Intensive two-day cognitive-behavioral intervention decreases cortisol secretion in soldiers suffering from specific phobia to wear protective mask Serge Brand a, c, * , Hubert Annen b, c , Edith Holsboer-Trachsler a , Andreas Blaser c a Psychiatric Hospital of the University of Basel, Depression and Sleep Research Unit, Basel, Switzerland b Military Academy at the ETH Zürich, Zürich, Switzerland c Psychological Service of the Swiss Army (PSSA), Land Forces of the Swiss Army, Thun, Switzerland article info Article history: Received 8 March 2011 Received in revised form 26 April 2011 Accepted 27 April 2011 Keywords: Specific phobia Claustrophobia Cortisol Cortisol awakening response Protective mask Cognitive-behavioral treatment abstract Research questions: Wearing a protective mask is compulsory for those in professions such as fire- fighters, rescue personnel and soldiers. The phobia to wear a protective mask is considered a specific claustrophobia and may become of major concern during military service. To date, no data are available with respect to the hypothalamus-pituitary-adrenocortical system activity (HPA SA) for both the so- called protective mask phobia (PMP) and its treatment. The aim of the present study was three-fold: 1) to assess HPA SA in soldiers suffering from PMP before and after intensive cognitive-behavioral treatment, 2) to compare these data with controls, and 3) to relate these data to subjective sleep. Methods: 46 Swiss Army recruits suffering from PMP were enrolled in a two-day intensive treatment course. During initial and final assessments, saliva was sampled to analyse HPA SA via salivary cortisol; saliva samples were also gathered in the morning. For comparison, saliva samples were gathered of 39 Emergency Rescue Service (ERS) recruits. All participants also completed a questionnaire related to sleep and to anxiety. Results: Compared to controls from the ERS, among army recruits suffering from PMP, cortisol secretion was significantly higher during initial and final assessments, and in the morning. Cortisol secretion decreased from initial and final assessment. Subjectively assessed sleep was more impaired in recruits suffering from PMP compared to controls. After cognitive-behavioral treatment, all recruits suffering from PMP were able to wear the protective mask. Conclusions: Specific phobia about wearing a protective mask is treatable via a two-day intensive course. Treatment success is reflected in modified HPA SA. Methodology and results may be transferred to treat patients suffering from sleep apnea syndrome and presenting high anxiety about wearing continuous positive airway pressure devices. Ó 2011 Elsevier Ltd. All rights reserved. 1. Introduction Within the broad range of psychiatric disorders, anxiety and specific phobias demand particular attention because they are among the most frequently occurring forms of such disorder (Wittchen and Jacobi, 2005). Among adults, lifetime prevalence rates are in the 2%e3% range for generalized anxiety disorders, and a 2.1%e2.4% range for agoraphobia and specific phobia (Wittchen, 1998). European epidemiological studies show twelve-month prev- alence rates of 1.3% for agoraphobia, 6.4% for specific phobias, and 2.3% for social phobias (Wittchen and Jacobi, 2005; Goodwin et al., 2005). Among children and adolescents, prevalence rates range from 8.3%e27%, depending on the age and disorder (separation anxiety disorder, generalized anxiety disorder, social phobia; cf. Sadock and Sadock, 2009). For some professions such as fire-fighters and rescue personnel the use of a protective mask (PM) and protective clothing (PC) is compulsory. More specifically, for soldiers, using PM and PC correctly and efficiently dramatically increase the chances of survival following an attack with chemical and biological weapons. The PM is worn on the face to give protection from airborne pollutants and toxic materials, and has various adjustable straps which may be tightened to secure a good fit. The core of a PM is the filter cartridge near the mouth. 1 Despite the fairly easy adjustments * Corresponding author at: Psychiatric Hospital of the University of Basel, Depression and Sleep Research Unit, Wilhelm Klein-Strasse 27, 4012 Basel CH, Switzerland. Tel.: þ41 61 32 55 114; fax: þ41 61 32 55 513. E-mail address: serge.brand@upkbs.ch (S. Brand). 1 Some models contain drinking tubes and corrective lens if required. Contents lists available at ScienceDirect Journal of Psychiatric Research journal homepage: www.elsevier.com/locate/psychires 0022-3956/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.jpsychires.2011.04.010 Journal of Psychiatric Research 45 (2011) 1337e1345