Claustrophobia


Article Author:
Christy Vadakkan


Article Editor:
Waquar Siddiqui


Editors In Chief:
Zina Clark
Barbara Simmons


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
5/13/2019 9:00:40 AM

Introduction

A phobia is a fear which causes significant impairment to a person's ability to live a normal life. An example of life impairment is avoiding the specific object or scenario that is feared.[1]

Per DSM-5, there are many categories of anxiety disorders. The categories are separation anxiety disorder, social anxiety disorder, panic disorder, generalized anxiety disorder, selective mutism, and specific phobias. The specific phobias can further subdivide as animal type, natural/environmental type, situational type, and blood injection injury type.[2] Specific phobias are an extreme fear of certain activities, persons, objects, or situations.[3] Claustrophobia is a type of specific phobia, where one has a fear of closed spaces. Examples of closed spaces are engine rooms, MRI machines, elevators, etc.[4] Those with specific phobias generally will endorse avoidance behaviors on the particular object or situation that triggers their fear. The fear can express as a danger of harm, disgust, or experience of the physical symptoms in a phobic scenario.[5]

Etiology

Social anxiety disorder is a DSM-V psychiatric condition, characterized by an intense fear of social situations and scrutiny. Patients suffering from claustrophobia display a great fear and anxiety of closed spaces. The belief with a social anxiety disorder is that the frontal regions of the brain are unable to downregulate amygdalar hyper-activation. The same disruptions in the amygdala-frontal network in social anxiety disorder is attributable to claustrophobia.[6] A meta-analysis of functional brain imaging in specific phobias showed the activated regions of the brain to phobic stimuli were globus pallidus, amygdala, and left insula.[7]

There are two phenomenons associated with innate pathological fear, fear sensitization and failure of fear habituation. The amygdala has a decreased threshold activity and decreased potentiation of activity in fear sensitization. Research suggests there is a dysfunction in the learning-independent fear circuit which drives defensive behavior without prior learning, in nonexperiential phobias. Habituation is the reduced emotional reaction of a person to repeated stimuli. In fear habituation, the amygdala has decreased habituation.[3] 

A single gene defect in the human GPM6A gene is a suspected genetic risk for claustrophobia. The GPM6A gene, expressed in amygdala and throughout the CNS, encodes a stress-regulated neuronal protein and is found on the chromosome 4q32-q34, associated with panic disorder.[8] 

Epidemiology

Claustrophobia is a specific phobia which has a lifetime and 12-month prevalence of 7.7% to 12.5%.[9] There is a higher prevalence of specific phobias in women.[10] Studies conclude that there is a 1 in 10 prevalence of anxiety disorder among youth before the age of 16.[2] 

History and Physical

Patients with specific phobias, endorse various physical and emotional symptoms. Based on these symptoms, practitioners utilize screening tools to diagnose patients with claustrophobia. Physical symptoms include, but not limited to, difficulty breathing, trembling, sweating, tachycardia, dry mouth, and chest pain. Emotional symptoms include, but not limited to, feeling overwhelming anxiety and/or fear, fear of losing control, feeling an intense need to leave the situation, the understanding of the fear as irrational, but an inability to overcome it.[11]

Evaluation

Claustrophobia evaluation starts with a patient that presents with endorsing the symptom of fear. There needs to be a determination if the fear represents a phobia, normal fear, general medical condition or an anxiety disorder. Questions, in the initial history taking part in the assessment, that assess how the fear impacts the person's development, daily life, and family dynamics is vital to distinguishing fear and phobias. For children, sample questions are: How is the fear responded to by the child's parents? Can the child or parent recall the exact trigger of the fear? Is there an interruption, more than three times a day, to the child's daily schedule?[12]

Questionnaires are options to evaluate claustrophobia. The Spielberger psychology questionnaire consists of 20 items; each scored from 20 to 80, that measure obvious anxiety.[13] There are three commonly used scales to assess symptoms of anxiety and fear in the youth population: Revised Children's Manifest Scale, Fear Survey Schedule for Children-Revised, and the State-Trait Anxiety Inventory for Children.[2] 

Treatment / Management

The mainstay treatment for claustrophobia is cognitive behavioral therapy, in which, the patient can discuss the negative and distorted beliefs.[14] 

Interoceptive exposure is a form of treatment, where the patient gets exposed to the physical sensation of anxiety in a controlled environment.[15] Utilization of virtual reality technology, in a stimulating computer-generated atmosphere, is one option of treatment for claustrophobia. The claustrophobia game is an example with both an elevator and magnetic resonance imaging device scenarios for closed spaces.[13] The many different treatment options for pathological fear have only resulted in about 40% of patient's having long-term benefits; the majority will fail to have complete remission.[3]

Medications are another method of treatment for this specific phobia. Options include benzodiazepines, selective serotonin reuptake inhibitors, and other investigational drugs (cycloserine, hydrocortisone, quetiapine).[16] Benzodiazepines are the most used pharmacological option for patients with specific phobias that infrequently encounter the unavoidable phobic stimulus. There have been studies on the effectiveness of both escitalopram and paroxetine.[17] Hydrocortisone is a glucocorticoid; endogenous glucocorticoids' mechanism of action is unknown, but we do know that they are released when a patient is in a fearful situation. A study conducted, showed that patient's undergoing cognitive behavioral therapy have an augmented effect with 10mg of oral hydrocortisone.[18]

Differential Diagnosis

A community survey of 9282 adults, residing in the United States, showed that the presence of one specific phobia is associated with the prevalence of post-traumatic stress disorder, social phobia, bipolar disorder, generalized anxiety disorder, alcohol dependence, separation anxiety disorder, and major depressive disorder.[19]

Post-Traumatic-Stress Disorder (PTSD) is a common disorder that merits consideration in the differential. The main distinguishing reason is the presence of a traumatic event causing PTSD. A specific phobia is not always precedent by a traumatic event; experiential-specific phobia vs. nonexperiential-specific phobia).[3]

Prognosis

Patients who have claustrophobia commonly have a chronic course of their anxiety disorder, which increases the risk of other psychopathology.[2] Studies have shown, that adolescents with an increased number of phobias had an earlier onset of the disorder. From the same studies, patients with situational and blood-injection-injury specific phobias were the most strongly associated with indices of impairment and severity.[10] Natural environment phobias correlated more social problems and increased symptoms of depression, somatic, and anxiety, than were animal phobias.[20] 

Complications

There is an 83% lifetime likelihood of uncovering multiple specific phobias, once diagnosed with a particular phobia.[10]

Deterrence and Patient Education

Patients require information on the symptoms and criteria that are necessary for the specific phobia of claustrophobia. They will be more able to seek help and address the anxiety they fear in enclosed environments, once they can identify the origin of their anxiety. 

Enhancing Healthcare Team Outcomes

There must be an interdisciplinary approach to patients with claustrophobia, as well as other specific phobias. The goal of the nursing staff, physicians, and ancillary staff members is to decrease the patient's anxiety, in anxiety-provoking scenarios, such as an MRI procedure. Clinicians need to determine which part of the MRI procedure is the most anxiety provoking for the patient and then give the patient acknowledgment and education on their specific phobia. However, it is essential to avoid undermining the patient's concerns and imply that they can simply choose to stop the fear they experience at will. The patient should receive counsel on how they can have the most significant amount of control during the procedure to give comfort, such as allowing a family member into the room with them during the procedure (if not clinically contraindicated).[21]

Anxiety disorder management requires the efforts of an interprofessional team that includes physicians, nurses, other technicians (e.g., rad techs), and where appropriate, pharmacists, to communicate and collaborate both in the treatment of the condition, as well as assisting the patient through anxiety-producing procedures (such as an MRI) to achieve optimal patient outcomes. [Level V]


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Claustrophobia - Questions

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A 17-year-old female with no past psychiatric history presented after having a panic attack in the elevator at work. The patient has a history of panic attacks, usually when in elevators, once when she was in an MRI machine. The patient has been told that she might have a fear of closed spaces by her primary care provider. What is the best therapeutic option for her diagnosis?



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A patient with a history of panic attacks was diagnosed with claustrophobia. She has a family history of generalized anxiety disorder and wants to know if claustrophobia is a form of anxiety. What is the object that produces fear in patients with claustrophobia?



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A 26-year-old female is planning an overseas trip. She is very concerned about the flight, particularly about having to be in a small seat for a 12-hour journey. She reports feeling this fear, when she was in a small car, traveling with her family for a vacation. Which of the following best identifies the classification of the patient's disorder according to DSM-5?



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Claustrophobia - References

References

Wardenaar KJ,Lim CCW,Al-Hamzawi AO,Alonso J,Andrade LH,Benjet C,Bunting B,de Girolamo G,Demyttenaere K,Florescu SE,Gureje O,Hisateru T,Hu C,Huang Y,Karam E,Kiejna A,Lepine JP,Navarro-Mateu F,Oakley Browne M,Piazza M,Posada-Villa J,Ten Have ML,Torres Y,Xavier M,Zarkov Z,Kessler RC,Scott KM,de Jonge P, The cross-national epidemiology of specific phobia in the World Mental Health Surveys. Psychological medicine. 2017 Jul;     [PubMed]
Yeh SC,Li YY,Zhou C,Chiu PH,Chen JW, Effects of Virtual Reality and Augmented Reality on Induced Anxiety. IEEE transactions on neural systems and rehabilitation engineering : a publication of the IEEE Engineering in Medicine and Biology Society. 2018 Jul;     [PubMed]
Minkova L,Sladky R,Kranz GS,Woletz M,Geissberger N,Kraus C,Lanzenberger R,Windischberger C, Task-dependent modulation of amygdala connectivity in social anxiety disorder. Psychiatry research. Neuroimaging. 2017 Apr 30;     [PubMed]
Ipser JC,Singh L,Stein DJ, Meta-analysis of functional brain imaging in specific phobia. Psychiatry and clinical neurosciences. 2013 Jul;     [PubMed]
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Burstein M,Georgiades K,He JP,Schmitz A,Feig E,Khazanov GK,Merikangas K, Specific phobia among U.S. adolescents: phenomenology and typology. Depression and anxiety. 2012 Dec;     [PubMed]
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Muris P,Simon E,Lijphart H,Bos A,Hale W 3rd,Schmeitz K, The Youth Anxiety Measure for DSM-5 (YAM-5): Development and First Psychometric Evidence of a New Scale for Assessing Anxiety Disorders Symptoms of Children and Adolescents. Child psychiatry and human development. 2017 Feb;     [PubMed]
Thorpe S,Salkovskis PM,Dittner A, Claustrophobia in MRI: the role of cognitions. Magnetic resonance imaging. 2008 Oct;     [PubMed]
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Alamy S,Wei Zhang,Varia I,Davidson JR,Connor KM, Escitalopram in specific phobia: results of a placebo-controlled pilot trial. Journal of psychopharmacology (Oxford, England). 2008 Mar;     [PubMed]
de Quervain DJ,Bentz D,Michael T,Bolt OC,Wiederhold BK,Margraf J,Wilhelm FH, Glucocorticoids enhance extinction-based psychotherapy. Proceedings of the National Academy of Sciences of the United States of America. 2011 Apr 19;     [PubMed]
Choy Y,Fyer AJ,Lipsitz JD, Treatment of specific phobia in adults. Clinical psychology review. 2007 Apr;     [PubMed]
Stinson FS,Dawson DA,Patricia Chou S,Smith S,Goldstein RB,June Ruan W,Grant BF, The epidemiology of DSM-IV specific phobia in the USA: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Psychological medicine. 2007 Jul;     [PubMed]
Ollendick TH,Raishevich N,Davis TE 3rd,Sirbu C,Ost LG, Specific phobia in youth: phenomenology and psychological characteristics. Behavior therapy. 2010 Mar;     [PubMed]
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Schowalter JE, Fears and phobias. Pediatrics in review. 1994 Oct;     [PubMed]
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