Continuing Education Activity

Claustrophobia is the fear of enclosed spaces. About 12.5% of the population have this fear, with the majority of them being females. This activity reviews the evaluation and management of claustrophobia and highlights the role of interprofessional team members in collaborating to provide well-coordinated care and enhance patient outcomes.

Objectives:

• Identify the etiology of claustrophobia.
• Outline the typical presentation of a patient with claustrophobia.
• Summarize the management options available for claustrophobia.
• Review interprofessional team strategies for improving care coordination and communication to manage claustrophobia and improve outcomes.

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]

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), there are many categories of anxiety disorders. These include separation anxiety disorder, social anxiety disorder, panic disorder, generalized anxiety disorder, selective mutism, and specific phobias. The specific phobias can further subdivide into 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 report avoidance behaviors regarding the particular object or situation that triggers their fear. The fear can be expressed 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 phenomena 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 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 the amygdala and throughout the central nervous system, encodes a stress-regulated neuronal protein and is found on the chromosome 4q32-q34, associated with panic disorder.[8] 

Epidemiology

Claustrophobia 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 people before age 16.[2] 

History and Physical

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

Evaluation

Claustrophobia evaluation starts with a patient that presents with 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 assesses how the fear impacts the person's development, daily life, and family dynamics are vital to distinguishing fear and phobias. For children, sample questions are: How do the child's parents respond to his/her fear? 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, which measures obvious anxiety.[13] There are three commonly used scales to assess symptoms of anxiety and fear in the younger 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 of management 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] The 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 patients having long-term benefits; most will fail to have complete remission.[3]

Medications may also be used in the management of this phobia. Options include benzodiazepines, selective serotonin reuptake inhibitors, and other investigational drugs (cycloserine, hydrocortisone, quetiapine).[16] Benzodiazepines are the most commonly 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 what is known is that they are released when a patient is in a fearful situation. A study conducted showed that patients undergoing cognitive-behavioral therapy have an augmented effect with 10 mg 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 preceded 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 with more social problems and increased symptoms of depression, and anxiety, than did animal phobias.[20] 

Complications

There is an 83% likelihood of uncovering multiple specific phobias once diagnosed with a particular phobia during a patient's life.[10]

Deterrence and Patient Education

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

Enhancing Healthcare Team Outcomes

There must be an interprofessional team 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, especially 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 acknowledge their concerns and education on their specific phobia. However, it is essential to avoid undermining the patient's concerns and implying that they can choose to stop the fear they experience at will. The patient should be counseled on how they can have the most significant control level during the procedure to have comfort, such as allowing a family member into the room with them during the procedure (when clinically appropriate).[21]

The management of anxiety disorders requires the efforts of an interprofessional team that includes physicians, nurses, other technicians (e.g., radiation 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 5]