Station 85
James Nolan
Age: 40 year old male
Full Case
Patient’s Data
Patient’s name: James Nolan
Age: 40-year-old male
Past medical history:
- Newly registered at the practice 2 months ago
- None recorded
Drug and Allergy History
- Not currently on any medication
- No Known Drug Allergy
Recent notes/ consultation
- No significant recent consultations
Patient booked an urgent telephone appointment to discuss some concerns.
Patient's Story (Role player’s brief)
Patient’s Story
You are James Nolan, a 40-year-old male.
Opening Statement: Hi doctor, I do not want to take up your time, I just need some diazepam for my flight anxiety, if that is okay. I have one tablet left and I am due to run out. I have a couple of flights ahead and would need some more, please.
You are calling today because you’re due to fly back to the UK from the Netherlands tomorrow, and you’re very anxious about the flight. You have a long-standing fear of flying, and in the past, you’ve taken diazepam before flying, which helped you stay calm during the journey. This was prescribed by your previous GP.
You have one tablet left, which you’re planning to use for the flight home tomorrow. However, you also have an upcoming long-haul flight to the United States in five days, and you’re calling to request a prescription for diazepam to help manage your anxiety for that flight.
You are currently in the Netherlands for work and will be returning to the UK tomorrow.
Your fear of flying began after experiencing severe turbulence during a flight to Singapore five years ago . During any flights take-off phase, landing phase or when there is turbulence, you start to feel very panicky. Your heart races, you begin to sweat, and you often notice a tingling sensation in your lips and fingers.
You haven’t been formally diagnosed with anxiety, and you’ve never had therapy or counselling. You’ve tried breathing exercises and listening to calming music on flights, but they don’t help much.
Social History: You don’t smoke or drink, and you’re not on any regular medication. You’ve never had any problems with addiction or misusing medications. You work as an IT consultant. You’re currently abroad for a short-term work trip and live in the UK with your wife.
Ideas: You believe diazepam helps you fly safely and manage your anxiety. You consider it the only effective solution for your flight-related symptoms.
Concerns: You are worried that you will panic during the long-haul flight to the US and will be unable to cope without diazepam.
Expectations: You would like the doctor to prescribe 2–3 tablets of diazepam (5 mg) for your upcoming flight to the United States. You plan for your wife to collect the medication and bring it to the airport.
Say NO to any other questions asked outside of the details already provided in the scenario. Accept anything offered to you by the doctor.
Marking Scheme
Data Gathering and Diagnosis
- Ask about the onset of flying anxiety, when it started, and whether anything specific triggered it.
- Ask what typically happens during flights (e.g. panic attacks, inability to board, physical symptoms).
- Ask if the patient experiences anxiety in other situations apart from flying.
- Ask how long he has been using diazepam and where he usually obtains the prescription.
- Ask about mood, sleep, and appetite.
- Ask about any history of substance misuse, alcohol intake, and smoking.
- Ask about his occupation.
- Clarify current location, return flight date, and detail of the upcoming flight.
- Ask if he has tried or considered non-drug approaches such as CBT, breathing techniques, or exposure therapy.
- Ask about his ideas, concerns, and expectations.
- Give a working diagnosis of flight anxiety.
Example of explanation to patient
Thank you for sharing this with me, James. I can hear how difficult flying has been for you and how much you rely on diazepam to manage those feelings of anxiety. I understand you have used it before and felt it helped, so I appreciate this request is important to you.
However, current medical guidance no longer supports prescribing diazepam for flight anxiety. The reasons are mainly to do with safety. Diazepam can cause sedation, confusion, and breathing problems, especially at high altitudes. It also increases the risk of blood clots in the legs which can travel to the lungs on long flights and can reduce your ability to respond in an emergency. In addition, it is illegal in some countries, which can pose serious legal risks while travelling. Are you following me so far?
Are you happy for me to talk you through some other alternatives that can really help?
Some people find that breathing exercises or using distraction techniques, like listening to music or podcasts, watching a film, reading, or even doing puzzles, can really help keep them calm during a flight. There are also calming apps, such as Headspace, which guide you through relaxation exercises step-by-step and can be very effective. What are your thoughts on trying some of these?
In the longer term, we can work together on finding a more lasting solution. Once you are back in the UK, I would be very happy to arrange a follow-up appointment. We can explore options like talking therapy, and structured fear-of-flying courses offered by airlines like British Airways and EasyJet, these have helped many people feel more confident and in control when flying.
How does that sound to you?
Management
Management
- Explain that diazepam is no longer prescribed for flight anxiety, as it carries risks including sedation, confusion, increased risk of deep vein thrombosis (DVT), respiratory depression, and reduced ability to respond in emergencies.
- In addition, diazepam is illegal in some countries, creating additional legal and safety risks when flying internationally
- Offer safer and evidence-based alternatives for managing flight anxiety. These include breathing exercises, distraction techniques such as listening to music or podcasts, watching a film or TV show, reading, or doing puzzles, and using calming and mindfulness apps like Headspace.
- Explain that a long-term approach is also important. Options such as talking therapy and structured fear-of-flying courses, like those offered by British Airways or EasyJet are helpful long-term strategies to overcome flight anxiety.
- Offer a follow-up appointment after his return to the UK to review his symptoms and create a personalised care plan for ongoing anxiety management.
Learning point from this station:
Flight anxiety, also known as aerophobia, is common. It can develop after a traumatic incident, such as severe turbulence or a previous flight-related emergency, or it may stem from a fear of losing control. On a train or in a car, a person can choose to get off, if needed. On a plane, you have no control over when you can leave. This loss of control can feel overwhelming.
Symptoms of flight anxiety may include: panic attacks even before the flight, or symptoms during the flight such as shaking, feeling dizzy or nauseous, sweating, a fast heartbeat (palpitations), shortness of breath, or a full panic attack while onboard.
Diazepam is no longer recommended for managing flight anxiety due to its safety risks, including sedation, impaired reaction in emergencies, increased risk of deep vein thrombosis (DVT), paradoxical agitation, and legal issues in certain countries. Instead, safer and evidence-based approaches should be encouraged. These include structured breathing exercises, distraction techniques (such as music, films, or reading), mindfulness apps like Headspace, and referral to airline-run fear-of-flying courses (e.g. British Airways or easyJet programmes).