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What is
Claustrophobia?
"When I get into an elevator I say to myself:
"Calm down, nothing will happen, everything is gonna be OK". However,
I cannot help feeling sick, my mouth gets dry and my heart starts pounding fast.
I am sweaty and breathless. I keep on thinking: "What if the elevator stops
and I cannot get out of here? There won’t be air enough. I cannot stand it, I
have to get out of here". Then, the elevator stops and the door opens. I
run out shaking and
feeling dizzy. Minutes later I calm down but I promise to myself to use the
stairs the next time. No matter how many floors I’d have to go up. I don’t
want to live that terrible experience again".
Claustrophobia is an intense fear to closed spaces. The Diagnostic and
Statistic Manual of Mental Disorders (DSM-IV, APA, 1994) classifies it into the
Anxiety Disorders as a Specific Phobia, defined as a marked and persistent fear
of clearly circumscribed objects or situations. When the individual is exposed
to the phobic object experiences an immediate anxiety response, which can takes
the form of a panic attack. The individual tends to avoid the phobic situation,
and he/she recognizes that the fear is excessive or unreasonable. The diagnosis
of specific phobia is appropriate only if the fear or avoidance interferes
significantly with the person’s functioning or if the person is markedly
distressed about having the phobia.
DSM-IV presents four subtypes of specific
phobia. Claustrophobia belongs
to the situational type because the fear is cued by specific situations.
Concretely, claustrophobia is a fear of enclosed spaces. The situations that
claustrophobics tend to avoid are elevators, tunnels, subway trains, small rooms,
medical diagnostic imaging techniques, underground parkings, etc. The person
does not fear the situation itself, but the negative consequences of being in
that place. The most common fears in this problem is restriction and entrapment
and fear of suffocation (Rachman, 1997). Most closed spaces entail a degree of
entrapment and a restriction of movements and many claustrophobics feel
excessively vulnerable when their movements are restricted (Rachman, 1997). The
fear of suffocating may arise from the belief that there is not air enough
available in the enclosed space.
When a person who suffers from this problem anticipates entering or
actually enters a closed space, he/she experiences an intense anxiety reaction (shortness
of breath, palpitations, feelings of unsteadiness, etc.). The individual usually
engages in extensive avoidance behaviors. For example walking up 20 floors
rather than use the elevator, refusing undergoing a medical scan even if it is
necessary, refusing to use the subway, etc. As in many other specific phobias,
the anxiety response decreases dramatically once the person leaves the enclosure.
The incidence of claustrophobia ranges from 2% to 5% in the general
population and twice as many women as men suffer from this fear. Claustrophobia
usually has an early onset and is usually associated to the consequences of
enduring an aversive experience in an enclosed space. It can also be acquired
indirectly, by receiving information about distressing experiences related to
closed spaces
or by seeing someone having such a distressing experience (Rachman, 1997).
What is our treatment
about?
Components:
Psychoeducation, breathing re-training, VR exposure, and relapse prevention.
Who can benefit from this
treatment? People
who suffer from claustrophobia with a significant interference in their lives
Treatment
components
Psychoeducation.
It
consists of giving a clear explanation about what claustrophobia is and of
clarifying concepts such as fear, anxiety, and phobia. Possible factors involved
in the development of fear to closed spaces are addressed, and the remaining
treatment components are presented to the patient with their rationale.
Breathing
re-training.
The
goal of this component is to change a fast breathing pattern by a slow breathing
pattern. A common response to anxiety provoking situations is hyperventilation.
The consequences of hyperventilation are the intensification or the appearance
of several physiological symptoms that intensify anxiety. In our treatment for
claustrophobia, patients are taught a slow breathing technique to face the
anxiety provoking situations in a more effective way.
Cognitive
therapy.
An
important issue regarding our responses to events or situations is the way we
interpret them, what we think about those situations and their meaning. The way
we think will determine how we will feel about things. Sometimes we make
erroneous interpretations that can lead to distressing feelings. Applying
cognitive techniques means trying to behave as scientists do: test if our
interpretations are right or wrong and find alternative ways of thinking about
the situations that would lead to less distressing feelings and will allow us to
face the situations in a more competent way.
VR
exposure.
Exposure
consists of facing the fear provoking situations gradually and progressively.
The importance of staying in the situation until the fear or anxiety goes down
is emphasized to the person. In our treatment for Claustrophobia, we elaborate
with the patient an individualized hierarchy with the feared situations and he/she
carries out exposure exercises to gradually face those situations. Then, we
present the advantages of VR exposure: it provides more safety to the patient (and
to the therapist) than traditional exposure does, the context generated by the
computer can be controlled at the therapist’s will and with no risks, and it
can be completely graded. Therefore, VR can be an intermediate step between the
therapist's consulting room (where the patient feels safe and protected) and the
real environment (so threatening for some patients that they decide not to face
it). It is easier to repeat the same exposure tasks once and again without
leaving the therapist’s office, which implies an important saving in money and
time. Finally, VR exposure allows the designing of a tailored hierarchy so the
patient can expose him/herself to all the possible situations, and even to
impossible ones (see the VR scenarios). In our treatment for Claustrophobia, the
patient finds a great number of situations related to enclosed spaces that he/she
uses to avoid. This is achieved by the immersion in the different VR scenarios
that we have designed for the treatment of Claustrophobia.
VR
scenarios
Setting
one: The house.
a) The
first room has a large window with a blind and a door that exits to a
terrace. When the door and the window are open, a blue sky can be seen and
the sound of birds can be heard. The door and the window can be opened and
closed in three stages, and the blind can be rolled up or down in the same
way
b) In
the second room, there is neither furniture nor windows. Ceiling and floor are
dark and have a wood texture to give a higher enclosure sensation. Once the
door is closed, it can be blocked. One of the walls in the room can be
displaced making a loud noise (also with different possibilities of advance)
enclosing the patient in 1 m2 wide space
Setting
two: The elevator.
This
virtual scenario consists of a large building hall and an elevator, which
measures 1m x 2m. The elevator offers different possibilities regarding size and
functioning:
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Elevator
on the ground floor. Open doors. The patient can stay inside the elevator
facing the entry, and get in and out at will.
-
Elevator
operating. The patient presses a button, doors close and the elevator starts
functioning. The elevator can go up to different floors and when it arrives,
doors open and the patient can get out at will.
-
Elevator
malfunctioning. The patient can block the elevator by pressing a stop button
and also can restore its functioning by pressing any of the floors buttons.
The therapist can also provoke a blackout, lights turns off and the elevator
stops in between floors. From that moment on he/she will not be able to get
out in any way during a period randomly determined by the system.
-
Elevator
"shrinks". One of the elevator walls can advance (producing a loud
noise) and enclose the patient in a 1 m2 space. The small
elevator offers the same possibilities that the regular elevator does.
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