Can diazepam (benzodiazepine) be used to treat specific phobia of flight?

Use of Diazepam for Specific Phobia of Flight

Diazepam can be used for acute management of flight anxiety, but should not be considered a first-line or long-term treatment for specific phobia of flight due to potential interference with exposure therapy and risk of dependence. 1

Diagnosis and Classification

Specific phobia of flight is characterized by:

• Marked and intense fear triggered by flying or anticipation of flying
• Immediate fear response upon exposure to flying situations
• Recognition that the fear is excessive (may be absent in children)
• Active avoidance of flying or endurance with intense fear
• Significant interference with normal routine or quality of life 2

Treatment Approach

First-Line Treatment: Cognitive Behavioral Therapy (CBT)

CBT is the gold standard treatment for specific phobia of flight with strong evidence of effectiveness 1:

• Cognitive restructuring to address catastrophic thoughts about flying
• Gradual exposure to feared flying situations
• Relaxation techniques to manage physiological symptoms

Role of Pharmacotherapy

Short-Term Benzodiazepines (including Diazepam)

Benzodiazepines like diazepam may be considered in specific circumstances:

• For acute management of severe anxiety during unavoidable flights
• When patients are non-adherent or resistant to exposure-based therapies
• When exposure therapy is not accessible 1, 3

Important Limitations of Diazepam Use

1. Interference with Exposure Therapy: Research shows benzodiazepines may actually hinder the therapeutic effects of exposure:

   • While alprazolam (another benzodiazepine) reduced anxiety during initial exposure, it led to increased anxiety and panic attacks during subsequent exposures 4
   • This suggests benzodiazepines may interfere with fear extinction learning

2. Short-Term Effects Only: Benzodiazepines provide only short-term reduction of subjective fear during exposure to the feared situation 3

3. Risk of Dependence: Regular use carries risk of tolerance and dependence

Alternative Pharmacological Options

For patients requiring medication:

• SSRIs: May be more appropriate for long-term management, especially with comorbid depression 1, 5
• Beta-blockers: Have shown mixed results for specific phobias 3
• Cognitive enhancers (D-cycloserine, glucocorticoids): May enhance exposure therapy effectiveness 3

Clinical Decision-Making Algorithm

1. Assess severity and impact on functioning and quality of life
2. Offer CBT as first-line treatment
3. Consider pharmacotherapy only if:
   • Patient refuses or cannot access CBT
   • Symptoms are severe and immediate relief is needed
   • Comorbid conditions warrant medication
4. If medication is needed:
   • For acute, one-time use: Diazepam may be appropriate
   • For ongoing treatment: Consider SSRIs rather than benzodiazepines
   • Always combine with psychological strategies when possible

Conclusion

While diazepam can provide short-term relief for flight anxiety, its use should be limited and cautious due to potential interference with exposure therapy effectiveness and risk of dependence. CBT remains the treatment of choice for specific phobia of flight, with long-term medications like SSRIs being preferable when pharmacotherapy is necessary.