Introduction
The behaviour of an air traveler depends on several factors. The healthy passenger is usually not much affected except for an occasional ear or sinus pain. (Lucas and Goodwin). However a person who takes medicines routinely may be upset by the break of his routine meal time as in diabetes mellitus. The features of his hypoglycemia may be mistaken for aggression, intoxication and or even an exhibition of psychiatric illness. Hypoglycemia is a situation where the passenger behaves in an altered manner due to the feeling of hunger associated with sweating and a fast heart rate makes him tense and worried. His behaviour is influenced by the biochemical changes occurring in his body. The onlooker gets a wrong impression of the situation. The health components, both the physical and mental, are further affected by the passenger’s personality. The air crew is a group of people who are trained in human factors but sometimes an upset passenger could relay the same feelings in the crew handling him as they are also human. The stress shows on the crew if a passenger is aggressive or demanding. (Lucas and Goodwin). Safety being the main function of the crew, they are to pacify the hassled person as cordially as possible without worsening the scenario, creating as much harmony as they can. Delay in resolution may cause confusion in the closed space of the airplane. Passengers expect some justice to the services advertised by the airlines. If they feel a little cheated of expectations, the crew has to make amends. The crew is as human as any passenger and their bodies and mental functions can undergo similar changes. Their bodily reactions may be worse in that their working and sleeping hours keep changing and they pass through different time zones. Flight times are lengthening and the risk of problems is more. However review by Bor has indicated that the incidence of air rage is actually decreasing (2003).
Air rage
Air rage is the resentment and anger that a person feels in a closed or confined space, being too close to people all around with no way of escape or even for avoiding them. Anger in any other situation is limited in that there is possibility of escape and alcohol abuse is rarer. Physiological factors are believed to incite it. The feeling of threat could cause the person to shout and become aggressive in nature. What started off as verbal abuse could go on to physical violence. (Lucas and Goodwin).
Air rage can evolve into a dramatic emergency if not controlled. The passengers and crew close to the troublesome person will be in immediate danger of being hurt. Even the aeroplane’s safety is compromised. Statistics show that of 1375 consultations to MedAire, 3.5% were for psychiatric problems. (Matsumoto and Goebert, 2001) 90 % were anxiety cases and 69% needed assessment on arrival. Three cases had to be immediately hospitalized by diverting the plane. The necessity for rapid onset anxiolytics was understood and added to the medical kits. Surprisingly no air rage was identified. Another study in the same direction indicated 15% psychiatric cases and 75% of the cases studied were from the economy class. (Rayman, 1998).
The trigger
The commonest cause which triggers an episode of air rage is the influence of alcohol. There would be early features of abnormal behaviour prior to the crisis. These would be missed by the busy crew. However the best attitude would be to be as sympathetic as possible and adopting the non confrontational approach. The patient behaviour must be sustained in the normal bracket as far as is possible. Disruptive behaviour is an expected problem which must be handled in a practical manner and ends with composure all around. (Lucas and Goodwin).
The causes
Alcohol abuse, psychiatric instability and environmental stress are the identifiable causes (Anglin, 2003).The disruptive behaviours seen in passengers is an area not much explored in research.
Stress, anxiety, depression in the fear of stigmatization and licensing issues are the issues faced by flight crew. (Lucas and Goodwin). Cabin crew has been known to develop acute stress reactions and post-traumatic stress disorder if abused in any manner. Turbulence and unusual noises disturb them as much as they do the passengers. Aviaphobia is a recognized entity. The crew involved need reassurance and support as much as the passengers.
Personality is one criterion which determines how a person will respond to a problem issue, how he interacts and then how he reflects on it. The stowing of hand baggage is one situation where passengers are selfish and do it as they please. Offence can be taken regarding the weight, quantity, bulk or the way it is kept. The influence of alcohol can fuel the situation and the whole thing erupts into a noisy scene with anger writ over the passenger’s face. It would take some effort to calm the passenger and bring things to normal. The other passengers may be upset and even think of terrorism or hijacking. Should the news reach the media, it would be blown out of proportion.
Common psychiatric problems of neurosis are causes which disrupt the duty of crew members. They range from anxiety, depression and somatisation to hypochondriacal and obsessional states. (Lucas and Goodwin). Demanding behaviour would be the presentation. Aviaphobia or fear of flying has to be included here. More serious illnesses like schizophrenia and manic depression are not usually seen in the flight. Delusions and hallucinations occur at times. Physical illness is equally stressful. A newcomer may experience pre-flight and in-flight stressors. Some amount of unsure decisions and uncertainty prevails. Physical ill health can affect mental health. The elderly passengers may have some confusion due to hypoxia. Supplemental oxygen would do a world of good psychologically and physiologically. (Lucas and Goodwin). Limited facilities for frequent visits to the toilet for passengers who have prostatitis or menorrhagia or irritable bowel syndrome could affect them. Cardiac patients or passengers prone to cerebrovascular illness or having diabetes have problems while in the air leading to air rage. Muscular pain, arthritic pain, feeling trapped because of immobility could be some of the situations which provoke a passenger into rage. A ear problem or a skin condition could also do the same. A hearing aid could perform badly due to plenty of background noise. Psychological and physiological risk factors include anxiety, panic, claustrophobia, proximity to strangers, disputes, lack of exercise, tight clothing and dehydration apart from the others mentioned above. (Lucas and Goodwin).
The usual routine of seat belt demonstration, safety demonstration, restricted space availability, noises of taking off and landing, air turbulence, restriction of seat belts, long waits at the toilet and disturbing incidents are situations which could trigger people into air rage. The fear of hijacking since the September 11 incidents is deeply embedded in everyone’s minds. (Lucas and Goodwin). The fear may make men react with rage rather than behave timidly like women. Admitting to the fear maybe degrading to them.
Low level anti-social behaviour can boil up to air rage if necessary measures are not taken to check it. This cause must be recognized early as is done in UK aircraft. (Bor, 2003) Though the attitude in UK aircraft causes stress to passengers and crew alike, the risk of air rage is diminished and aircraft safety is maintained.
Publicity crazy personalities of the film world or sports world have a tendency to attract attention through pretensions of air rage. Such behaviour should be countered immediately without any bias. Smoking or drunkenness can be proceeded against under the Public Order Act of 1986. (Lucas and Goodwin).
Alcohol has been found to contribute to 58.25% of air rage. (Fine, 2002). About 20% has been related to smoking. Arguments with an attitude with flight attendants constituted 15.05% while drug-related incidents came to 2.4%. Psychiatric morbidity also has been mentioned.
Other factors which are part of air travel but could possibly contribute to air rage are long queues, flight delays, lack of information, hand baggage, seating disputes and unsatisfactory food. (Lucas and Goodwin).
Prevention
Prior to departure passengers are to report any significant illness to the airlines. Completion of a “MEDIF” form may be requested by the airlines medical adviser and it is to be obtained from the family doctor or specialist. Psychiatric illness is usually hidden from the airlines. Ground staff has the duty of observation of passengers and of reporting if they see any abnormal behaviour. If psychiatric illness is declared, mental assessment is made to rule out the risk of adverse behaviour during flight. If the patient is in a stable condition, he is allowed to travel. (Lucas and Goodwin). Details of medication must be carried in the hand baggage of the passenger. On arrival this person would be transferred as planned earlier with sufficient escort. Administration of diazepam 1.5 mg. is effective during the flight. It is given in the presence of a friend or family and the passenger is observed during the flight.
A passenger who is already under the influence of alcohol may be either disembarked and proceeded against or prevented from more alcohol during the flight. Air rage is thereby preventable. Other responsible passengers would be reassured (Anglin, 2003). People who are known to have uncontrollable anger or violence are to have anger management and social skills training to behave without aggression. This is difficult to implement.
Travel fatigue occurs due to physical stress and physiological stress due to the flight itself and the resetting of the biological clock. (Waterhouse, Reilly & Edwards, 2004). Caffeine should be discouraged on the flight as it causes stimulation, diuresis and dehydration. Sleep would be disturbed. Rehydration, in-flight exercise, avoiding heavy meals and alcohol abstention during the flight must be advised.
Clear communication and reassurances on the part of the captain explaining reasons for delay in take-off or in-flight changes or noises could calm worried passengers. (Lucas and Goodwin).
Management
The hazards of disruptive behaviour must be remembered. Appropriate management would prevent safety hazards. Psychiatric illness should be diagnosed only after ruling out cardiac illness, alcohol intoxication, drug-induced illness or any organic illness which has not been informed. (Lucas and Goodwin).
Psychiatric patients can be calmed with reassuring tones. These emergencies are rare. If the passenger is disturbed or disruptive or violent, isolating him in one area may help. (Lucas and Goodwin). Reassurances are continuously given and behavioural strategies are tried. A ground physician may be informed. If the patient shows no response, intramuscular diazepam may help. It may be administered by a health personnel. This medicine is found in the kit available.
Acute stress reaction is what the crew can suffer from due to the stress of work. Individual or group de-briefing is advised for crew and passengers. It is relieved in a few days. (Lucas and Goodwin). Emotional support must be provided to these people so that they understand that someone is caring for them. Mood and behaviour must not be further disrupted with alcohol or drugs. These in-flight traumas can recur while in flight. The persons must be observed well.
Post-traumatic stress disorders occur when persons experience near-death situations. Cabin crew is exposed to terrorism which is a global problem. The stress can present as PTSD. Personality traits, previous psychiatric illness, accidents or childhood abuse are considered as predisposing factors. Trauma-focused cognitive behavioural therapy and eye movement desensitization and reprocessing are first line treatments for PTSD (National Institute for Health and Clinical Excellence).
References
Anglin, L., Neves, P., Giesbrecht, N. & Kobal-Mathews, M.J. (2003). Alcohol-related rage: From damage control to primary prevention. Journal of Primary Prevention, Vol. 23, No. 3. p. 283-299
Bor, R. (2003). Trends in disruptive passenger behaviour on board UK registered aircraft 1999-2003 Travel Medicine and Infectious Diseases. Vol. 1, p. 153-157
Fine,E.W. (2002). Air rage: implications for forensic psychiatry American Journal of Forensic Psychiatry Vol. 23, No. 1. p. 29-44
Lucas and Goodwin, Matsumoto & Goebert, (2001).
National Institute of Health and Clinical Excellence (2005). Post-traumatic stress disorder: The management of PTSD in adults and children in primary and secondary care. London, Department of Health
Waterhouse, Reilly & Edwards (2004).