Claustrophobia, MRI and the human factor
uring the four decades since MRI's invention, many problems
connected with it could be solved thanks to the ingenuity of scientists and engineers, but one problem remains unchanged: the anxieties felt by patients. Claustrophobia is one concrete fear many people are haunted by. It is said that commonly at least three or four in 100 patients suffer from it severely enough to interrupt or terminate any MR examination.
Thus, dealing with claustrophobia was a task physicians faced from the very beginning of routine clinical MRI. One of the most pragmatic and down-to-earth studies on the topic was presented earlier this year by a group of radiographers from Trondheim, Norway. Some of them have nearly 30 years of experience, and have worked in MRI since the opening of their facility in 1986.
For one month, all patients (1,007) examined on six different MR systems were enrolled, actively involving 17 radiographers . A total of 90% of patients underwent their examinations with only the information they received orally and in writing before their examination. The rest needed special attention. In the end, all patients completed their examinations; nobody terminated early due to claustrophobia. How did they – staff and patients – manage to fight claustrophobia and other anxieties?
Claustrophobia isn't a technical problem
that can be solved by technical means.
Claustrophobia isn't a technical problem that can be solved by technical means. Of course, one should avoid inadequate and noisy equipment that might boost anxieties. However, even the authors of a recent multicenter study with a strong bias toward recommending supposedly claustrophobia-reducing MR machines had to concede eventually [2,3]:
"The present study in high-risk patients demonstrated claustrophobia precluding MR imaging in more than 25% of examinations despite using equipment designs expected to lower the rate of claustrophobic events. The most problematic phase of the scan procedure is during positioning, as well as on entry into the examination room. Thus, procedural modifications might also be influential for reduction of claustrophobic event rates."
What matters is the fear of the confinement in a tube, of having no escape. This human problem can be dealt with by human measures – in an exchange between the examiner and the patient. The contact, dialogue, and understanding between patient and radiographer are among the most important ingredients of a successful MRI examination. Communication leads to the choice of the right strategy for the individual patient, as the radiographer can act on the response of the patient. Most claustrophobic patients are able to complete their examination when some effort is made to support them, according to their individual needs.
Communication with the patient should include the following:
explanation of the strategy and handling of the examination;
Deciding which strategy to be used depends on the patient. When given some advice about how to handle stress inside the magnet, the patients included in the Norwegian study achieved the required feeling of self-control.
Particular considerations that proved helpful to patients in the Norwegian study are listed below:
Whenever possible, patients should enter the machine feet first;
a mirror to the head coil helped a quarter of the patients to feel more comfortable;
an accompanying person, laying a hand on the patient's feet, made it easier for them to cope with the situation;
patients in pain should be comforted with something such as an extra cushion, helping them to find a comfortable position that they can keep during the examination;
to shorten the examination time when the patient is in pain or very uncomfortable inside the magnet, the application of preplanned "short" pulse sequences for the examinations proved helpful;
use of a coil that might not be the optimal or most common for the kind of study but suits the patient;
allow certain patients to come out of the magnet between sequences;
talk between the scans.
These actions are simple, but very practical and helpful. They indicate a positive attitude toward the patients' problems and aid the patients in building up the confidence in themselves to manage the situation. The actions are, however, time-consuming and require well-trained radiographers with an understanding of psychology. They do not fit the trend to industrialized, assembly-line patient examinations.
Technology can be very helpful; many medical personnel, radiology professionals included, believe that state-of-the-art equipment is the most important facet of their job. However, working as a doctor, a radiographer, or a nurse concerns human relations – first and foremost. The physical well-being and mental relaxation of a sick person while being examined must always be on top of our priorities when trying to find a diagnosis in medical imaging, not the shareholder value of the owners of a commercial imaging center. So-called personalized imaging – not only of claustrophobic patients – means showing an interest in, and responding to, the worries, concerns, fears, and problems of the person who is to be examined and taking care of their individual needs.
Germany leads the worldwide use of MR examinations with close to 100 examinations per 1,000 inhabitants, and the greater Berlin area has the highest ratio worldwide at about 110 examinations per 1,000 inhabitants. This is more than in the U.S. and 50% more than the number in France and Denmark . Interestingly, claustrophobia seems to also depend on the structure of the society and its healthcare system. German data on claustrophobia show higher percentages than those of other countries.
Finally, a study on the topic from Malaysia points out:
"A recognized cause of incomplete or cancelled MRI examinations is anxiety and claustrophobic symptoms in patients undergoing MR scanning. This appears to be a problem in many MRI centers in Western Europe and North America, where it is said to be costly in terms of loss of valuable scan time. ... To determine the incidence of failed MRI examination among our patients and if there are any associations with a patient's sex, age, and education level, we studied claustrophobia that led to premature termination of the MRI examination. ... The incidence of failed MRI examinations due to claustrophobia ... was found to be only 0.54%. There are associations between claustrophobia in MRI with the patients' sex, age, and level of education. The majority of those affected were male patients and young patients in the 25-45-years age group. The patients' education level appears to be the strongest association with failed MRI examinations due to claustrophobia, where the majority of the affected were highly educated individuals. Claustrophobia in MRI is more of a problem among the educated individuals or patients from a higher socioeconomic group, which may explain the higher incidence in Western European and North American patients ."
It's for you to draw the conclusions.
1. Landrø Svarliaunet AJ. Pasientkommunikasjon og gjennomføringsstrategi ved MR. Hold Pusten. 2014; 41: 24-28.
2. Enders J, Zimmermann E, Rief M, et al. Reduction of claustrophobia during magnetic resonance imaging: Methods and design of the "CLAUSTRO" randomized controlled trial. BMC Medical Imaging. 2011; 11(4): 1-15.
3. Enders J, Zimmermann E, Rief M, et al. Reduction of claustrophobia with short-bore versus open magnetic resonance imaging: A randomized controlled trial. PLOS One. 2011; 6(8): e23494.
4. Total magnetic resonance imaging (MRI) examinations per 1,000 population provided by OECD 2013 (data from 2011 and 2009); data for Germany provided by Barmer GEK, Arztreport 2009.
5. Sarji SA, Abdullah BJ, Kumar G, Tan AH, Narayanan P. Failed magnetic resonance imaging examinations due to claustrophobia. Australas Radiol. 1998; 42 (4): 293-295.