Claustrophobia

Claustrophobia is a morbid and irrational fear of enclosed and confined spaces. This anxious manifestation is often the result of a traumatic experience associated with the memory of a confined environment. The term claustrophobia is derived from the Latin claustrum, meaning enclosed place, and the Greek phobia, meaning fear. When pervasive, persistent and limiting, claustrophobia becomes a full-blown anxiety disorder, affecting 2 to 5 percent of the population in its most severe forms.

The sufferer is assaulted by a feeling of fear, discomfort or intense anxiety whenever he or she finds him/herself – or is in danger of finding him/herself – confined in a car, elevator, dressing room, basement, subway, etc. Therefore, the claustrophobic person tries to avoid situations in which he or she feels confined and deprived of spatial freedom, using avoidance strategies or seeking the reassuring presence of a family member, with severe limitations on his or her activities.

Like all phobias, claustrophobia is accompanied by anxiety and often somatic manifestations such as sweating, increased heart rate (tachycardia), feeling faint, difficulty breathing, and fear of death.

Often, claustrophobia is a transient phenomenon, destined to disappear spontaneously. In some cases, however, this phobic disorder requires recourse to psychotherapy or behavioral therapy.

In general, claustrophobia is associated with other so-called situational or environmental phobias (e.g., darkness, heights, flying in an airplane), i.e., people who fear one type of stimulus also fear other stimuli in the same group (Muris, Schmidt, & Merckelbach, 1999; OST & Csatlos, 2000; Stravynski, Basoglu, Marks, Sengün, & Marks, 1995). It is commonly said that people with claustrophobia fear situations of restriction and/or confinement (Febbraro & Clum 1995, Rachman & Taylor, 1993). However, Martinez, Garcia y Botella (2003) argue that this view is changing and that people who suffer from claustrophobia are not necessarily afraid of enclosed spaces, but what may happen in these cases is that they perceive the restriction of movement as a threat.

What does the claustrophobic person fear?

The claustrophobic person fears objects and circumstances that are associated with a feeling of constriction, oppression, or lack of freedom of movement. The fear is generated by thoughts that have at their core the fear of being crushed, suffocated, unable to bend and thus fainting or even dying. If access to air is prevented for any reason, the fear or anxiety tends to be heightened.

Triggering situations may therefore include:

  • Elevators
  • Subways
  • Airplanes, cars, trains
  • Tunnels, caves, burrows
  • Narrow rooms with no windows or windows that do not open
  • Locker rooms
  • Medical scans, such as CT or MRI scans, in which you are placed in a closed, narrow capsule.

Note that even the thought of being in such a situation can put the claustrophobic person into a state of deep anxiety. This leads to a series of behaviors – called avoidance behaviors – that may seem strange to an outsider and that are designed to avoid the feared circumstances: walking up six flights of stairs to avoid the elevator, or walking two kilometers to avoid the subway.

The symptoms of claustrophobia: avoidance and fear

Claustrophobia can include two groups of symptoms. The first is avoidance, which occurs when people try to avoid a situation that could lead to claustrophobia. For example, when in a confined space, people with claustrophobia may constantly check the exits to make sure they are not blocked; in a vehicle, they may prefer to sit by the door and only drive when there is little traffic; in public places, they may stand by the door or avoid crowded bathrooms.

The physical symptoms and anxious somatization of claustrophobia

However, when it is not possible to avoid the circumstances that actually cause the feeling of constriction in a confined space, a high peak of anxiety may occur, which may be accompanied by some of the following symptoms:

  • sweating
  • rapid breathing or hyperventilation
  • nausea and vomiting
  • fast heartbeat, tachycardia
  • fainting
  • shaking or trembling
  • dizziness
  • numbness and tingling
  • difficulty breathing or feeling like you are suffocating.

Fear of suffocation and feeling trapped

A factorial study by Rachman & Taylor (1993) showed the presence of two moderately related factors in claustrophobic subjects, the feeling of suffocation and the feeling of being trapped.

These symptoms are common to other phobias, and the fear of suffocation, experienced as a threat from within, can be expressed either with the perception of having an insufficient amount of air, or with a feeling of airway constriction with a perceived inability to expand the chest and/or a feeling of shortness of breath, or with a feeling of entrapment (Rachman, 1997).

Fear of suffocation is the other essential element of claustrophobia, and when access to air is prevented, the fear or anxiety tends to be heightened, forming a strong association with the perception of physical restriction and the need to feel freedom of movement.

When these conditions are found to be associated, they tend to result in feelings of panic; in fact, many claustrophobic individuals with panic report feeling short of breath and extreme fear of suffocation (Rachman, 1997).

Fear of enclosed spaces and fear of suffocation are the most common fears in the general population, and since the latter is an internal feeling, the presence or help of other people is of little psychological support; the crucial factor is the perception of having sufficient air and the sensation of regular breathing.

Why do people become claustrophobic?

Some scientists speculate that the fear of enclosed spaces may be a derivative of ancient evolutionary survival mechanisms that, although no longer necessary, still have the power to determine how some of us respond to certain stimulus situations.

Others believe that claustrophobia – as well as other specific phobias – may be rooted in hyperactivity of the amygdala, a small, almond-shaped brain structure dedicated to processing our emotions and, in particular, fear.

It also appears that genes play a key role in the onset of the disorder: children of claustrophobic parents are more likely to develop this type of phobia.

Finally, the association between confined spaces and the perception of imminent danger may have its origin in past experiences, often in childhood: for example, being trapped in an accident, being grounded in a confined space, being abused or bullied without being able to escape. According to a mechanism known as classical conditioning, the trauma experienced there and then influences our ability to deal rationally with the feared situation (the phobic stimulus) here and now. The body, which remembers everything, reacts accordingly by activating as if the threat were imminent.

Onset of claustrophobia and triggers

Following studies on the development of animal neurosis and in human subjects following natural disasters (e.g., workers trapped in a mine), Rachman (1997) points out that, according to the available data, the onset of the disorder is primarily due to the presence of a conditioning experience, such as being trapped in a confined space and/or experiencing feelings of suffocation.

According to other data, the onset of the phobia can also occur as a result of television and newspaper information, which supports the hypothesis of an indirect, non-associative acquisition of the disorder, or even as a result of a symbolic perception of confinement in an unsatisfactory interpersonal relationship; however, it remains constant that there must have been a previous experience of perceived confinement.

New triggers of claustrophobic reactions are modern diagnostic imaging techniques (CT scans, MRI), which in 4-10% of cases are not performed by the subjects or lead to worsening of symptoms when the disorder is present. Patients undergoing CT and MRI who abandon the examination due to a claustrophobic crisis show an increase in anxiety symptoms, in contrast to those who resist despite their anxiety; in fact, the latter show a reduction in anxiety at the end of the examination in 42% of cases.

The effects of confinement have also been studied in laboratory animals, and it has been observed that the absence of hope of escape or rescue leads to death; on the other hand, repeated immobilization induces habituation and reduced physiological reactivity, but not interchangeability of response with other similar immobilization situations.

How is claustrophobia diagnosed?

Claustrophobia is usually diagnosed by a psychologist or psychotherapist: It may arise during a diagnostic process requested by the patient for unspecified anxiety problems. In general, claustrophobic people turn to mental health professionals when:

  • anxiety in coping with the feared situation is out of control and affects the perception of personal well-being
  • The measures taken to avoid the undesirable situation become so great that they limit one’s freedom of action in everyday life.
  • One realizes that one’s fear is disproportionate and irrational.

After ruling out the possibility that the physical symptoms reported by the patient are of organic origin or due to another type of psychological distress, the specialist arrives at the diagnosis of claustrophobia by evaluating:

  • the nature, duration and intensity of the symptoms
  • the anxiety-provoking situations
  • Reactions to the phobic stimulus
  • Reactions to the anticipation of the phobic stimulus
  • Avoidance behaviors
  • The presence (or absence) of panic attacks.

The relationship between claustrophobia and other disorders

The incidence of claustrophobia in the world population is between 15 and 37% and in many cases it presents with other types of anxiety disorders: generalized anxiety disorder, social phobia, panic disorder.

Several studies show that claustrophobia correlates with indicators of psychological distress (stress) (Martinez et al, 2003; Radomsky et al, 2001, 2006.). Therefore, people who suffer from claustrophobia are generally more anxious and depressed. These psychological symptoms are more common in women (Chaves, 2003; Gouveia et al, 2003), which would explain the higher incidence of the disorder in the female sex.

Claustrophobia: the aetiological theories

Dormant survival mechanism

One theory is that claustrophobia is a survival instinct buried in our genetic code. It was once useful, but today it no longer has any survival value. A team of German and British researchers argues that claustrophobia is instead the result of a unique genetic defect.

Smaller amygdala

The amygdala is part of the limbic system and processes everything related to our emotional responses. One study suggests that people with panic disorder have a smaller amygdala than the average person. It is thought that this size difference may interfere with the way the brain processes the perception of danger by generating fear.

Claustrophobia and spatial awareness

Everyone has their own “personal space” – the distance or boundary that an individual needs to define their comfort zone. New research suggests that those who project their personal space too far beyond their bodies – beyond arm’s length – are more likely to experience claustrophobic fear.

The study is one of the first to focus on the perceptual mechanisms of claustrophobic anxiety. The underlying theory is that people with claustrophobic anxiety have problems with spatial perception.

Some form of claustrophobic fear is common to all. However, true claustrophobia, found in about 4 percent of the population, can cause panic attacks when one is in a “tight” situation, such as a crowded elevator or tunnel.

Claustrophobia is not easy to define because some people who experience traumatic events in confined spaces do not develop true claustrophobia,” Lourenco said. “This led us to wonder if other factors might be involved. Our results show a clear relationship between claustrophobic anxiety and fundamental aspects of spatial perception.”

The researchers believe that claustrophobia and acrophobia (fear of heights) are related to an imbalance in the perception of near and far objects.

Individuals with high levels of claustrophobia underestimate horizontal distances, and those with more acrophobia overestimate vertical distances.

In particular, people with larger personal spaces experienced higher rates of claustrophobic fear than people with smaller personal spaces. These findings are consistent with a defensive function of personal space representations and suggest that overprojection of personal space may play an important role in the etiology of claustrophobia.

Claustrophobia: a relational dilemma

According to Valeria Ugazio (1998), the phobic organization (Guidano, 1988) is an arrangement that develops in the child from early experiences with a caregiver who discourages exploratory behavior and conveys a negative definition of self. This organization may then give rise to symptomatic behavior in childhood or adolescence following overly intense events that touch either polarity.

The phobic’s dilemma is: do I give up the security of companionship in order to be free (but only in the face of danger), or do I give up the freedom to explore in exchange for protection that reassures me (but can also suffocate me)? The ways out are two dichotomous paths: either I adhere to a self-image that excludes fragility and weakness and identifies self-esteem with independence, or I enter into close emotional relationships on which I am dependent. The first path coincides with claustrophobia, the second with agoraphobia. The person with claustrophobia finds situations that he or she interprets as a loss of freedom (such as an overly close relationship or the birth of a child) dangerous; the agoraphobic fears what he or she interprets as a loss of protection (the end of a romance or a job that requires more responsibility). This is a continuum at the extremes of which we can choose to be independent but give up emotional involvement, or to be protected by a bond but have low self-esteem.

The claustrophobic can have an emotional attachment as long as it is a low level of involvement. He will choose a low profile partner: lackluster, dependent, emotionally involved for both. In the couple he is in the “one up” position, centralizing, fleeing and devaluing. The agoraphobic, on the other hand, privileges the relationship at the expense of the self. For fear of losing the bond, he controls significant others and subjects the relationship to constant scrutiny. Lack of independence undermines his sense of accomplishment. At a young age, he will bond with a seemingly strong and protective partner to whom he will devote everything. In the couple he is in a “one down” position.

The phobic organization of an individual, exemplified by the two extremes “claustrophobic” and “agoraphobic”, is thus rooted in relational difficulties, which are expressed in an unbalanced way of experiencing relationships: the former tends to feel suffocated (closed spaces distress him), the latter is afraid that, alone and lost, no one will come to his rescue (open and dispersed spaces give him a sense of threat and lack of protection).

How is it treated?

Claustrophobia can be successfully treated and people can regain a sense of mastery and control over their lives. The very fact that the claustrophobic person recognizes his or her distress as excessive lays the foundation for a good alliance during the therapeutic process.

TCC has been empirically shown to produce excellent results in the treatment of this type of phobia. The cognitive behavioral therapist:

  • Helps the patient untangle the relationship that exists between the feared situation and the dysfunctional thoughts that drive the fear emotion. The goal is for the claustrophobic subject to arrive at a more realistic assessment of the distressing stimulus and to learn to better manage the difficult feelings it generates;
  • therefore proposes the technique of exposure to the anxiety-provoking circumstance, which is usually gradual and can take place in vivo, in the imagination (preferable in the presence of a disorder triggered by a traumatic experience), or through virtual reality. Over time, the patient expands his ability to tolerate the distress and to prevent his habitual reactions to it;
  • It also teaches the mastery of muscle relaxation techniques that can be used whenever one is exposed to the feared circumstance and that act as an anxiety antagonist;
  • finally, through systematic desensitization, it helps the person in therapy not only to tolerate the feared situation, but also to respond to it in a different, more adaptive way that is not determined by fear or anxiety. Over time, the claustrophobic person learns that he or she can take the risk of experimenting with alternative ways of coping with the discomfort. The changes that are made in the mind and body through experience gradually solidify, giving the patient back a greater range of action and a greater sense of freedom.

Therapeutic interventions with clear efficacy for the treatment of claustrophobia, as for other phobias, include exposure therapy and cognitive therapy, which have been shown to be equivalent. Behavioral methods aim to weaken the specific association with phobic stimuli through repeated exposure or by developing specific skills to deal with the stimulus and response, while cognitive methods aim to change the evaluation and meaning given to the stimulus and response.

The general feature of exposure therapy for claustrophobia is to encourage and persuade the subject to remain in the feared situation, despite fear and discomfort, until the fear is reduced and later eliminated. With the patient, it is useful to describe the intervention methodology that will be used in the session, explaining its theoretical aspects and the differences between a gradual and planned exposure in a controlled setting and an occasional exposure in life, in order to reduce the fear of not being able to cope with the situation that will arise.

It is also important to explain that the therapeutic session is only the starting point of a subsequent gradual and more extensive exposure, since a long-lasting phobia such as claustrophobia is unlikely to disappear completely after one session; however, the session is the central and extremely useful element within the program that will lead to the gradual disappearance of the phobia.

In general, since the most common fear is the fear of being massively exposed to the feared stimulus, it is important to emphasize to the patient that this will happen gradually, with the possibility of stopping the session at any time; it is also appropriate to give truthful and non-contradictory information, explaining the importance of learning to manage fear and avoidance in small steps, being satisfied with achieving gradual and tolerable goals; the optimal ones will be achieved later.

After explaining the theoretical model of controlled exposure, gradual visual exposures are made; obviously, in a brief intervention, the goal is only to reduce the subject’s anxious response in this situation.

Simultaneously with these exposures, the negative cognitions and automatic thoughts inherent to the object of the phobia can also be addressed, trying to identify logical inconsistencies and modify cognitive distortions, as well as inducing changes in sensory perception.

Outpatient claustrophobia treatment

For the outpatient treatment of claustrophobia, it is possible to create a series of situations, planned in advance with the patient, that gradually expose him to the feeling of closure, such as entering a room with him (leaving the door open), explaining the various steps to be followed, and teaching him to focus on the task at hand.
Once outside, you will have the patient open the door by inviting him to observe the details of the room, encouraging him to enter, having him describe the thoughts and feelings he is experiencing, and teaching him to resist thoughts and feelings of escape by focusing his attention on objects.

Next, have the person leave the door ajar and then close it, have him or her stay in the closed room for a few moments and then more and more, monitoring the changes in the intensity of discomfort over the course of the exposure with a score that is a function of both the sensation felt and the self-control in the situation compared to what the person attributed to himself or herself before the exposure; finally, have the person stay alone by talking to him or her behind the door and then remaining silent.

The attempts can be varied, but it is important that each one produces even a slight change and makes the person feel a greater sense of mastery and control.

During the course of the session, as mentioned above, thoughts, feelings and emotions can be assessed by giving the subject tasks to do at home, depending on the severity of the disorder and the subject’s skills/abilities.

An exposure to the internal sensations of fear and anxiety can also be used, in which the subject is made to experience, imaginatively or actually, the physical sensations experienced during rapid breathing or after physical exercise, which are similar to those experienced during the exposure and in phobic situations.

Treatment of claustrophobia with virtual reality

The results of this study support the clinical effectiveness of virtual reality (VR) exposure for the treatment of claustrophobia. A decrease in all measures was observed and, in addition, the data support the results of the previous study (Botella, Bafios, Perpifi~ i, Villa, et al., 1998), where it was shown that the virtual claustrophobic context activates a high degree of anxiety in participants and that they were able to overcome the phobia through virtual exposure. VR, was used alone, without any combination with other psychological treatments and with a three-month follow-up. Therefore, it seems to be very useful in a therapeutic perspective (Botella, Bafios, Perpififi~ i, & Ballester, 1998; Botella, Bafios, Perpifi~ i, & Garcfa-Palacios, 1998).

What do we mean specifically by talking about the virtual reality medium? The basic instrumentation consists of a pc with dedicated 3D scenario software to which we connect: a joy-pad; a viewing device (helmet or goggles); and one or more position and motion sensors (trackers). Thanks to these tools, one can speak of immersive virtual reality, which allows the subject to experience a sense of sensory absorption in the three-dimensional environment. Virtual reality therefore allows the subject to experience relevant involvement due to the ‘sense of presence’ experienced within the virtual scenarios, and consisting of:

  • proto presence: possibility of bodily movement and interaction;
  • nuclear presence: perception of a vivid environment;
  • extended presence: perception of elements significant to the subject.

The operating characteristics of the medium can be assumed in three points:

  1. the subject immersed in the virtual scenario observes phenomena and behaviors;
  2. can intervene with his own action within the scene;
  3. can observe in situ the effects of his own behaviors and modify them again, considering different consequences as he goes.

In doing so, cycles of perception and action can be repeated, each operating on the outcome of the other. Knowledge and change are obtained from experiencing in the here and now. Therefore, the main opportunity offered by virtual reality within a psychotherapeutic path consists in the possibility of actively participating in the recognition and awareness of one’s own thoughts, emotions and behaviors, in situation.

References

  1. American Psychiatric Association (APA) (2013). DSM-5.
  2. Choy, Y., Fyer, AJ., Lipsitz JD. (2007). Treatment of specific phobia in adults. Clin Psychol Rev. Apr; 27(3):266-86.
  3. Vadakkan, C., Siddiqui, W. (2021). Claustrophopia. In Statpearls. Statpearls Publishing, Treausre Island
  4. Stella F. Lourenco, Matthew R. Longo, Thanujeni Pathman. Near space and its relation to claustrophobic fear. Cognition, 2011; 119 (3): 448 DOI: 10.1016/j.cognition.2011.02.009
  5. Valdiney V. Gouveia1; Emerson-Diógenes de Medeiros; Rildésia S. V. Gouveia; Walberto S. Santos; Pollyane K. C. Diniz. Claustrophobia Questionnaire: evidences of its validity and reliability. Interamerican Journal of Psychology. Interam. j. psychol. v.42 n.3 Porto Alegre dez. 2008.
  6. A El-Kordi1,2,8, A Kästner1,8, S Grube1,8, M Klugmann3,9, M Begemann1,2, S Sperling1, K Hammerschmidt4, C Hammer1, B Stepniak1, J Patzig3, P de Monasterio-Schrader3, N Strenzke5, G Flügge2,6, H B Werner3, R Pawlak7, K-A Nave2,3 and H Ehrenreich1,2. A single gene defect causing claustrophobia.  Translational Psychiatry (2013) 3, e254; doi:10.1038/tp.2013.28. Published online 30 April 2013
  7. Fumi Hayano phd,Motoaki Nakamura md, phd,Takeshi Asami md, phd,Kumi Uehara md ,Takeshi Yoshida md, phd,Tomohide Roppongi md ,Tatsui Otsuka md, phd,Tomio Inoue md, phd,Yoshio Hirayasu md, phd. (2009). Smaller amygdala is associated with anxiety in patients with panic disorder. Psychiatry and Clinical Neurosciences. DOI: 10.1111/j.1440-1819.2009.01960.
Subscribe
Notify of
guest

0 Comments
Inline Feedbacks
View all comments
Scroll to Top