The reduction of claustrophobia--II: Cognitive analyses

Using targeted cognitive behavioural therapy in clinical work: a case study

Research shows high levels of complex co-morbidities within psychiatric populations, and there is an increasing need for mental health practitioners to be able to draw on evidence-based psychological interventions, such as cognitive behavioural therapy (CBT), to work with this population effectively. One way CBT may be utilised when working with complexity or co-morbidity is to target treatment at a particular aspect of an individual’s presentation. This study uses a single-case A-B design to illustrate an example of using targeted diagnosis-specific CBT to address symptoms of a specific phobia of stairs in the context of a long-standing co-morbid diagnosis of schizophrenia. Results show the intervention to have been effective, with a change from a severe to mild phobia by the end of intervention. Clinical implications, limitations and areas for future research are discussed.

Key learning aims

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The Effect of Augmented Reality and Virtual Reality on Inducing Anxiety for Exposure Therapy: A Comparison Using Heart Rate Variability

Claustrophobia is an anxiety disorder characterized by the fear of enclosed spaces. Although medication treatment can effectively control symptoms, the effects quickly disappear once medication is discontinued. Many studies have shown that combining psychotherapy and medication is more efficacious than solely using medication. However, the weaknesses of the traditional psychotherapy are that it is time-consuming and expensive. Alternatively, vivo exposure therapy is proposed in which anxiety is gradually triggered with stimuli. Targeting claustrophobia is diagnosed using the traditional method, and this study established virtual reality (VR) and augmented reality (AR) environments consistent with claustrophobic characteristics, comparing the two using an experimental process to examine whether VR and AR environments are equally capable of triggering anxiety in participants. This study further analysed the efficacies of VR and AR by measuring changes in participant's heart rates variability (HRV) and examining data from survey questionnaires. HRV results indicated that the proposed VR system and AR system were both able to trigger anxiety. Furthermore, the AR environment produced a stronger experience for the participants and caused physiological reactions more evident than those caused by the VR environment. Regarding the anxiety questionnaire, the participants suggested that their anxiety was significantly higher in the VR environment than in the AR environment.

The psychology of HPA axis activation: Examining subjective emotional distress and control in a phobic fear exposure model

The HPA axis plays a key role in mediating the effects of "stress" on health, but clarifying mechanisms requires an understanding of psycho-biological linkages. There has long been an implicit assumption that subjective emotional distress (e.g., fear) should activate the HPA axis. Although this assumption was challenged 25 years ago (Curtis, 1976), laboratory studies in humans are limited. In this study we sought to replicate Curtis' findings and extend it by investigating if presence or absence of stressor control shapes HPA axis reactivity in a phobic fear exposure model. We recruited 19-45-year-old specific phobia participants (n=32 spider/snake phobia; n=14 claustrophobia) and gradually exposed them to their feared object or situation while measuring hormonal (ACTH and cortisol) and subjective (emotional distress, perceived control) responses. Utilizing a dyadic yoked design, we compared HPA reactivity when the pace of exposure was controlled by participants to identical exposure given to matched participants in the absence of control. Results showed that phobic fear exposure generated intense emotional distress without a corresponding increase in HPA axis activity. Although our actual manipulation of control failed to impact HPA responses, perceived control during exposure was associated with lower cortisol, an effect that was moderated by actual availability of stressor control. Our findings replicate Curtis' findings and challenge the still common but unsupported assumption that HPA axis activity reflects subjective distress. These results also highlight the importance of both perceived and actual aspects of stressor control in understanding what is truly "stressful" to the HPA axis system.

MR imaging of claustrophobic patients in an open 1.0T scanner: Motion artifacts and patient acceptability compared with closed bore magnets

OBJECTIVE

To evaluate motion artifacts and patient acceptability of MR imaging of claustrophobic patients in an open 1.0T scanner.

SUBJECTS AND METHODS

Thirty six claustrophobic patients were enrolled prospectively, 34 of which had previous MR examinations in closed bore magnets. Anxiety and pain during MR examination in an open 1.0T scanner were evaluated by visual analogue scales and various tests. Influence of motion artifacts on image quality was evaluated by two radiologists independently using a five-point scale. Additionally, 36 non-claustrophobic patients delivered a reference value of a non-claustrophobic population for the visual analogue anxiety scale.

RESULTS

Termination rate of MR imaging of highly claustrophobic patients decreased from 58.3% (n=21) in closed bore magnets to 8.3% (n=3) in the open scanner (p<or=0.001). Anxiety during MR examination was reduced from 87.1+/-16.7 (closed magnets) to 30.4+/-30.8 (open magnet) (p<or=0.001) on visual analogue scale ranging from 0 to 100. Influence of motion artifacts on image quality was very little (inter-rater reliability r=0.74; p<0.01).

CONCLUSIONS

MR imaging using an open 1.0T scanner yielded a significantly decreased anxiety and subsequently an improved acceptability in claustrophobic patients compared with closed bore magnets. Motion artifacts did not influence image quality.

Temporal relationship between dysfunctional beliefs, self-efficacy and panic apprehension in the treatment of panic disorder with agoraphobia

The aim of this study is to assess if changes in dysfunctional beliefs and self-efficacy precede changes in panic apprehension in the treatment of panic disorder with agoraphobia. Subjects participated in a larger study comparing the effectiveness of cognitive restructuring and exposure. Four variables were measured: (a) the strength of each subject's main belief toward the consequence of a panic attack; (b) perceived self-efficacy to control a panic attack in the presence of panicogenic body sensations; (c) perceived self-efficacy to control a panic attack in the presence of panicogenic thoughts; and (d) the level of panic apprehension of a panic attack. Variables were recorded daily on a "0" to "100" scale using category partitioning. Multivariate time series analysis and "causality testing" showed that, for all participants, cognitive changes preceded changes in the level of panic apprehension. Important individual differences were observed in the contribution of each variable to the prediction of change in panic apprehension. Changes in apprehension were preceded by changes in belief in three cases, by changes in self-efficacy in six cases, and by changes in both belief and self-efficacy in the remaining three cases. This pattern was observed in participants in the exposure condition as well as those in the cognitive restructuring condition. These results provide more empirical support to the hypothesis that cognitive changes precede improvement. They also underlie the importance of individual differences in the process of change. Finally, this study does not support the hypothesis that exposure and cognitive restructuring operate through different mechanisms, namely a behavioral one and a cognitive one.

Treatment of specific phobia in adults

This is a comprehensive review of treatment studies in specific phobia. Acute and long-term efficacy studies of in vivo exposure, virtual reality, cognitive therapy and other treatments from 1960 to 2005 were retrieved from computer search engines. Although specific phobia is a chronic illness and animal extinction studies suggest that relapse is a common phenomenon, little is known about long-term outcome. Treatment gains are generally maintained for one year, but longer follow-up studies are needed to better understand and prevent relapse. Acutely, the treatments are not equally effective among the phobia subtypes. Most phobias respond robustly to in vivo exposure, but it is associated with high dropout rates and low treatment acceptance. Response to systematic desensitization is more moderate. A few studies suggest that virtual reality may be effective in flying and height phobia, but this needs to be substantiated by more controlled trials. Cognitive therapy is most helpful in claustrophobia, and blood-injury phobia is uniquely responsive to applied tension. The limited data on medication have not been promising with the exception of adjunctive D-clycoserine. Despite the acute benefits of in vivo exposure, greater attention should be paid to improve treatment acceptance and retention, and additional controlled studies of more acceptable treatments are needed.

Fear responses to mock magnetic resonance imaging among college students: toward a prototype experiment

Two hundred randomly selected student participants (139 females, 61 males) responded initially to questionnaires that quantified variables such as state and trait anxiety, anxiety sensitivity, claustrophobia, and panic/agoraphobia. Later they were informed that a mock magnetic resonance imaging (MRI) procedure was upcoming, and were prompted to provide self-efficacy ratings vis-à-vis completing the procedure. Finally, the participants' behavioral reactions to a mock MRI procedure were characterized; their heart beats were recorded and ratings of fearfulness were acquired. One purpose of the research was simply to tally numbers of participants who responded fearfully in various ways: 7 failed the procedure behaviorally, 7 others completed the procedure but did so fearfully, 17 others completed the procedure but manifested excessive heart-rate responsivity. A second purpose of the research was to "predict" subjects' fear-response categorization psychometrically and/or with self-efficacy ratings: psychometric data related to claustrophobia predicted subjects' fear-response categorization as did self-efficacy ratings. According to these results mock MRI assessment among college students provides a promising context for research on claustrophobia.

Relationships between the anxiety sensitivity index, the suffocation fear scale, and responses to CO2 inhalation

Interest in documenting ways to predict anxious responding in panic disorder (PD) patients has proliferated recently in the literature. In the current study, two self-report measures were assessed to determine their relative utility in predicting responses to a panicogenic challenge. The Anxiety Sensitivity Index (ASI) and the Suffocation Fear Scale (SFS) were evaluated by correlating scores on these measures with reactions to inhalation of 35% carbon dioxide (CO2), assessed via anxiety ratings, panic symptom intensity, tidal volume (VT) and respiratory rate (RR). A sample of 14 PD patients and 14 matched control (MC) participants demonstrated that the relationship between ASI scores and responses to 35% CO2 were stronger than the relationship between SFS scores and responses to CO2. Specifically, both respiratory responses (VT and RR) and self-reported reactions (anxiety and symptom intensity) were significantly correlated with scores on the ASI. In contrast, scores on the SFS were significantly correlated with only one measure of respiratory change (VT). Although preliminary, these data indicate that the ASI may be a more useful tool than the SFS in predicting self-reported and respiratory responses to CO2 challenges.

Graded exposure in vivo in the treatment of pain-related fear: a replicated single-case experimental design in four patients with chronic low back pain

The aim of this investigation was to examine the effectiveness of a graded exposure in vivo treatment with behavioural experiments as compared to usual graded activity in reducing pain-related fears, catastrophising and pain disability in chronic low back pain patients reporting substantial fear of movement/(re)injury. Included in the study were four consecutive CLBP patients who were referred for outpatient behavioural rehabilitation, and who reported substantial fear of movement/(re)injury (Tampa Scale for Kinesiophobia score>40). A replicated single-case cross-over design was used. After a no-treatment baseline measurement period, the patients were randomly assigned to one of two interventions. In intervention A, patients received the exposure first, followed by graded activity. In intervention B, the sequence of treatment modules was reversed. Sixty-three daily measures of pain-related cognitions and fears were recorded with visual analogue scales. Before and after the treatment, the following measures were taken: pain-related fear, pain catastrophising, pain control and pain disability. Using time series analysis on the daily measures of pain-related cognitions and fears, we found that improvements only occurred during the graded exposure in vivo, and not during the graded activity, irrespective of the treatment order. Analysis of the pre-post treatment differences also revealed that decreases in pain-related fear concurred with decreases in pain catastrophising and pain disability, and in half of the cases an increase in pain control. This study shows that the external validity of exposure in vivo also extends to the subgroup of chronic low back pain patients who report substantial fear of movement/(re)injury.

Research on posttreatment return of claustrophobic fear, arousal, and avoidance using mock diagnostic imaging

Fear sometimes returns after attenuation via exposure. Return of fear is poorly understood due to conflicting results from diverse experiments. This article reports on two experiments in which claustrophobic fear during mock diagnostic imaging was attenuated and allowed to return so the experiments could be evaluated and return of fear studied. Attentional focus versus distraction during exposure was a between-subjects independent variable. Attempts were made to predict return of fear, return of heart-rate responsivity, and behavioral avoidance using levels of fear and heart-rate during initial mock diagnostic imaging as predictor variables. One third of participants displayed return of fear, heart-rate response, or avoidance 1 week after fear reduction. Heart-rate response during initial mock imaging predicted posttreatment return-of-fear classification; level of fear during initial imaging did not. Neither initial heart rate nor initial fear predicted return of heart-rate reactivity or avoidance. The experiments are offered as models for programmatic research.

MRI of the claustrophobic patient: interventionally configured magnets

The aim of this study was to determine whether or not claustrophobic patients would tolerate a scan in an open configuration interventional magnetic resonance (iMR) imaging unit, when they had failed to complete a diagnostic scan in a conventional MRI system. 50 claustrophobic subjects were entered into the study. Their response to the iMR environment was compared with their previous experience in an MRI scanner by means of a two-stage questionnaire. Part 1 was completed before their iMR scan and Part 2 following their attempt at imaging in the iMR unit. 60% (n = 30) of the participants were female and 40% (n = 20) were male, age range 25-71 years (mean 49.5 years). 48% (n = 24) were lumbar spine studies and 28% (n = 14) were studies of the head. 24% (n = 12) underwent scanning of other anatomical regions. 94% (n = 47) of participants underwent successful MRI in the interventional magnet without extra sedation. 6% (n = 3) failed to complete a diagnostic scan in the iMR machine. The GE Signa 0.5 T SP magnet allows successful MRI in 94% of the claustrophobic population who have failed to complete a scan in a conventional diagnostic machine.

Context-specificity of relapse: effects of therapist and environmental context on return of fear

Context-specificity of fear extinction was tested among 65 participants who were fearful of spiders by manipulating the contexts used for exposure treatment and two-week follow-up assessment. Context was defined by both meaningful (presence of a particular therapist) and incidental (room location and furnishings) environmental cues. Distinct phobic stimuli were used to examine interactions of context with stimulus. Physiological, behavioral and verbal indices of fear were measured. Results provided modest support for context-specific return of fear. With one stimulus, participants assessed in a non-treatment context at follow-up exhibited greater returns in heart rate levels. In addition, three of four participants who could not touch the stimulus at follow-up had been tested in a non-treatment context. Future investigations may benefit from greater distinctions between contexts or manipulation of contextual features more directly relevant to fear. Finally, post hoc analyses identified high trait anxiety, slow treatment response, recovery of phobic cognitions and long duration/high intensity phobic encounters post-treatment as significant predictors of increased return of fear.

Claustrophobia and the magnetic resonance imaging procedure

We examined fear induced by the magnetic resonance imaging (MRI) procedure in 80 adult patients who were undergoing the procedure for the first time. Participants completed self-report measures of claustrophobia, anxiety sensitivity, thoughts about the scan, and pain. Participants were assessed pre- and postscan, and at 1-month follow-up. Twenty-five percent of the participants experienced moderate to severe anxiety during the MRI scan. Prescan scores on the Claustrophobia Questionnaire (CLQ: Rachman and Taylor, 1993) significantly predicted participants' distress during the scan: pain and anxeity sensitivity did not. Furthermore, CLQ scores discriminated between participants who reported panic during the scan and participants who did not report panic. A brief screening instrument consisting of six items from the 29-item CLQ is suggested. This brief screening instrument administered prior to the scan may help identify in advance those people who are most likely to experience claustrophobic fear and, in particular, those who panic during the MRI procedure.

Toward a standard experiment for studying post-treatment return of fear

Fear sometimes returns after successful fear attenuation via in vivo exposure to fear signals. Post-treatment return of fear is of considerable interest both practically and theoretically, but factors associated with return of fear are poorly understood due to conflicting results from procedurally diverse experiments. This paper reports two very similar experiments in which fear of animal specimens was weakened then allowed to return so that factors associated with return of fear could be studied. In each experiment attentional focus versus distraction during exposure served as a between-subjects independent variable. In each case, attempts also were made to predict return of fear via several nonmanipulated variables: initial fear, initial avoidance during voluntary exposure, initial heart rate during voluntary exposure, and speed of fear reduction during repeated exposure trials. With the sample sizes used there was only suggestive evidence that return of fear was associated with distraction during exposure, and with relatively rapid fear decline during exposure. More importantly, the experiments are offered as standard, replicable models for research that will permit procedurally homogeneous investigations of variables with which return of fear is associated.

One-session cognitive treatment of dental phobia: preparing dental phobics for treatment by restructuring negative cognitions

The purpose of this study was to investigate the effectiveness of a single session of cognitive restructuring in a sample of phobic dental patients. Fifty-two patients were randomly assigned to one of three conditions: cognitive restructuring (modification of negative cognitions), provision of information (about oral health and dental treatment), and a waiting list control condition. Both interventions maximally lasted one hour. In comparison with the waiting list control condition and the information intervention condition, the cognitive intervention condition not only showed a large decrease in frequency and believability of negative cognitions, but also exhibited a clear decline in dental trait anxiety. Analysis at a follow-up of one year demonstrated a further, drastic reduction in dental anxiety in both intervention conditions, wherein the difference among these conditions was not maintained. It is concluded that it is possible to obtain substantial reductions of dental trait anxiety through a single session of cognitive restructuring. Nevertheless, repeated exposure to the dental situation seems necessary for a further reduction of anxiety.

Negative cognitions of dental phobics: reliability and validity of the dental cognitions questionnaire

This study investigated the psychometric properties of the Dental Cognitions Questionnaire (DCQ). This measure contains 38 items and assesses both frequency and believability of negative cognitions related to dental treatment. The results indicated that the DCQ has good internal consistency, high test-retest reliability, and satisfactory concurrent validity, as indicated by positive associations with indices of anxiety and other cognitive measures (n = 180). Factor analysis revealed a one factor solution. Furthermore, the DCQ discriminated strongly between dental phobics (n = 85) and non-phobic Ss (n = 70). Moreover, it was found that combinations of DCQ items have substantially more explanatory power than did a measure of dental trait anxiety, explaining up to 70.7% of the variance in state anxiety ratings in the dental situation. Overall, it appears that dental phobics have many extremely negative beliefs and self-statements about themselves and about what might happen during treatment. Since certain cognitions seem to play a critical role in fear evocation, diminishing catastrophizing ideation may be an important determinant of adjustment to dental treatment and reduction of psychological distress.

Acquisition and maintenance of dental anxiety: the role of conditioning experiences and cognitive factors

This study presents a contribution to the understanding of the mechanisms that are involved in the development and maintenance of dental anxiety. Subjects were 224 undergraduate psychology students who completed questionnaires regarding dental anxiety, painful and traumatic experiences, negative cognitions, dental beliefs, and how their attitude to dental treatment had changed during their life. The results showed that both the extent to which earlier dental treatments were perceived as painful and the extent to which these incidents were reported as traumatic were significantly related to dental anxiety. Evidence was also found to support the latent inhibition hypothesis, which predicts that patients less easily acquire dental anxiety in case they received a number of relatively painless treatments prior to conditioning. Both findings confirmed those earlier obtained by Davey in a conceptually similar design (Behaviour Research and Therapy, 27, 51-58, 1989). In addition, frequency of negative cognitions about dental treatment and dental anxiety appeared to be positively related (r = 0.74; P < 0.001). Significant differences were found between highly anxious Ss and Ss showing low levels of anxiety on a variety of expectations and beliefs related to undergoing dental treatment. The results are discussed in terms of a cognitive-behavioural perspective of dental anxiety.

Treatment of claustrophobias and snake/spider phobias: fear of arousal and fear of context

Forty-nine individuals with fears of snakes or spiders, and 21 individuals with claustrophobic fear were assigned randomly to two sessions of either in vivo exposure plus relaxation or in vivo exposure plus disconfirmation of misappraisals of bodily sensations. Behavioral, subjective and physiological assessments were conducted pre and post treatment, and 4 weeks later. As hypothesized, disconfirmation of misappraisals of bodily sensations benefited claustrophobic fear reduction, but had little effect on fears of snakes or spiders. However, differential treatment effects failed to generalize to nontargetted phobic situations, or generalize over time. In addition, the two treatments affected basic beliefs about arousal sensations equally.

The overprediction of fear: a review

There is converging evidence that many people overestimate how frightened they will be when faced by a fear-provoking situation (Arntz & van den Hout, 1988, Behaviour Research and Therapy, 26, 207-223; Rachman & Bichard, 1988, Clinical Psychology Review, 8, 303-313; Rachman, 1990, Fear and courage (2nd edn). New York: W. H. Freeman). This overprediction of fear is commonly seen in people who are troubled by excessive fear (e.g. claustrophobics, panic patients), but is not confined to them. Anecdotal, clinical, and research evidence suggests that the tendency to overestimate the subjective impact of an aversive event is a common psychological phenomenon. This review will present examples of overpredictions, put forward some explanations of why people might overpredict, consider the function that overpredicting might serve, and the possible consequences of overpredicting. The process by which overpredictions are reduced is also considered and an attempt will be made to relate this strong tendency to overpredict fear to other types of psychological overestimation.