258 Handbook of Exposure Therapies

incremental effect of select treatment components and parameters in relation to

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maintenance of short-term and long-term therapeutic gains.

CLAUSTROPHOBIA

According to data from the national comorbidity survey, the lifetime preva-
lence rate of claustrophobia is 4.2% (Curtis, Magee, Eaton, Wittchen, & Kes-
sler, 1998). This makes claustrophobia the third most prevalent phobia, following
animal and height phobias. Several controlled treatment outcome studies have
examined exposure techniques for claustrophobia (Booth & Rachman, 1992; Öst,
et al, 2001; Öst, Johansson, & Jerremalm, 1982), all of which demonstrate that
individual exposure approaches produce significant improvements in claustro-
phobia symptoms.

Comparative Studies

There is some evidence that exposure interventions are as effective as cognitive

and relaxation interventions. One of the earliest studies conducted by Öst, et al.
(1982), who randomly assigned 34 claustrophobic individuals to exposure, applied
relaxation, or control conditions for 8 to 10 weeks over 3 months. Participants
were classified as either behaviorally reactive or physiologically reactive based on
pretreatment behavioral testing. In the exposure condition, participants progressed
through idiosyncratically developed hierarchies. Relative to the control condi-
tion, individuals in the treatment conditions showed greater improvement at post-
treatment and 14-month follow-up period. The exposure group yielded better
outcomes than the relaxation group at post-treatment, but differences disappeared
at follow-up evaluation. Behaviorally reactive individuals improved to a greater
extent with exposure than relaxation, whereas the reverse pattern was seen with
physiologically reactive participants.
In a later study, Booth and Rachman (1992) compared three independent
treatments (i.e., gradual in vivo exposure, interoceptive exposure, and cognitive
therapy) to a control condition. Individuals in the exposure condition developed
hierarchies using situations available in the laboratory setting (e.g., staying in the
laboratory closet with the door open and the light on, being in the closet with
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the door locked and the light off) and completed the hierarchy over the course
of three sessions. Individuals in the interoceptive exposure condition completed a
series of behavioral tasks (e.g., overbreathing, spinning, running in place) to simu-
late physical sensations they experienced when anxious. At post-treatment, the
in vivo exposure condition showed the greatest gains on self-report, behavioral,
and physiological measures of anxiety on exposure to claustrophobic situations. In
contrast, the cognitive and interoceptive exposure groups demonstrated marginal

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 Exposure Therapy for Phobias 259

improvement relative to the control condition. However, no differences among

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the treatment groups were found at post-treatment and 6- to 8-week follow-up

evaluation.
Another study by Öst and colleagues (2001) compared 3-hour single-session
individual in vivo exposure, five 1-hour weekly individual in vivo exposure, and
five 1-hour weekly individual cognitive therapy to a wait-list control condition.
A total of 46 claustrophobic individuals were treated. Individuals in the exposure
groups selected personally relevant fear-eliciting situations (e.g., elevator, window-
less room, subway). Individuals in the single-session group were exposed to two or
three situations while accompanied by a therapist. Individuals in the five-session
group confronted four to five situations with the therapist. All treatment groups
showed improvement across a variety of assessment measures relative to the wait-list
condition at post-treatment, with treatment gains maintained at 1-year follow-up
evaluation.
The preceding studies demonstrate the effectiveness of in vivo individual expo-
sure techniques, including short-term treatment strategies (i.e., single-session). At
this point, the available controlled treatment outcome studies for claustrophobia
support similar efficacies of several types of psychological interventions, including
exposure, with long-term treatment gain up to 14 months.

Factors Affecting the Efficacy of Exposure

for Claustrophobia

Several studies using individuals with subclinical levels of claustrophobia have

examined factors that mediate the effectiveness of in vivo exposure (Kamphuis &
Telch, 2000; Powers, Smits, & Telch, 2004; Sloan & Telch, 2002; Telch, Valentiner,
Ilai, Petruzzi, & Hehmsoth, 2000; Telch, Valentiner, Ilai, Young, Powers, & Smits,
2004). In these studies, brief exposure trials of about 5 minutes, with several differ-
ent behavioral and cognitive conditions, were repeated for up to 30 minutes in a
small room. These studies yielded three primary conclusions. First, instructing indi-
viduals to focus on claustrophobia-related cognitions during exposure enhanced
the effectiveness of exposure therapy, whereas distracting thoughts or mental pro-
cesses appeared to impede treatment. Second, treatment was also impeded if partici-
pants were aware that they could engage in an escape behavior that could decrease
their anxiety (e.g., opening a window). Finally, physiological feedback enhanced
Copyright @ 2007. Academic Press.

the effectiveness of exposure therapy. These findings appear to be consistent with

Foa and Kozak’s emotional processing theory (1986) in that they suggest activation
of the fear network, and the presentation of corrective information that is incom-
patible with pathological elements in the fear network, are two important requi-
sites for fear reduction. These studies, however, were conducted with nonclinical
individuals, and the question remains whether the results will generalize to clinical
populations.

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 260 Handbook of Exposure Therapies

Summary for Claustrophobia

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Overall, brief in vivo exposure techniques are effective in the treatment of

claustrophobia. The available research results suggest that exposure is at least as
effective for treating claustrophobia as cognitive therapy and relaxation. It also
seems to be the case that maximizing emotional processing during exposure is a
key factor for modifying less severe symptoms. Little is known, however, regard-
ing optimal treatment delivery and whether a combination of disparate treatment
modalities (e.g., in vivo exposure plus cognitive restructuring) might enhance treat-
ment outcome. In addition, other issues remain: the effects of varying the way
exposure is delivered, how the hierarchies are constructed, and whether clinical
samples respond to treatment in a way that is similar to nonclinical participants.

FLYING PHOBIA

The available literature suggests that exposure treatments and cognitive-behavioral

approaches that include in vivo exposure components are equally effective and
superior to no-treatment conditions for flying phobia (e.g., Howard, Murphy, &
Clarke, 1983; Öst, Brandberg, & Alm, 1997; Van Gerwen, Spinhoven, Diekstra, &
Van Dyck, 2002). Because many people have a fear of flying, and because the fear
may interfere with an individual’s professional obligations, a relatively large research
base has developed in this area. More recently, fear of flying has received increased
attention because of the ease with which flight cabins can be simulated in a virtual
environment (in addition to the following section, see Bouchard, Côte, & Richard
in this volume).

Virtual Reality

Compared to other in vivo exposure situations, taking a commercial airplane

flight is a costly part of treatment. The creation of a virtual flight cabin with all
the attendant sounds made on takeoff, landing, and so forth offers a cost-effective
treatment option for clinicians that allows a degree of control not possible in real
environments.
The most impressive series of studies on fear of flying was performed by Roth-
Copyright @ 2007. Academic Press.

baum and colleagues (Rothbaum, Hodges, Anderson, Price, & Smith, 2002; Roth-
baum, et al., 2000). In these two studies they reported treatment and follow-up
results for 49 individuals assigned to VR, in vivo exposure, or wait-list conditions.
Participants were eligible for the study if they had a phobic fear of flying, panic with
agoraphobia, or agoraphobia without panic. Participants completed eight sessions
over 8 weeks or were placed on a treatment wait list. VR exposure included simula-
tion of flight-related events (e.g., taking off, flying, a thunderstorm, turbulence, and

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 Exposure Therapy for Phobias 261

landing). Prolonged in vivo exposure with standardized exposure hierarchy items

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took place at the airport terminal and on a stationary airplane where individuals
engaged in imaginal exposure. Both the VR and in vivo exposure groups received
anxiety management and cognitive restructuring training before exposure. Both
exposure groups displayed significant reductions in self-reported fear of flying and
were superior to the wait-list control at post-treatment, 6-month follow-up, and
12-month follow-up. More than 90% of individuals in both treatment groups took
an actual flight during the 12-month follow-up period. There were no differences
in treatment outcome between the exposure groups.
Other controlled treatment outcome studies support the efficacy of VR exposure
for flying phobia. Mühlberger, Herrmann, Wiedemann, Ellgring, and Pauli (2001)
compared a single-session VR program to a single-session relaxation program. The
VR program consisted of 18 minutes of audiovisual information with motion simu-
lations of all flight components, including leaving the terminal, taking off, turbulence,
and landing. The VR group repeated the program four times. In addition, both
groups underwent VR exposure (6 minutes, no audio or turbulence effects) as part
of the assessment process. Results from a total of 30 individuals with flying phobia
revealed that the exposure group yielded more significant improvement in some
self-reported symptoms than the relaxation group at post-treatment. At 14-week
follow-up evaluation, a trend in favor of the VR group was found.
Another study (Mühlberger, Wiedemann, & Pauli, 2003) compared two sin-
gle-session, VR exposure programs (VR with motion simulation plus cognitive
treatment, VR without motion simulation plus cognitive treatment) and a cogni-
tive intervention to a nonrandomized wait-list control condition in a total of 47
diagnosed flying phobics. The VR programs provided audiovisual with or without
motion simulation of all flight components similar to those used by Mühlberger,
et al. (2001). Individuals in the VR groups briefly learned cognitive techniques
and completed four successive 18-minute VR flights in the session. The cognitive
therapy group received one session of cognitive restructuring psychoeducation.
Results revealed that both VR exposure conditions were significantly superior to
the wait-list condition in reducing symptoms at post-treatment and the 6-month
follow-up period, whereas the cognitive and wait-list control groups were not
significantly different. This latter finding is not especially surprising given that
cognitive therapy is not intended to be delivered in only one session. Presence
or absence of motion simulation also had no impact on the effectiveness of the
virtual treatments. At 6-month follow-up evaluation, 62% of individuals in the
Copyright @ 2007. Academic Press.

VR groups had taken a commercial flight since treatment relative to 45% of those
in the cognitive treatment condition. There was no follow-up evaluation for the
control group.
The burgeoning VR treatment literature for fear of flying suggests that virtual
treatments for flight phobia are superior to wait-list control conditions and may be
superior to other treatments, although the evidence is limited. No study to date has
shown VR exposure to be superior to in vivo exposure. It may be the case that VR

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