Best Therapy for Fear of Flying
For a patient with fear of flying, lorazepam 0.5-1mg taken 30-60 minutes before boarding is the recommended first-line pharmacological treatment, combined with non-pharmacological strategies including booking direct flights, requesting aisle seats, and ensuring adequate hydration while avoiding alcohol. 1
Pharmacological Management
First-Line Medication
- Lorazepam is the preferred benzodiazepine at doses of 0.5-1mg for situational flight anxiety, with administration timing 30-60 minutes before boarding for short flights 1
- For elderly patients, reduce the dose to 0.25-0.5mg (maximum 2mg in 24 hours) 1
Critical Medication Cautions
- Avoid alprazolam for flight phobia - research demonstrates that alprazolam paradoxically increases physiological activation (heart rate increased to 114 vs 105 bpm with placebo) and significantly worsens anxiety on subsequent flights (71% panic attacks vs 7% with placebo), actively hindering therapeutic exposure effects 2
- This finding is particularly important as it contradicts the common practice of prescribing alprazolam for situational anxiety 2
Alternative Considerations
- Fluoxetine may resolve fear of flying when treating comorbid depression, though this requires weeks of treatment and is not suitable for acute situational use 3
Essential Non-Pharmacological Interventions
Pre-Flight Planning
- Book flights in late morning or early afternoon to minimize disruption to daily routines 1
- Request direct flights to reduce travel stress and complexity 1
- Secure aisle seats for easier movement and reduced claustrophobia 1
- Consider proximity to lavatories for accessibility 1
During Flight
- Maintain appropriate hydration but avoid excessive caffeine consumption which may worsen anxiety 1
- Strictly avoid alcohol before and during the flight as it interacts with anxiety medications and worsens cognitive function 1, 4
- Use earplugs or eye masks to reduce sensory stimulation 1
Important Contraindications and Warnings
Absolute Alcohol Prohibition
- Alcohol consumption must be avoided as it potentiates benzodiazepine effects and can trigger anxiety, disinhibition, or acute confusional states 4
When to Consider Medical Clearance
- If the patient has other medical conditions that may be affected by flight environment (hypoxia, immobility, dehydration), consider airline medical clearance 1
Common Clinical Pitfalls
Medication Selection Errors
- Do not prescribe alprazolam - despite its popularity for anxiety, it demonstrably worsens flight phobia outcomes and increases panic attacks on subsequent exposures 2
- Avoid combining benzodiazepines with alcohol, which patients may be tempted to use for additional anxiolysis 1, 4
Timing Errors
- Ensure medication is taken with sufficient lead time (30-60 minutes) before boarding, not at the gate or on the aircraft 1
Long-Term Considerations
- For patients requiring frequent air travel, consider referral for cognitive behavioral therapy or virtual reality exposure therapy, as these provide durable benefits without medication dependence 5, 6
- Fear of flying is heterogeneous and acquired through complex psychological, social, and physiological factors unique to each individual, suggesting that comprehensive functional assessment may benefit patients with severe or treatment-resistant phobia 6