How to understand and manage Claustrophobia

I once flew many years ago with a patient whose main self-assessed complaint was claustrophobia. We flew after a number of office sessions after she had been presented with most of the material and training I share with patients.

At one point during our outbound flight, she left the main cabin and found solace in the restroom, one of the smallest areas of the aircraft accessible to passengers (There are other small rest areas for crew). Here, she overcame her feelings of dread and shortness of breath she had been experiencing, even though she was now in a much smaller volume compared to the main cabin. It was a very good lesson for me all those years ago, when I was still putting together my ideas about fear of flying and other anxieties.

In effect, she was able to isolate herself from a significant trigger within the cabin: looking about, and telling herself she was “trapped” and couldn’t escape. But in her own way, she did escape – not from the aircraft, but from her triggering perceptions of entrapment. She literally took a breather in the loo.

Claustrophobia is more than just an experience of being enclosed. It’s about escapability and freedom to move, and thus survive. In this way, it’s an extreme aspect of a very old, evolutionary significant safety valve.

When I ask patients to describe what claustrophobia means for them, after they’ve cited it as a significant contributor to their fear response, a variety of replies come back to me (some will sound familiar to you):

“I’m trapped”

“I can’t get out”

“I’ll suffocate”

“I feel I’ll lose the plot”

“I can’t relax”

“My mind goes wild with thoughts”

“I need to get out”

“I’ll die in there”

(If you have others to share, use the comments section at the end of this entry)

Being on board a plane brings together many fears, but they become potent because one cannot leave the aircraft once it’s airborne, and in some cases the flight duration may be 16 hours or more! Australians in particular are acutely aware of the time needed to travel, both domestically but more importantly, internationally. Melbourne to New York City is at minimum 14 hours to Los Angeles, then a little over 5 hours to NYC. It’s even longer coming back.

Other places where claustrophobia can be experienced

But claustrophobia occurs not just on board planes, but anywhere an exit might be prohibited should the person become overwhelmed with sensations of panic or loss of control and feel the rush to escape. On a plane, it could be in the window seat in a row of three in economy; in the theatre it could be seated in the middle of a wide row, with twenty people either side of you to clamber over to get to an aisle.

For others, it could be heavy traffic over a bridge or in a tunnel, or just on a very slow moving freeway in the middle lane or caught between two heavy semi-trailers on a rainy night with impaired vision, windscreen wipers thumping away at full tilt; or it could be standing in a queue at the bank or takeaway shop on a limited lunchtime break where very slow progress is being made and others might evaluate you if you leave before being served.

Others I have worked with say it’s being in the Underground train system (in Melbourne, in the City Loop) where there’s no light and the train might not move between stations for a period of time; and there is always the situation on board a cruise ship where you didn’t realise you had booked an inner cabin with no windows. (I’ve done Enrichment talks on Royal Caribbean ships and part of the deal is an inner cabin – I can quite well understand how for some it results in them cancelling their trip or begging for an upgrade to an outer cabin with a view).

Sometimes, people discover their plight when they are part of a school group going to explore a cave system, or they’re referred for an MRI scan where they must remain motionless enclosed in a noisy, clanging, and ultimately scary device. (Patients are given a “panic” button by the operator in case of emergency, and in the case of children some hospitals, like Melbourne’s Royal Children’s Hospital, employ colourful mockups to help the child practise first).

And of course, there is the safest form of mass transit ever invented – the elevator – which can see people huffing and puffing up stairs so as to avoid the sense of confinement. (True story – I’ve lost two acquaintances in stair wells when they’ve tripped and hit their heads on concrete steps). Both of my Virtual Reality setups include elevator simulations.

Many patients tell me their problem has been around a long time, and they have found ways to get around or accommodate to it just to be a part of regular society. They book theatre tickets only if aisle or very close to aisle is available; they only visit friends or go on holidays in high rise buildings if they can use the stairs; and when it comes to flying they prefer to break up their trips into smaller, more manageable flights even though it might take an extra day or two to get to their final destination. And they refuse middle seats, waiting for another later flight perhaps to ensure their comfort. They also become expert at recognising all the various EXIT signs that adorn buildings.

Claustrophobia may have been around a long time for some people

Unfortunately, by the time they come to see me, many have been living an “in the corner” lifestyle as the late family therapist Michael White, from Adelaide, once told me. Increasingly, as the metaphor goes, they move from the centre of the room to standing in the corner with their back to the centre – the only thing that’s missing is the Dunce’s hat. It’s not surprising many share feelings of failure with how life has turned out.

How they come to see me is also something I’m curious about, and it also encompasses “when?” When did you decide enough is enough? How did you decide to see a psychologist? Do you know what you’re in for?

For many, a family member or colleague has made the referral, because for them, enough is enough. Other family members often have to work around one member’s avoidance behaviours and sometimes they reach a tipping point where acceptance is no longer acceptable, and a supreme effort is called for, otherwise…

There have also been other occasions when a dream job or advancement is offered, but a decision now has to be made to either forgo it, or do something about the problem. I once treated a patient who had been promoted to a plum job but it meant spending time supervising tours of historical jails; another patient had been imprisoned and this had left long standing psychological scars such that he could now only fly in first class. On his preferred airline, this meant a cosy suite to himself.

In the case of the historical jail patient – for whom elevators were also a significant issue – she had an epiphany during the course of treatment: it was her recall that when very young she had been visiting an older cousin with her family, and had been playing hide and seek, when she was locked in a wardrobe and seemingly (to her) abandoned for hours. She recalled how terrified she found the experience, and the relief she felt when she was released. (Feeling abandoned or separated from one’s parents in busy shopping centres or at the beach is commonly cited in the history-taking with claustrophobia.)

After telling me this history, I asked if she would be seeing her cousin or aunt or uncle anytime soon, and it was fortunate a family event was approaching. I asked if she would ask her cousin if she could recall the event of decades before.

The event came and went, and in the session that followed, the patient sheepishly shared that she had asked the family members, and was astonished to learn it was she who had locked her cousin in the wardrobe! Indeed, on sharing the story in the belief it would shed light on the origins of her claustrophobia (many people do want to search for this and there is no shortage of treating practitioners happy to spend months at patient expense diving down an Alice in Wonderland wormhole in pursuit of the problem “origins”), the patient was eventually told by her parents she must have forgotten the time around the same age when she had almost drowned on a surf beach and had to be rescued and resuscitated by surf lifesavers.

Some concerns about history taking and “insight” approaches

I must share with you my reluctance to spend a great deal of time and sessions trying to find out how a problem started. I usually do ask early on, but more to check out a patient’s theory of problem change: “I had this really bad flight home from Singapore where we were in the worst thunderstorm ever. After that, just the thought of getting on board scared me”.

Many times however, patients are perplexed because there is no obvious cause, and this applies not just to fear of flying but many other anxiety presentations. It might prove satisfying for a patient to know their anxiety’s origins, but rarely does a magic lightbulb “aha” moment occur, and the problem behaviour spontaneously resolves. This is the stuff of Hitchcock movies.

No, usually twenty five years of well-rehearsed and practiced avoidance behaviours requires more than just insight, corroborated history taking and exposing the “subconscious” to the light, as some who practice “hypnotherapy” would have you believe (More on that in another post soon).

Indeed, you are best to know I am not so interested in how a problem got started (I am professionally curious however).  The issue I address with some vigour is:
What is currently maintaining the problem, if not making it worse as time goes on?
This then leads to a problem formulation phase early in treatment, which will lead to a set of well researched interventions which are more skills-based and outcome-oriented. This approach may then also lead to changes not just in behaviours and thoughts, but in affect or emotionality too. Indeed, what maintains an anxiety presentation may not have much to do with how that anxiety originated.
Not all therapists choose to work this way, but once explained, most patients understand that changing behaviours and feelings go hand in hand. (For a full explanation of how I work go the my post here – still in development).

What does the evidence show is best for treating Claustrophobia?

The intervention that has the most evidence to show is that of Exposure Based therapy, with appropriate cognitive work (self-talk) in the mix. This can include some of the newer approaches which have their origins in Eastern meditation practices, known as Mindfulness. Just so you know the way an exposure program can work, here’s a video from a US news network looking at how a Boston University team works (about 2007). For some, it will be not easy to watch, and it will send others into the welcoming arms of those who will make promises they can cure a lifetime of avoidance behaviours in an easy, single session – maybe even 7 minutes – but here goes:

Not easy to watch to begin with, but the outcome at the end of the piece is a reminder that this kind of work has its rewards, for both patient and psychologist.

This video was made in 2007, and since then more cognitive approaches have been added, and exposure work has also taken on new developments, including more sophisticated virtual reality environments. The one I use can make an elevator stop between floors, make the lights go out, and change the size of the car (the term used by elevator companies to describe the space passengers occupy – the elevator for them is the entire mechanism they install, most of which is out of sight).

The latest Virtual Setup can also add more people to the car to make the scene more crowded,  a sources of distress for many patients.

The Panic Room At UCLA (from a workshop of Prof. Michelle Craske)
The Panic Room At UCLA
(from a workshop of Prof. Michelle Craske)

At UCLA in Los Angeles, Professor Michelle Craske, an Australian, and her team have been researching anxiety, and the place of exposure-based treatments. They have constructed in the laboratory a “Panic Room” in which patients (and research subjects) can be exposed to a very enclosed space. Their physiological responses are measured and various interventions assessed for their immediate effect, as well as long term improvement in real-life scenarios.

I regularly take patients into elevators nearby in Caulfield’s Monash University, as well as the Eureka Skydeck, some 88 floors above Melbourne near the CBD. Indeed, I have an Annual Pass ($60) so I can go anytime I like and my patients can get discounted entry and cheap parking nearby. Because my work is known to the staff, we can practise in the two elevators alone and go up and down several times.

For other patients, exposure treatment utilises another of Melbourne’s tourist attractions, the Melbourne Star (official video below).

This is modelled on several such attractions around the world, perhaps the most famous being the London Eye on the banks of the Thames. Singapore has its own wheel also, known as the Singapore Flyer.

What these new attractions share in common are enclosed gondolas on a wheeled frame which slowly rotates while they remain upright. The original Ferris wheels stopped continuously to let new passengers on. The Melbourne Star is in constant, very slow motion and one is guided to both step on and step off by professional staff.

The gondolas themselves can hold a dozen or so people, but what makes them useful for exposure is not so much the height they achieve, but the idea that one cannot escape for the duration of the ride, about 30 minutes. That’s a little less than the total in the air time for flights I take with patients to Launceston, Tasmania (about 45″ in the air), so it’s good practice in the time leading up to our flights.

Before we go on, a little issue about exposure-based therapies needs to be mentioned:

(To be published soon)





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