Claustrophobia: When Small Spaces Are Scary
You're earning less than you should because the better paying job you've been offered requires using an elevator to get to your office. You're late for dinner at the in-laws, again, because you avoided the tunnel shortcut. For years, you've been managing your claustrophobia by avoiding enclosed spaces that might stir up feelings of ]]>anxiety]]> and suffocation. Now you're beginning to realize that your phobia has had the upper hand all along.
You're not alone. Claustrophobia, from the Greek claustro (closed spaces) and phobos (flight), is just one of the many specific phobias that affect some 8% of the US adult population, according to the United States Surgeon General.
The actual number of people with claustrophobia is undoubtedly higher, since many sufferers go to great lengths to accommodate their lives to their phobias rather than seek treatment. That's unfortunate because there is treatment for the condition. In many cases, the treatment is not limited just to claustrophobia.
Claustrophobia is known to the psychiatric community as a type of "specific phobia” (and formerly known as a “simple phobia”), meaning that there is one specific aversion causing the anxiety, in this case fear of enclosed spaces or crowds. This is in contrast to ]]>generalized anxiety disorder]]> in which a broad spectrum of situations produce anxiety reactions.
Stefan Hofmann, PhD, of Boston University's Center for Anxiety and Related Disorders, feels that this type of classification can be tricky. He bases this on the fact that fear of enclosed spaces is "basically a symptom that can be caused by a number of different factors, including ]]>panic disorder]]> , fear of a ]]>heart attack]]> with no help available, fear of suffocation, or fear of negative evaluation by people [nearby]. It would make more sense to classify people in a way that describes their pathology and possible treatment options," says Hofmann.
He makes a good point, considering that claustrophobia and other specific phobias generally coincide with other conditions, especially anxiety disorders.
Origins of Claustrophobia
Unlike other specific phobias, which seem to present themselves during childhood or in the mid-20s, the onset of claustrophobia is more spread out, from as young as age four to as old as 45, according to Hofmann. Its origins might be one traumatic experience such as being stuck in an elevator, or from vicarious learning such as hearing about a man trapped in an elevator for the weekend.
As in any specific phobia, the claustrophobic's avoidance of what he fears most serves to reinforce the phobic pattern.
"We'd love to outlaw avoidance because it reinforces the idea that there is something to be afraid of," said Aldo R. Pucci, MA, DCBT, president of the National Association of Cognitive-Behavioral Therapists (NACBT). "Avoidance doesn't give people a chance to see that what they fear is unlikely to happen."
For a person with claustrophobia, the ultimate fear is being caught in an elevator and running out of air. Although the patient may understand that the fear is irrational, even imagining such an event is enough to cause an anxiety attack. That's because the mind doesn't always differentiate between reality and illusion, a fact Pucci uses in his treatment of people with both claustrophobia and specific phobias.
The following types of therapy have been helpful in some cases:
- Cognitive behavioral techniques
- Exposure therapy
- Relaxation exercises
- Eye movement desensitization and reprocessing
Multiple treatments have been tested for use in specific phobias, all with varying success. These include relaxation exercises, eye movement desensitization and reprocessing, and antidepressant drug therapy. The therapy that has proven to have the most success for claustrophobia and other specific phobias is in vivo exposure. This involves exposing the patient to real life encounters with the feared situation.
A Closer Look at Cognitive Behavioral Therapy
Cognitive behavioral treatment is a type of cognitive therapy that helps clients to think and act differently has been quite successful in tackling phobias. Rather than talking through his fears, the patient is exposed to the feared object or situation in a gradual and controlled way known as systematic desensitization. Exposure to the feared situation replaces the reinforced fear with a sense of control.
"Cognitive behavioral therapy is a very instructive form of therapy that makes use of homework assignments to both strengthen the client's learning and to expedite change," says Pucci. On average, his patients' phobias are worked out in 16 sessions, unless there are other complicating factors.
The Course of Therapy
Therapy begins with an evaluation to determine if the client is a good candidate for psychotherapy.
Identifying Irrational Thinking
Next, clients are taught to identify irrational thinking. The biggest problem plaguing people with a specific phobia is their tendency to see a remote possibility as a distinct probability. For example, despite rationally understanding that people safely take elevators every day, people with claustrophobia keep harkening back to stories they've heard about unsafe cables or about some unlucky person who got stuck in an elevator during a city-wide blackout.
Learning and Practicing New Thinking Patterns
Without destroying the therapist-patient rapport, the therapist works on pointing out the absurdity of such reasoning. Once the problematic thinking has been worked through, patients are taught to practice their new thoughts by imagining themselves in their feared situation feeling calm and rehearsing their new thoughts. Pucci also has clients keep a daily evidence log, in which they record, for instance, evidence of elevators that they witnessed not crashing or the number of airplanes taking off and landing safely at an airport.
Using Systematic Desensitization
In this next step, a claustrophobic patient will be brought to an elevator and encouraged to watch it go up and down, and watch people get on and off without a single lock-in or crash. The next step is actually going up one floor and then back down. The length of time is increased until the patient no longer needs to think calming thoughts to handle the situation.
Hypnosis as a Supplement to Therapy
Pucci makes use of a technique called rational living therapy, or rational hypnotherapy, which incorporates hypnosis with cognitive-behavioral therapy.
"We give them the suggestion that seeing an elevator will cause them to relax," says Pucci. "The reason hypnotherapy is so helpful is that up until then, clients have to believe what you're saying in order to make use of your words. With hypnosis, though, believability has nothing to do with it. The person doesn't have to believe that the elevator will make him relax he just knows it."
For more entrenched phobias, pharmaceutical intervention may help relieve symptoms. Benzodiazepines are effective in reducing anxiety; however, they can cause physical dependency. Selective serotonin reuptake inhibitors (SSRIs), such as Paxil, Prozac, Zoloft, and Lexapro, have also been useful.
Why Therapy Makes Sense
Pucci recalls a 27-year-old male patient who walked the 20 flights of stairs up to his office every day rather than brave the confines of the elevator.
"He was in good shape but it was wearing him out," Pucci explains. For people who can't climb 20 flights, foregoing the job might seem the only option.
"The real loss, the greatest loss, is productivity," said Hofmann. "People can't perform on the job or continue in their career. People restructure their lives around phobias. This causes life changes and limits normal development."
Anxiety Disorders Association of America
National Alliance for the Mentally Ill
Anxiety Disorders Association of Canada
Canadian Psychiatric Association
Alamy S, Zhang W, Varia I, Davidson JR, Connor KM. Escitalopram in specific phobia: results of a placebo-controlled pilot trial. J Psychopharmacol. 2008;22:157-161.
American Psychological Association website. Available at: http://www.apa.org .
Anxiety Disorders Association of America website. Available at: http://www.adaa.org .
Barlow JH, Ellard DR, Hainsworth JM, Jones FR, Fisher A. A review of self-management intervention for panic disorders, phobias and obsessive compulsive disorders. Acta Psychiatr Scand. 2005;112:272–285.
DeJongh A, Van den Oord HJ, Broke E. Efficacy of eye movement desensitization and reprocessing in the treatment of specific phobias:four single case studies in dental phobias. J Clin Psychol. 1999;58:1453-1463.
Freedom From Fear website. Available at: www.freedomfromfear.org .
National Alliance on Mental Illness (NAMI) website. Available at: http:// www.nami.org .
National Anxiety Foundation website. Available at: http://www.lexington-on-line.com/naf.html .
National Association of Cognitive-Behavioral Therapists website. Available at: http://www.nacbt.org .
National Institute of Mental Health website. Available at: http://www.nimh.nih.gov .
Straube T, Glauer M, Dilger S, Mentzel HJ, Miltner WH. Effects of cognitive-behavioral therapy on brain activation in specific phobia. Neuroimage. 2006;29:125-135.
Last reviewed February 2008 by ]]>Ryan Estévez, MD, PhD, MPH]]>
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
Copyright © 2007 EBSCO Publishing All rights reserved.