Claustrophobia: lifts, tunnels, MRI scans

Claustrophobia affects between 5% and 7% of the adult population. It usually appears in late adolescence or early adulthood, and the symptom most people associate with it — being stuck in a lift — is in fact just the tip.

The deep core of claustrophobia is not the size of the space. It is the perception of not being able to get out. A wide tunnel with no exit triggers more anxiety than a narrow alley with the way open. The cognitive theme is captivity, not smallness.

Typical situations

• Lifts (especially small ones, with people, with delays).
• Tunnels (driving through them, the underground in long sections).
• MRI scanners (closed bore, 20-45 minutes still).
• Aircraft (the closed door before take-off).
• Small public toilets.
• Crowds (subjective lack of "exit", though objectively there is space).
• Garments such as polo necks, tight wetsuits.

A claustrophobe usually has triggers in several of these categories, with different intensities. Not all reach phobic level: many people manage tunnels but block at MRI scans.

What is happening in the body

The sympathetic system activates anticipating "if I need to get out, I won't be able to". The thought "I won't be able to get out" feeds back the body, which generates more sensations, which feed the thought, which… The loop classically ends in a panic attack.

A key feature: there is no actual external danger. The lift is not falling, the tunnel is not collapsing. The danger is internal: a feeling that escalates and you do not know how to stop.

The exposure ladder

A standard ladder, adjustable:

1. Look at a photograph of a small lift for 2 minutes (SUDS 2-3).
2. Look at videos of crowded lifts on YouTube (SUDS 3-4).
3. Enter a lift with the door open. Stay 1 minute (SUDS 4).
4. Lift with closed door, ground floor only, not going up (SUDS 4-5).
5. Lift one floor, accompanied (SUDS 5).
6. Lift 3-4 floors, accompanied (SUDS 5-6).
7. Lift alone, 2-3 floors (SUDS 6-7).
8. Long lift, peak hours, with many people (SUDS 7-8).

For tunnels and MRI scans, similar ladders, starting with virtual exposure and gradually moving to real environments.

Specific case: MRI scan

The MRI is one of the most common claustrophobic experiences in adults because you cannot avoid it: when a doctor orders it, you usually need it. Practical strategies:

• Ask for an open MRI if available. They are less common but exist.
• Ask the radiographer if you can be face down instead of face up. Less feeling of enclosure for many people.
• Take an eye mask. Sometimes not seeing helps more than looking at the closed roof.
• Music with headphones. Most clinics let you choose.
• Speak with the radiographer through the panic button any time. Knowing you can always pause it reduces the feeling of captivity.
• Conscious breathing: inhale 4, exhale 6. For 20-30 minutes.
• Mental script: "I'm not trapped. I'm choosing to be still. I can ask to come out any time."

For severe claustrophobes, anxiolytic premedication (low-dose benzodiazepine, 30-45 minutes before) is acceptable in this specific case. Discuss with your GP or referring doctor.

Specific case: lifts

The lift is the most "trainable" of all because you can decide when to do it. Recommended frequency: 3-4 times a week, in different lifts. Avoid the very specific lift that has scared you most before — start with neutral ones.

If you live in a tower block and you have not used the lift for months, the recovery plan can take 4-6 weeks. Going up the stairs in the meantime is fine, but should not become permanent: avoidance maintains the phobia.

Common safety behaviours

• Always going up with a specific person.
• Carrying water "in case".
• Looking at the phone the whole journey.
• Carrying anxiolytics "just in case" without taking them.
• Going up at off-peak hours only.
• Always with the same shoes/clothes that feel "safe".

These behaviours work for a while, but they prevent the brain from confirming that the lift is safe without them. The goal is to retire them gradually.

What NOT to do

• Force yourself to a long underground journey "to overcome it". Massive exposure tends to backfire.
• Avoid medical tests you need. The cost is too high.
• Skip lifts for years and then expect to take one without preparation.
• Drink alcohol before. It accentuates the catastrophic thoughts.
• Talk yourself out of it just before ("calm down, nothing's going to happen, calm down"). It is a safety behaviour that maintains the fear.

When to seek a professional

• If the phobia affects work (specific journeys, mandatory meetings).
• If you have avoided medical tests you needed.
• If there is comorbidity with panic disorder or agoraphobia.
• If you have lost autonomy: not visiting people, not travelling, not going to events.
• If self-applied exposure has not produced changes in 8 weeks.

Claustrophobia responds very well to cognitive-behavioural therapy in 8-12 sessions. Virtual reality is also useful for tunnels and MRIs.

Closing

Claustrophobia is not lack of courage. It is a brain that has learned to read certain spaces as "no way out". With patience and a graded plan, the brain learns that the way out is always there — even when there is no door.