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QUESTIONS: Is 1 session of exposure treatment (ET) effective in people with claustrophobia? Is 1 session of ET as effective as 5 sessions of ET or 5 sessions of cognitive therapy (CT)?
Uppsala and Stockholm counties, Sweden.
50 patients who were 18–60 years of age, were afraid of and avoided confined spaces, had claustrophobia for ≥1 year (mean duration 26 y), could not complete >50% of the steps in behavioural tests, and had no psychotic or organic illnesses or other psychiatric problems requiring immediate treatment. Follow up was 92% (mean age 41 y, 91% women).
Patients were allocated to 1 of 4 groups: one 3 hour session of ET (n=10), 5 one hour sessions of ET (n=11), 5 one hour sessions of CT (n=11), or a waiting list for 5 weeks (n=18). In the ET groups, patients were exposed to anxiety arousing situations. In the CT group, patients were taught to recognise and challenge negative automatic thoughts and basic beliefs about the claustrophobic situations, and they were not discouraged from practising in phobic situations between sessions.
Main outcome measures
Clinical improvement (statistically significant improvement in behavioural tests score plus score within normal range or outside patient group range), self report measures of claustrophobia (the Claustrophobia Scale and the Claustrophobia Questionnaire), and anxiety ratings during behavioural tests (elevator ride 9 floors up and 9 floors down, entering a small windowless room, and putting on a gas mask).
Treatment groups did not differ for the number of patients who were clinically improved after treatment (table) or after 1 year. Anxiety and claustrophobia scores did not differ among the 3 treatment groups after treatment or at 1 year.
In people with claustrophobia, 1 session of exposure treatment (ET) was as effective as 5 sessions of ET or 5 sessions of cognitive therapy.
Claustrophobia, a fear of enclosed spaces, has a lifetime prevalence of about 4% and can be substantially handicapping in a proportion of cases.1 Of course, most people with fears of sufficient persistence and intensity to meet diagnostic criteria for specific phobia manage to find ways of living with their fear and few seek professional help. For those who do, cognitive behaviour therapy using in vivo exposure and therapeutic modelling can be effective and is clearly the treatment of choice; psychotropic medication, in contrast, is relatively ineffective.2
Öst et al have been at the forefront of developing intensive, exposure based treatments, the most rapid of which consists of a single session of extended duration up to a maximum of 3 hours.3 Previous research has shown the effectiveness of this approach with phobias of flying, injections, blood and injury, and spiders. Öst et al's study confirms that claustrophobia can also be treated in this way, and successfully too, with few dropouts (8%) and with almost all patients (80–100%) at 1 year follow up achieving a maximum score on 1 of the behavioural outcome measures (eg, riding an elevator up and down a 9 storey building). Of particular interest is the finding that exposure is broadly equivalent to cognitive therapy based on the cognitive model of panic. This may be because the cognitions in claustrophobia are similar to those in panic disorder.4
The treatments in this study require experienced cognitive behaviour therapists. Clinicians should also note that, although clearly handicapped by their phobia, these patients had low scores on standard symptom inventories and no other complicating psychiatric conditions.
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