ORIGINAL CONTRIBUTIONSReduction of anxiety during MR imaging: a controlled trial
Introduction
Severe anxiety reactions have been reported in between 1% and 30% of patients undergoing magnetic resonance imaging (MRI) examinations [1], [2], [3], including many patients who do not normally consider themselves to be claustrophobic. Patients have also commented that they feel “buried alive” or “abandoned” or “disorientated.” These reactions present a problem because they make the procedure unpleasant for the patient, sometimes resulting in premature termination of the scan or outright refusal, leading to adverse clinical consequences and representing an expensive waste of resources. Motion artifacts, which may arise from movement of the patient, respiration, fluid flow or swallowing [4], [5], may be increased in patients who are worried about the procedure [6]. Functional MRI research may be compromised by severe anxiety reactions that may disrupt the cognitive or neurological processes under investigation. Finally, a bad experience in the scanner may lead to procedure-induced claustrophobia.
The anxiety associated with medical procedures may be attributable to various factors, including anticipation of pain or discomfort, unfamiliarity with the procedure, concerns about diagnosis or prognosis, the predictability of aversive experiences, and the patient’s sense of control over the procedure [7]. There may also be some factors which are specific to MRI scanning, such as the small spatial dimensions of the tube, the duration of the scan and the loud machine noise [8], [9].
Various interventions have been tried in order to reduce the anxiety related to medical procedures, including provision of information, modelling, distraction with music or video, and prior training in relaxation and cognitive techniques [10], [11]. In adults, a combination of procedural and sensory information has been found more helpful than procedural information alone [12]. Other strategies have involved reducing unexpected elements and giving patients elements of choice or control [13].
In the case of MRI procedures, a number of anxiety reduction strategies have been suggested, such as sedation [14], lying prone rather than supine [15], prior rehearsal in an ‘MRI simulator’ [16], combinations of relaxation training, information and counseling [17], [18] or, for individual cases of severe anxiety, systematic desensitization [19]. All these approaches have some value, but sedation or lying prone may not be suitable for brain or spinal scans in psychiatric or neurology patients and the other procedures are too time-consuming to be suitable for routine use. Other workers have suggested that prior to scanning patients should be assessed for claustrophobia, levels of pain, and apprehension about diagnosis [20], [21]. It is certainly desirable that the medical service requesting the scan should carry out such an assessment and take steps to prepare their patient prior to attendance at the MR Unit. In practice, however, this is unlikely to be done consistently and the responsibility remains with MR staff to ensure that discomfort is kept to a minimum for all patients.
Psychological therapies for treating clinical anxiety and phobias are now well-established [22]. The most powerful techniques use a combination of cognitive and behavioral strategies such as prior imaginal rehearsal, relaxation training, graded exposure and cognitive reframing. The purpose of the present study was to develop and evaluate an anxiety reduction protocol which informs patients about the procedure and the sensations they are likely to experience, instructs them on cognitive strategies for reducing anxiety while in the scanner, maximizes their sense of connection with the outside environment and increases their sense of control and predictability. The new procedure is intended to be applicable to a wide range of MRI situations, including fMRI, involve no special equipment and cause no interference with other clinical or research protocols.
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Participants
All patients who attended for brain and/or spine scans on the designated days (see Materials and Methods) were asked to participate in the study, except for two patients who spoke little or no English. In the study period only two children under 16 years attended. They were excluded because their anxiety and understanding of the procedure might be expected to differ from the rest of the sample and because the anxiety measures had been developed for use with adults. In total, 91 adults were
Materials and methods
Patients attended the Maudsley Hospital MR Unit for scanning using a 1.5 Tesla GE Signa System (General Electric, Milwaukee, WI, USA) fitted with Advanced NMR hardware and software (ANMR, Woburn, MA, USA). Data were collected on the same day of each week, with each day designated as either a Standard (Control) or an Experimental day, according to the sequence SEESESSE. Since the majority of patients could not be seen prior to attendance and frequent changes in procedure would have been
Results
Table 1 shows that the groups did not differ in terms of age, sex, trait anxiety, or total time in the scanner. Both groups included patients with a range of types of scan, some including angiograms or contrast injections. Type of scan was categorized into broad groupings of head, head and spine and spine only (see Table 1). There were somewhat fewer patients having only spinal scans in the experimental group than in the standard treatment group. Since type of scan might be expected to interact
Discussion
The results of this study demonstrate that patients undergoing the modified procedures experienced less anxiety while in the scanner than patients undergoing standard procedures. Although this difference was not apparent at the start of scanning, experimental patients reported less anxiety after scanning had commenced and in retrospect than patients in the control group. The modifications include increased written procedural and sensory information prior to the scan, simple instructions in
Acknowledgements
Thanks are due to General Electric Medical Systems (UK) for financial assistance in the production of the booklet, the staff of the Maudsley MR Unit for help carrying out the research and to Professor B. S. Everitt for statistical advice.
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