoculation training, systematic

desensitization, and relaxing training.6

While cognitive behavioral therapy (CBT) is considered

to be the first-line therapy for fear of flying, there are limited

data on whether other psychotherapeutic techniques are also

effective in treating aerophobia. Eye movement desensitiza-

tion and reprocessing (EMDR) is a relatively new technique

of treatment based on the theory that disturbing experiences

are stored in the brain and the associated negative emotions

become trapped in the body, preventing the person from

processing them during periods of rapid eye movement.

EMDR may aid to unlock these thoughts, helping the brain

to process them without experiencing the negativity that was

once associated, therefore reducing anxiety. Specifically,

the therapist helps the person to recall events, images, or

thoughts and gently couples rapid eye movements to each

event by careful observation and then redirects the eye

movements using a stimulant or distraction such as a light,

object, or music.

The effectiveness of CBT for fear of flying has been

scientifically well established,2 whereas the effectiveness

of EMDR in the treatment of a specific phobia has not

been long since investigated.7?9 This method is still lacking

empirical evidence supporting its efficacy with complex

or trauma-related phobias.10?13 Therefore, the application

of EMDR with specific phobias merits further clinical and

research attention.

Virtual reality exposure therapy (VRET14,15) provides

a controlled environment for people who are exposed to

a computer-generated virtual world that simulates a real

experience with the feared object or situation. Some experi-

mental studies to examine the efficacy of VRET have found

encouraging results in treating anxiety disorders and a wide

range of specific phobias,16 including claustrophobia,17

acrophobia,18?20 agoraphobia,21,22 and flying phobia.17,23?25

The aim of the present paper was to compare the effective-

ness of the following treatment methods for fear of flying:

cognitive behavioral therapy integrated with systematic

desensitization (CBT-SD), cognitive behavioral therapy

combined with eye movement desensitization and reprocess-

ing therapy (CBT-EMDR), and cognitive behavioral therapy

combined with virtual reality exposure therapy (CBT-

VRET). Sequence of the design included a pre-treatment

assessment, an intervention phase consisting of 10 weekly

treatment sessions, a post-treatment assessment 1 week after

the last treatment session, and a 1-year follow-up assessment.

It was hypothesized that CBT-SD, CBT-EMDR, and CBT-

VRET would similarly reduce flying anxiety and avoidance

between pre- and post-treatment assessments based on out-

come measures, which included self-report instruments and

flying avoidance. Fear of flying levels were derived from

the participants? mean scores obtained at pre-treatment and

post-treatment assessment phases. It was expected that the

analyses would reveal statistically significant changes in

fear of flying measures with a decreasing trend from pre- to

post-treatment assessments. To reduce measurement error,

self-report measures with adequate psychometric properties

and sensitivity to treatment effects were included.

Methods
Participants
Participants were 65 flight phobics self-referred to the Labora-

tory for Psychosomatic Disorders of the Local Health Trust

of Palermo, asking for a training program aimed to reduce

or eliminate fear of flying. They were 30.8% males and

69.2% females, with a mean age of 43.52 (standard deviation

[SD] =10.42; range =24?70). All participants were involved in
the assessment phase before and after the treatment program.

They were interviewed with the Millon Clinical Multiaxial

Inventory (MCMI-III26,27), conducted by a trained psycholo-

gist and met the Diagnostic and Statistical Manual of Mental

Disorders (DSM-V) criteria for neurotic diseases, phobia,

anxiety, and panic attacks. Exclusion criteria were neuro-

logical disorders, posttraumatic stress disorder or acute stress

disorder not related to fear of flying, severe agoraphobia, and

a comorbid psychiatric diagnosis. Subjects were also excluded

if they had suicidal tendencies or did not want to stabilize their

antidepressant medication during the course of treatment.

The first group received the CBT-SD program. It con-

sisted of 22 patients (36.4% men and 63.6% women), with

a mean age of 43.57 years (SD =10.13; range =29?70).

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They were employers (57.1%), teachers (4.8%), freelancers

(23.7%), pensioners (4.8%), housewives (4.8%), and man-

agers (4.8%). The most frequent marital status was married

(60%), followed by single (30%), single in a committed

relationship (5%), and divorced (5%). Educational level

ranged from lower school certificate (4.8%) to university

graduates (28.6%), with 57.1% high-school graduates and

9.5% postuniversity certificates.

The second group received the CBT-EMDR program.

It consisted of 22 patients (31.8% men and 68.2% women),

with an average age of 41.55 years (SD =10.89; range =24?63).
They were employers (45.5%), teachers (4.5%), freelancers

(18.2%), unemployed people (9.1%), housewives (4.5%),

manager (9.1%), students (4.5%), and entrepreneurs (4.5%).

The most frequent marital status was married (47.6%), fol-

lowed by single (42.9%), single in a committed relationship

(4.8%), and widowed (4.8%). Educational level ranged

from lower school certificate (4.5%) to university graduates

(63.6%), with 31.8% high-school graduates.

The third group received the CBT-VRET program. It con-

sisted of 21 patients (23.8% men and 76.2% women), with an

average age of 45.52 years (SD =10.32; range =27?67). They
were employers (33.3%), teachers (14.3%), freelancers (23.8%),

pensioners (4.8%), housewives (9.5%), manager (9.5%),

and students (4.8%). The most frequent marital status was

married (57.1%), followed by single (28.6%), single in a com-

mitted relationship (4.8%), and divorced (9.5%). Educational

level ranged from high-school graduates (33.3%) to university

graduates (47.6%), with 19% postuniversity certificates.

After complete description of the study to the partici-

pants, written informed consent was obtained. Institutional

review board (IRB) approval was obtained. This research was

approved by the Italian Ministry of Health with registration

n. 311 and protocol n. DGPREV/P/28610 F.3 A.D./317.

Procedure
Prior to enrolling in the study, participants were informed

about the aim of the research, and a strong emphasis was put

on voluntary adherence and data confidentiality. To minimize

the subject characteristics that might differentially affect

treatment effects across individuals, flight phobic patients

were randomly assigned to one of three experimental groups

based on a previously generated random numbers table.

The three treatment programs were carried out in 10 weekly

sessions, each one lasting 2 hours, by an experienced clinical

psychotherapist and two psychologists. All the participants

were treated in small groups during the first three sessions

consisting of 1) psychoeducation, providing information about

anxiety, teaching how to manage anxiety, and enhancing a

differential analysis of fear, phobia, and anxiety; 2) cognitive

and behavioral techniques, introducing both in vivo and ima-

ginal exposure and teaching how to restructure dysfunctional

thoughts; 3) relaxation techniques, teaching how to practice

Schultz?s autogenic training or progressive relaxation; and

4) education about flying, providing data regarding the basic

notions of flight and aviation, including safety issues, objective

risks, turbulence, and accidents. Sessions 4?6 were specific to

each treatment group. From sessions 7?10, the program was

carried out identically for the three treatment groups. After

visiting the air traffic control tower, patients could ask their

questions to both an airline pilot and an air traffic controller.

A demo flight allowed them to go through the different phases

that precede a real flight. A simulated departure in a real air-

plane and a real flight ended the treatment.

instruments
Two inventories were administered to the participants for

assessing several aspects of fear of flying, focusing on feel-

ings, attitudes, and cognitions referring to specific flight-

related events:

1. Flight Anxiety Situations Questionnaire (FAS28)

(32 items), which measures the level of anxiety produced

by specific flying situations. It consists of three subscales:

Generalized Flight Anxiety, referring to anxiety experi-

enced in connection with airplanes in general, regardless

of personal involvement in a flight situation (eg, seeing or

hearing planes or bringing someone to the airport); Antici-

patory Flight Anxiety, pertaining to anxiety experienced

before the time the flight actually starts (eg, planning a

trip, boarding the plane); and In-Flight Anxiety, concern-

ing anxiety experienced during a flight, from takeoff until

landing (eg, different situations in flight). Respondents are

asked to circle the number corresponding to their level of

anxiety in the situations mentioned, using a scale from 1

(no anxiety) to 5 (overwhelming anxiety).

2. Flight Anxiety Modality Questionnaire (FAM28), which

focuses on symptom expressions, such as physiological

responses of anxiety and thoughts related to the danger

of flying. The FAM consists of 18 items structured into

two subscales: Somatic Modality, referring to physical

symptoms, and Cognitive Modality, pertaining to the

presence of distressing cognitions. Here the respondents

are asked to rate the degree to which each item accurately

describes the intensity of their own reaction using a scale

from 1 (not at all) to 5 (very intensely).

Both FAS and FAM revealed good psychometric proper-

ties and cover distinct reactions to aerophobia, in terms of

behavior, physiology, and cognitions. Besides, FAS allows

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assessing one?s responses at various stages of a flight, from the

preliminary phase to the actual flight. Therefore, the admin-

istered instruments seem helpful in obtaining a thorough and

accurate assessment of the most relevant phobic stimuli. Based

on their sensitivity to change, they appear suitable to evaluate

treatment outcomes on flight anxiety. In particular, both FAS

and FAM may be supportive in measuring differential treat-

ment effects on specific aspects of fear of flying.29,30

Design
An experimental group design was applied with measure-

ments at three stages: pre-treatment, post-treatment, and at

a follow-up of 1 year postflight. The first group received

the CBT-SD treatment, the second group received the

CBT-EMDR treatment, and the third group received the

CBT-VRET treatment. As dependent variables, data were

collected regarding 1) flight anxiety situations, in terms of

generalized flight anxiety, anticipatory flight anxiety, and

in-flight anxiety and 2) flight anxiety modality, in terms of

somatic modality and cognitive modality.

We analyzed differences both in pre- and post-treatment

measures and in pre- and follow-up measures on the FAS and

FAM with paired t-tests to evaluate the degree of change.

Besides, as a measure of effect size, we calculated Cohen?s d

coefficients within groups. For the purpose of interpretation,

according to Cohen?s conventional criteria, d=0.20 is consid-
ered to be a slight effect, d=0.50 is considered to be a moder-
ate effect, and d=0.80 is considered to be a substantial effect.
An analysis of means comparison, computed with a one-way

analysis of variance (ANOVA), was performed to determine

whether there was any evidence that the average scores of the

three groups were different at the pre-test. A comparison of

both the post-treatment and follow-up scores between groups

was also conducted via one-way ANOVA.

Results
Based on paired t-test results, both FAS and FAM subscales

seemed to be sensitive to the CBT-SD treatment intervention.

On all scales, the difference between pre- and post-treatment

scores revealed a high effect size (Cohen?s d ranged from

1.32 to 2.23) (Table 1).

As shown in Table 2, both FAS and FAM scales seemed

to be sensitive to the CBT-EMDR treatment intervention.

The difference between pre- and post-treatment scores

reported a very high effect size for all self-report instruments?

subscales (Cohen?s d ranged from 1.23 to 2.67).

Table 1 average scores on the FaM and Fas subscales at cBT-sD pre- and post-treatment and 1-year follow-up

Measures Pre-treatment,
M (SD)

Post-treatment,
M (SD)

Follow-up,
M (SD)

Pre?post Pre?follow-up

t-value Cohen?s d t-value Cohen?s d

Fas gFa 15.45 (6.16) 9.14 (2.73) 8.86 (5.18) 4.81*** 1.32 5.12*** 1.16
Fas aFa 47.45 (8.46) 26.59 (12.53) 25.19 (15.31) 8.57*** 1.95 6.92*** 1.80
Fas i-Fa 48.68 (9.85) 26.86 (10.75) 27.71 (15.82) 9.60*** 2.12 6.57*** 1.59
Fas Ts 111.59 (20.40) 62.59 (23.48) 61.76 (34.49) 9.78*** 2.23 7.00*** 1.76
FaM sM 27.86 (9.74) 15.32 (7.39) 16.57 (9.56) 5.93*** 1.45 4.42*** 1.17
FaM cM 24.86 (7.09) 14.00 (6.31) 14.67 (8.07) 7.35*** 1.62 5.57*** 1.34
FaM Ts 52.73 (14.04) 29.32 (13.22) 31.24 (16.69) 7.22*** 1.72 5.40*** 1.39

Note: ***P,0.001.
Abbreviations: FaM, Flight anxiety Modality; Fas, Flight anxiety situations; cBT-sD, cognitive behavioral therapy integrated with systematic desensitization; M, mean;
sD, standard deviation; gFa, generalized Flight anxiety; aFa, anticipatory Flight anxiety; i-Fa, in-Flight anxiety; sM, somatic Modality; cM, cognitive Modality; Ts, total
score.

Table 2 average scores on the FaM and Fas subscales at cBT-eMDr pre- and post-treatment and 1-year follow-up

Measures Pre-treatment,
M (SD)

Post-treatment,
M (SD)

Follow-up,
M (SD)

Pre?post Pre?follow-up

t-value Cohen?s d t-value Cohen?s d

Fas gFa 12.86 (4.44) 8.23 (1.86) 8.27 (2.47) 4.48*** 1.36 4.02** 1.28
Fas aFa 44.27 (8.58) 23.86 (8.03) 25.59 (8.91) 10.22*** 2.46 9.09*** 2.14
Fas i-Fa 49.09 (8.90) 26.91 (10.67) 24.36 (9.77) 10.19*** 2.26 11.72*** 2.64
Fas Ts 106.23 (17.55) 59.00 (17.78) 58.23 (17.73) 11.40*** 2.67 11.52*** 2.72
FaM sM 25.18 (8.56) 15.50 (7.12) 13.64 (2.77) 6.34*** 1.23 6.12*** 1.81
FaM cM 25.55 (6.46) 13.68 (6.14) 13.82 (4.95) 9.14*** 1.88 7.48*** 2.04
FaM Ts 50.73 (10.77) 29.18 (10.90) 27.45 (5.85) 8.92*** 1.99 8.05*** 2.68

Notes: **P,0.01; ***P,0.001.
Abbreviations: FaM, Flight anxiety Modality; Fas, Flight anxiety situations; cBT-eMDr, cognitive behavioral therapy combined with eye movement desensitization and
reprocessing therapy; M, mean; sD, standard deviation; gFa, generalized Flight anxiety; aFa, anticipatory Flight anxiety; i-Fa, in-Flight anxiety; sM, somatic Modality;
cM, cognitive Modality; Ts, total score.

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The treatment of flight anxiety: a randomized trial

Table 3 average scores on the FaM and Fas subscales at cBT-VreT pre- and post-treatment and 1-year follow-up

Measures Pre-treatment,
M (SD)

Post-treatment,
M (SD)

Follow-up,
M (SD)

Pre?post Pre?follow-up
t-value Cohen?s d t-value Cohen?s d

Fas gFa 15.67 (6.81) 9.57 (3.79) 10.45 (5.39) 4.53*** 1.11 2.84* 0.85
Fas aFa 45.29 (6.93) 24.71 (10.55) 26.30 (10.06) 9.82*** 2.31 5.73*** 2.20
Fas i-Fa 50.19 (9.04) 29.86 (14.36) 27.70 (11.35) 6.86*** 1.69 6.66*** 2.19
Fas Ts 111.14 (18.57) 64.14 (27.57) 64.45 (24.33) 8.58*** 2.00 6.09*** 2.16
FaM sM 27.00 (9.60) 15.38 (4.81) 15.10 (5.35) 6.92*** 1.53 4.72*** 1.53
FaM cM 27.38 (4.53) 14.86 (5.27) 14.15 (5.58) 11.03*** 2.55 8.11*** 2.60
FaM Ts 54.38 (12.09) 30.24 (9.53) 29.25 (10.49) 10.84*** 2.22 6.88*** 2.22

Notes: *P,0.05; ***P,0.001.
Abbreviations: FaM, Flight anxiety Modality; Fas, Flight anxiety situations; cBT-VreT, cognitive behavioral therapy combined with virtual reality exposure therapy;
M, mean; sD, standard deviation; gFa, generalized Flight anxiety; aFa, anticipatory Flight anxiety; i-Fa, in-Flight anxiety; sM, somatic Modality; cM, cognitive Modality;
Ts, total score.

Figure 1 average scores on the FaM and Fas subscales at cBT-sD, cBT-eMDr, and cBT-VreT pre-treatment.
Abbreviations: FaM, Flight anxiety Modality; Fas, Flight anxiety situations; cBT-sD, cognitive behavioral therapy integrated with systematic desensitization; cBT-eMDr,
cognitive behavioral therapy combined with eye movement desensitization and reprocessing therapy; cBT-VreT, cognitive behavioral therapy combined with virtual reality
exposure therapy; gFa, generalized Flight anxiety; aFa, anticipatory Flight anxiety; i-Fa, in-Flight anxiety; sM, somatic Modality; cM, cognitive Modality; Ts, total score.

As shown in Table 3, both FAS and FAM scales seemed to

be sensitive to the CBT-VRET treatment intervention. On all

subscales, the difference between pre- and post-treatment scores

showed a very high effect size (Cohen?s d ranged from 1.11 to

2.55). Composite scores for each measure were computed by

summing the responses of subset of the subscales? items. The

min?max possible values for each composite score is 6?30

(FAS Generalized Flight Anxiety), 11?55 (FAS Anticipatory

Flight Anxiety), 12?60 (FAS In-Flight Anxiety), 29?145 (FAS

Total score), 10?50 (FAM Somatic Modality), 7?35 (FAM

Cognitive Modality), and 17?85 (FAM Total score).

A one-way ANOVA was performed to contrast

pre-treatment measures between the three experimental

groups. No mean differences were found between CBT-SD,

CBT-EMDR, and CBT-VRET groups, indicating that the

three groups did not differ previously to the intervention:

FAS Generalized Flight Anxiety (F=1.54; P=0.223), FAS
Anticipatory Flight Anxiety (F=0.90; P=0.413), FAS In-
Flight Anxiety (F=0.15; P=0.860), FAS Total score (F=0.54;

P=0.584), FAM Somatic Modality (F=0.48; P=0.624), FAM
Cognitive Modality (F=0.96; P=0.389), and FAM Total
score (F=0.47; P=0.627). Average scores on the FAM and
FAS subscales at CBT-SD, CBT-EMDR, and CBT-VRET

pre-treatment are reported in Figure 1.

Based on our findings, CBT-SD, CBT-EMDR, and CBT-

VRET treatments seemed to be effective in reducing fear of

flying without statistical significant differences. No mean

differences were found between the three groups after treat-

ment: FAS Generalized Flight Anxiety (F=1.22; P=0.303),
FAS Anticipatory Flight Anxiety (F=0.39; P=0.682), FAS In-
Flight Anxiety (F=0.44; P=0.649), FAS Total score (F=0.28;
P=0.757), FAM Somatic Modality (F=0.00; P=0.996), FAM
Cognitive Modality (F=0.22; P=0.800), and FAM Total
score (F=0.06; P=0.947). Average scores on the FAM and
FAS subscales at CBT-SD, CBT-EMDR, and CBT-VRET

post-treatment are presented in Figure 2.

Similarly, no mean differences were found between

the three groups at the follow-up: FAS Generalized Flight

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