MRI and Claustrophobia
MRI (Magnetic Resonance Imaging) tests are an essential diagnostic tool, providing detailed internal images used to detect and diagnose health conditions. However, with an estimated 2-5% of the general population having claustrophobia (an abnormal fear of being confined in a small space), and up to 30% of patients reporting claustrophobia during MRI scans, this common phobia poses a significant problem for administering MRIs.
Claustrophobia is defined as an extreme fear of tight or confined spaces. It can induce severe anxiety, panic attacks, and an intense desire to escape the confined situation. For claustrophobic patients undergoing an MRI scan, which involves lying still for an extended period inside the narrow bore of an MRI machine, this experience can be highly distressing. Their anxiety may lead to an inability to complete the scan or motion artifacts that reduce the diagnostic value of the images. Finding effective ways to accommodate claustrophobic patients is crucial to ensure they can undergo medically necessary MRI procedures.
Causes of Claustrophobia in MRI
The narrow enclosed space inside an MRI scanner can trigger claustrophobic reactions in many patients. MRI machines are small tubes that patients need to lay still inside of for up to 90 minutes. This tight enclosed space can provoke anxiety and panic in those predisposed to claustrophobia.
Additionally, MRI scans require patients to lay still while loud buzzing and thumping sounds occur. The combination of being in an enclosed space unable to move while loud noises occur around you can further increase anxiety. Many patients describe the experience as being buried alive in a coffin.
The duration of MRI scans, often 30-90 minutes, can also exacerbate claustrophobic symptoms. Patients need to stay completely still for the entire duration of the scan, further adding to the anxiety and feeling of being trapped. As time passes, the confinement can feel more intense.
Understanding the triggers behind claustrophobic reactions to MRI exams, including the tight space, loud noises, and scan duration, can help medical staff better accommodate these patients.
Impacts of Claustrophobia During MRI
Claustrophobia during MRI scans can have significant impacts on patients and medical facilities. One major impact is the inability to complete MRI scans. It is estimated that up to 37% of patients experience apprehension or anxiety during MRIs, with 2-15% unable to tolerate and finish their scans [1]. This can delay diagnosis and treatment for conditions that may require imaging.
Another impact is the need for sedation procedures to help claustrophobic patients complete MRI scans. Sedation comes with risks of side effects and requires monitoring by an anesthesiology team, adding time and costs to the process. There are also costs associated with rescheduling incomplete scans. Estimates indicate over $100 million per year is spent in the U.S. on rescheduling MRIs due to claustrophobia [2].
In summary, claustrophobia can prevent the completion of medically necessary scans, require expensive sedation procedures, and lead to rescheduling costs. Addressing claustrophobia is important to improve patient experience and limit unnecessary expenses.
Screening Patients for Claustrophobia
It is important to screen patients for claustrophobia before an MRI procedure. Undiagnosed claustrophobia can lead to patient distress, inability to complete the scan, and wasted resources if the scan needs to be rescheduled. There are several validated screening tools that can be used:
The Claustrophobia Questionnaire (CLQ) is a self-report scale that measures anxiety related to enclosed spaces. It contains 26 items scored on a 5-point scale, with total scores categorizing patients as not claustrophobic, moderately or severely claustrophobic.
The Claustrophobia Scale (CS) is a brief 10-item scale measuring fear and avoidance of enclosed spaces. Patients rate items on a 5-point scale, with higher total scores indicating greater claustrophobic symptoms.
Visually showing the patient pictures of the MRI machine and tunnel can gauge reactions. Signs of anxiety like sweating, fidgeting, vocal concerns can clue clinicians into possible claustrophobic symptoms.
Asking direct questions about fear of enclosed spaces, feelings of panic in tight spaces, and past scan experiences can reveal claustrophobia.
Identifying claustrophobic patients in advance allows time to plan accommodations, provide reassurance, consider sedation or open MRI when appropriate. Thorough screening leads to smoother scans and improved patient-centered care.
Accommodations for Claustrophobic Patients
There are several accommodations that can help patients with claustrophobia feel more comfortable during an MRI scan. Some options to discuss with patients include:
Music - Allowing patients to listen to calming or favorite music during the MRI can help distract from the confined space. MRI facilities should offer music selections or allow patients to bring their own playlists.
Mirrors - Installation of angled mirrors can allow patients to see out the end of the scanner bore rather than staring at the inside tunnel. This increases perceived space.
Communication - An intercom system allows patients to talk with the MRI technician during the procedure. The technician can offer reassurance, updates on timing, and advice for coping strategies.
Eye masks - Providing eyes masks can help block out the inside of the scanner so patients feel less enclosed. These should be offered in addition to ear protection.
Anxiety medication - In some cases, a mild anti-anxiety medication may be prescribed beforehand to take the edge off claustrophobia during the scan. This is only advisable for patients who have tried other options without success.
Counseling - Having an MR counselor or anxiety coach available to talk through concerns, demonstrate equipment, and teach relaxation techniques can make a major difference for claustrophobic patients.
Accommodating anxious and claustrophobic patients requires patience, empathy and a variety of tools. An open dialogue with patients and a willingness to adjust protocols can help ease MRI procedure stress.
Sedation Procedures
For some patients with severe claustrophobia or anxiety, sedation may be required for them to tolerate the MRI procedure. There are different levels of sedation that can be used, depending on the patient's needs:
Minimal Sedation
This involves using anti-anxiety medications like benzodiazepines (Valium, Ativan) to help the patient relax. This level of sedation does not put the patient fully asleep, but takes the edge off anxiety. Patients are still able to follow instructions and communicate. Risks are relatively low.
Moderate Sedation
This uses medications to make the patient drowsy and comfortable, but not fully unconscious. Medications like propofol or ketamine are used. Patients may fall asleep but can still respond to touch or loud noises. There are more risks with moderate sedation including lowered blood pressure and slowed breathing. Monitoring by an anesthesia provider is required.
Deep Sedation
The patient is very close to general anesthesia with this level. Medications like propofol and fentanyl produce unconsciousness. The airway may need protection and vital signs require continuous monitoring. Risks include low oxygen levels, low blood pressure, airway obstruction. An anesthesia care team must administer and monitor deep sedation.
The costs and risks increase with deeper levels of sedation. Minimal sedation can often be done with just an extra medication, while moderate or deep sedation requires specialized providers to administer and monitor the effects. If sedation is required, the medical team will determine the safest and most cost-effective method to allow the patient to complete the MRI.
Open MRI Scanners
Open MRI scanners are designed with open sides and more space, which can help alleviate feelings of claustrophobia. Unlike traditional tunnel MRI machines, open MRI scanners do not fully enclose the patient. This allows patients who experience anxiety or panic in enclosed spaces to undergo MRI imaging in a more comfortable environment.
There are several benefits of open MRI for claustrophobic patients:
More space and openness. Open MRI machines have open sides, providing more room for the patient's head and more visibility of the surrounding area. This can help reduce trigger points for anxious patients.
Less noise. Some open MRI designs eliminate noise from the scanner, which can also help patients feel calmer and more relaxed.
Ability to see out. With open sides, patients can see out into the room and are less isolated. This allows for better communication with the tech operating the scanner.
Accommodates larger patients. Open scanners have wider and shorter bores, which can better accommodate larger body sizes that may have difficulty fitting into traditional MRI machines.
Less restrictive. The open design has fewer physical barriers, eliminating feelings of being trapped or confined.
Easier interaction. Open MRI allows for better interaction between patient and medical staff, which can help keep patients at ease.
For patients that experience fear or panic in enclosed spaces, an open MRI can greatly reduce anxiety and improve the imaging experience. The ability to see out, reduced noise, and more space allows claustrophobic patients to undergo necessary MRI scans they may have avoided with a traditional closed scanner.
Preparing Claustrophobic Patients
Undergoing an MRI scan can be very distressing for claustrophobic patients. However, with the right preparation and coping techniques, these patients can successfully complete their MRI procedures.
The psychological preparation starts with education. Patients should be informed in detail about the MRI procedure, including the reason for the scan, what will happen during the scan, and for how long they will need to be inside the scanner. Knowing what to expect can help alleviate anxiety. The MRI staff should reassure patients that they will be monitored at all times and can communicate with staff during the scan.
Relaxation techniques like deep breathing, progressive muscle relaxation, and guided imagery can help patients remain calm when entering the scanner. Patients may find it helpful to practice these techniques ahead of time. Listening to soothing music during the scan is another effective strategy.
In some cases, having a trusted friend or family member present during the procedure can help. This support person can offer encouragement, remind the patient to use their coping strategies, and provide a sense of safety. Some facilities even allow the support person to be in the scan room.
For patients with severe anxiety about small spaces, gradually exposing themselves to confined spaces through desensitization techniques can help. This may involve asking the patient to briefly sit in a small room, closet, or MRI simulator machine. Over multiple sessions, the patient spends more time in confined spaces while practicing relaxation skills.
While challenging, with proper psychological readiness and coping methods, claustrophobic patients can successfully manage MRIs. The right preparation empowers patients and helps them feel a sense of control over their experience.
Alternatives to MRI
For patients who cannot tolerate MRI due to severe claustrophobia, there are some alternatives that can provide similar diagnostic information in certain cases. However, MRI is often preferred due to its lack of radiation exposure and superior contrast for soft tissue imaging.
CT Scans
Computed tomography (CT) scans use X-rays and computer processing to create cross-sectional images of the body. They can provide high resolution images of bone injuries and pathologies. However, CT scans do expose patients to ionizing radiation and often require intravenous contrast agents. They also do not provide the same level of soft tissue contrast that MRI offers. CT may be an acceptable alternative to MRI for concerns like sinusitis or dental issues, where radiation exposure is less of a factor.
PET Scans
Positron emission tomography (PET) scans involve injection of radioactive tracers that accumulate in tissues with high metabolic activity. This allows PET to map functional processes in the body. However, the spatial resolution of PET is lower than MRI or CT. PET-CT scanners combine PET with CT imaging to improve anatomic localization. PET has specialized diagnostic uses in oncology, neurology, and cardiology, but could not replace MRI in most cases.
Ultrasound
Ultrasound uses high-frequency sound waves to produce images without any ionizing radiation. It provides excellent resolution of soft tissues, making it a first-line choice for many abdominal and obstetric indications. However, ultrasound has limited utility for assessing deeper structures like the brain or pelvis. It also requires a skilled operator and proper patient positioning to obtain good image quality. Ultrasound cannot serve as a full substitute for MRI in most contexts.
Summary
While advanced CT, PET, and ultrasound technology can address certain diagnostic needs when MRI is not an option, MRI remains the preferred modality for a wide range of soft tissue imaging due to its versatility, contrast, and lack of radiation. Keeping patients as comfortable as possible during MRI through open scanners and sedation protocols is ideal to avoid unnecessary exposure from other modalities.
Conclusion
Getting an MRI scan can be a stressful and challenging experience for claustrophobic patients. However, with proper screening, preparation, and accommodations, these patients can successfully complete their MRI exams.
The key points to remember are:
Claustrophobia is a common barrier to successful MRI completion, but there are ways to address it. Screening patients ahead of time allows for planning.
Open MRI scanners with more space are the optimal solution for claustrophobic patients when feasible. Other accommodations like mirrored goggles, music, or sedation can also help.
With the right approach, even severely claustrophobic patients can find a way to tolerate MRI scans. This is critical for allowing them to access this important diagnostic imaging tool.
Alternative imaging methods exist, but MRI provides unique benefits for many conditions. Finding ways for claustrophobic patients to undergo MRI should be a priority.
Addressing claustrophobia proactively is crucial for ensuring MRI access and positive patient experiences. While challenging, clinicians can develop effective strategies and protocols to make MRIs possible for most claustrophobic patients.
