COMMON QUESTIONS
Travel Phobias
fuin B. Mclntosh
Do Phobic Disorders Interfere with a Person's Ability
affected by specific phobias, social phobias, agoraphobia,
and panic disorder. Specific phobias usually relate to one
particular situation or object and are often the easiest to
treat. Social phobias are intense, irrational, and accompanied by persistent fears of being scrutinized and evaluated by others, with the patient anticipating either
humiliation or ridicule.The fear results in avoidance of
a range ofsocial situations such as eating in public. Social
phobias show much comorbidity with agoraphobia and
panic disorder and depression.
to Travel?
A phobia is a morbid fear that is disproportionate to
the causative stimulus and is out of proportion to the situation or trigger. It is involuntary,cannot be explained away,
and can lead to an incapacitating avoidance. Many travelers admit to disabling fears and panic responses to travel
situations. A considerable number of the public, who
never travel overseas, have intense fear of transportation by
sea and air or other travel-related conditions. Business
people can develop a fear of flying,be inhibited fiom making air journeys, and consequently can put their jobs in
jeopardy. In these days of global travel, relatives on opposite sides of the globe are often constrained b m organizing
family reunions,not for lack of finance,but because a member of the f d y group is afraid to undertake a journey
by air.These crippling fear reactions interfere with lifestyle,
and when severe, fall within the criteria defining travelrelated phobias.The Diagnostic and Statistical Manual of
Mental Disorders (DSM) IV classification of anxiety disorders includes panic disorder with or without agoraphobia,
agoraphobia without panic disorder, specific phobia, social
phobia, and generalized anxiety disorder.
Do Phobias Show Age or Sex Differences in
Presentation?
There is a marked difference between the sexes, with
the majority of phobics reported to be women, although
this may be a reflection of women being more willing
to report on being fearful. A preponderance of women
report severe anxiety in relation to travel-related stressors compared to men, with the ratio, however, reversed
in those with intense fear of needle injections. In one
study, anxieties about flying were reported by five times
as many women travelers as men. Aerophobia was found
to be twice as frequently reported in those who had not
traveled abroad in the previous year as in those who had
traveled overseas in that time. Phobias for travel-related
situations may play a dominant part in disinclining people to undertake world travel.
Are Travel Phobias Common?
The incidence of phobias in the population is not
definitely known; travel phobias have been poorly
researched. Community surveys have suggested that
5-10% of people over 65 years of age suffer from phobia, and the figure of 3% is suggested for the general population. The one year prevalence of social phobias in a
cohort 15-54 years old, in a recent US. study,was stated
as almost 5%, and the lifetime risk per individual was as
high as 13%.Travel phobias are not therefore uncommon
mental conditions. Individual freedom to travel can be
Are There Many Travel-Related Phobias?
People adnut to a wide range of intense fears in regard
to world trave1,Transportation fears are very common (e.g.,
fear of flying,traveling by boat, using public transport, and
traveling through tunnels). Fears of heights, enclosed
spaces, being locked-in, insects, animals, and needles are
common.Airports and bus and train stations are crowded,
creating fear-provoking situations for some people with
agoraphobia, who may also be fearful of conversing with
strangers or of the unknown features inherent in world
travel. Others with social phobias will find eating in public places and use of public toilets frightening. Many are
very fearful of becoming ill abroad. One of my older
patients was married to a merchant sailor, and the couple long discussed her visiting some of the places to
lain B. Mclntosh, BA (Hons), MBChB, DGMRCe DRCOG:
General Practitioner and Hospital Practitioner, Stirling and
Stirling Royal Infirmary, Stirling, Scotland.
Reprint requests: Dr. I. 6. Mclntosh, 11 Shirra's Brae, St.
Ninians, Stirling FK7 OAV, Scotland
( J Travel Med 2:99-100, 19951
99
100
which he had been in the past.The possibility remained
a pipe-dream, however, for she had a marked claustrophobia and several features of social phobia. She could not
use a small place like the toilet unless the door was slightly
ajar, and the husband was on guard outside. Eating a
meal in public view was a terrifying prospect for her. A
considerable number of the population find some element
of international travel fearsome and intimidating.
Do Many People Suffer From the Fear of Flying?
Many people fear transport by air.The incidence is
not known for certain, but in one large study, 24% of
people over 16 years old reported anxieties about flying,
17%reported moderate fear, and 11%had phobic anxiety.The ratio of flight phobias between those who had
traveled abroad in the previous year to those who had
not was 1:4, and women were twice as likely to admit
to phobia than men. Fear of flying may be a major reason for people not to travel abroad, if the only means to
do so is by air travel. In many instances, those questioned
adrmtted that their fear had interfered with work, affected
their quality of life, and had caused strife within the family. O n e businessman lost his job after developing a
severe phobia for airplane travel. H e had resorted to
travel by car, thereby spending most of his time traveling. He thus became an ineffective manager.
What Means Are There for Treating Travel Phobias?
Behavioral therapy is the treatment of choice. It
can be time consuming, and intending travelers must present early, as many sessions are sometimes required in treatment. Some form of graded systemic desensitization is
usually used, with a hierarchy based on the perceived fearful elements in the phobic scene. In specific and social
phobias, psychologists often find a flooding technique can
be used, which brings quick cure in some cases. Some
of the airlines offer courses based on desensitization and
ultimate test exposure in a flight around the airport.
Hypnotherapy can be very successful, especially in
people who present within a few days of impending
flight. Hypnotherapy incorporates trance induction,
ego-strengthening, relaxation, desensitization, and autohypnosis in a therapeutic program.
Drug therapy with anxiolytics is still offered by
some doctors to phobic patients.These medications are
best avoided or given briefly to support a passenger
unable to face a flight due to depart shortly.
Are Drugs the Treatment of Choice for Travel
Phobias?
Drug medication is not the best means of treating
phobias with the exception of the use of an antidepressant where the phobia is a symptom and part of clinical
J o u r n a l o f Travel M e d i c i n e , V o l u m e 2 , N u m b e r 2
depression.The phobia will often disappear, as the depression lifts. Anxiolytics are often used to treat the generalized anxiety associated with the phobic state, but they
treat the symptom of the disorder and do not bring
cure. Behavior therapy is the preferred means of treatment and has a good success rate. Occasional use of
diazepam is justified to help situational anxiety in people like air travelers who have barely managed to cope
with the outgoing flight, but cannot face up to the
return. One has to keep in mind that many aerophobic
travelers try to contain their fears by drinking alcohol
before and during the flight, which may compound the
effects of the drug.
What Are the Main Components of the Phobic
Status?
There is the cognitive element, where the person is
subjectively afiaid and presents with generahzed anxiety
and increased arousal or with situational anxiety. The
behavioral response results in avoidance of the feared situation. Physiologic manifestations include tachycardia,
hyperventilation, tremor, increased sweating, and stomach
butterflies. The latter are sympathomimetic responses to
the feared situation,the fight or flight response. Finally,there
is the social element which often disrupts ability to travel.
Is Hypnotherapy of Value in Treating Travel Phobias?
The use of hypnosis in treatment can expedite cure.
A medical hypnotherapist often succeeds in helping
patient’s to manage or rid themselves of the phobia
within a few sessions. If modified flooding techniques are
used, therapy can often be successful with one or two
treatment contacts. In a survey of patients attending a
medical hypnotist for treatment, 25% were being treated
for phobias. Half of these patients had their phobic
symptoms completely removed, and most of the others
had their symptoms moderately or markedly improved.
What Part Does the Travel Health Clinic Play
Regarding Travel Phobias?
Staffin the travel health clinic are well placed to idenpeople with phobias.These are often not fieely admitted and may require direct questioning to elicit.The use
of a general health questionnaire incorporating questions
about travel fears and their intensity is useful in this respect.
Problem areas can be defined and general counseling
offered. This may include suggestions toward appropriate therapy and a list of local professionals working in this
field. Some people will resist treatment and efforts should
be made to discourage them from avoiding behavior
which will merely reinforce the phobia.With good support, most will be able to fight their phobia and recondition themselves to global travel without internal disquiet.