Anxiety in Healthy Subjects Participating in 7T Examinations—Longitudinal Study

Abstract

Anxiety before an MRI examination is common, even though the technique is noninvasive and painless. In a 7T MRI study, healthy volunteers also reported anxiety before the examination. This study aimed to assess anxiety levels in healthy individuals undergoing 7T MRI and to determine if their anxiety decreased during subsequent examinations. Participants filled out a questionnaire on anxiety. Eleven questions were compared between the first and second examinations using a paired t-test. Results show that significantly more participants felt worried before the first examination compared with the second. However, more participants felt tense after the second examination. Participants felt better informed before the second examination, but more felt fine after the first one. Six participants (14%) felt nervous about the second examination despite having completed the first one. This study reveals that healthy participants still experience anxiety even after a prior MR examination. However, most participants felt retrospectively that their anxiety was unnecessary. This study suggests that providing more information may help reduce anxiety among healthy volunteers in research studies.

1. Introduction

The demand for radiological examinations has been increasing for a long time. Diagnostic examinations might be stressful events for both patients and healthy volunteers. MRI is a radiological examination using Magnetic Resonance Imaging that causes more anxiety than others [1]. Anxiety involves feelings of insecurity, helplessness, and a sense that something bad is about to happen. Anxiety prior to an MRI examination occurs even though MRI is a noninvasive technique and is considered painless. MRI examinations have been shown to induce claustrophobia in 2% of the participants in a conventional MRI scanner in a large-scale study [2]. In the publication “It’s like Being in Another World—Patients’ Lived Experience of Magnetic Resonance Imaging” by Törnqvist et al., the feeling of patients going through MRI examinations are thoroughly described, and it is suggested that participants need individualized support to be able to cope and relax during the examination [3]. If patients discontinue or refuse the examination due to discomfort and anxiety, it might lead to clinical consequences and expensive waste of resources. MRI examination is a very valuable diagnostic tool for pathologies and should not be at risk of being interrupted or of poor quality due to psychological restrictions experienced by patients. It is shown that information and communication together can reduce anxiety [4].

Depending on the patient’s history, it might not always be the scanning that is of greatest concern for the patient. In a study of patients suffering from Multiple Sclerosis (MS), the fear of the MRI results was more pronounced than the fear of the MRI scanning itself [5]. Further, the level of anxiety was found to be deceased if the participant underwent repeated MRI scanning sessions [6]. Patient-friendly audiovisual systems have also been shown to reduce anxiety for participants in MRI examinations [7]. Research MRI facilities can also benefit from these improvements. For the MRI examination to be of the best quality, the scanning procedure needs to be facilitated as much as possible for both patients and healthy volunteers. For example, fMRI (functional Magnetic Resonance Imaging) studies may be contaminated by severe anxiety, disrupting the cognitive process under investigation and essentially leading to inaccurate conclusions being drawn based on the participant’s brain activity during testing.

There are a lot of different elements that may have an impact when it comes to anxiety before an MRI examination. To be able to ease the anxiety of the patient as well as the healthy volunteers, the information and support needed must be individually varied. Delic et al. report that communication between operators and patients prior to an MRI examination is a key factor in reducing anxiety in patients [8]. Communication in addition to information can reduce anxiety, and it is suggested that some of the information could be as simple as a five-minute-long standard video in the waiting room [4]. However, standard information should be complemented with person-centered care by the MRI operators with the ability to see the individual in front of them. Self-report data in a study by van Minde revealed that patients experienced high levels of anxiety before the MRI examination. Additionally, electrophysiological data indicate that anxiety was at its peak when the MRI table (the slab that participants are placed on during the examination) first moved into the scanner, gradually decreasing as the examination progressed [9].

Aiming to create a relaxing environment within the scanner room, light and acoustic effects are utilized. Additionally, efforts to improve compliance with MR examinations include using wider and shorter bores, reducing noise, providing distractions like music and movies during the scan, and speeding up the scanning process. Moreover, the communication skills of the personnel conducting the MR examinations are crucial in establishing a calming atmosphere during the procedure [10]. Although the difference in anxiety levels reported by patients and healthy volunteers was shown to be significant, with a higher anxiety level for patients prior to the MRI examination in a 7T study, there were still healthy volunteers who felt anxious before the examination [11]. Results in a large-scale fMRI study underscore the need to examine trait anxiety at recruitment and to implement appropriate selection procedures or selection strategies to reduce bias in fMRI studies [12]. Another fMRI study shows a limitation of anxious patients’ ability to adapt to demanding cognitive tasks [13], which can be important to include in the assessment when setting up an fMRI study.

2. Aim

The aim of this study was to map the anxiety levels of healthy subjects participating in 7T examinations. Our goal was to determine whether healthy volunteers, who do not have anxiety about the outcome of the images, still feel anxious before the examination, and whether the anxiety is eliminated on the second MRI scanning session. The findings can serve as an important first step towards a baseline for both healthy volunteers and clinical populations that can suffer from both anxiety related to the MRI itself as well as anxiety regarding any possible findings.

3. Material and Method

3.1. Data Collection

Participants participating in a language training study were asked to fill out an additional questionnaire on anxiety; 42 of the 44 participants answered the questionnaire after both MRI examinations. The 42 healthy volunteers had a median age of 24 years (range: 19–40 years). All participants completed a written informed consent. The questionnaire was filled out on a laptop. The questionnaire used REDCap 13.1.37; research electronic data capture; http://project-redcap.org (accessed on 3 July 2024). The questionnaire consisted of 12 questions after the first MRI examination and 11 questions after the second MRI examination, since one question specifically stated “If you feel nervous about the second MR examination later the same day”, which is irrelevant after the second MRI examination. The questionnaire also included some questions regarding the short-term effects of the strong magnetic field, such as dizziness.

3.2. MR System

The MR examinations were conducted in an actively shielded 7T MR scanner (Achieva Multix 8, Philips, Best, the Netherlands) in first-level-controlled mode, not exceeding the specific absorption rate (SAR) limit of 4 W/kg for the whole body and 3.2 W/kg for the head. The maximum spatial field gradient (dB/dz) of the stray field at 130 cm from the isocenter was 7.86 T/m in a tunnel with a diameter of 58 cm and a length of 3.3 m. The scanning time was approximately 1 h during the first scanning session and approximately 45 min during the second scanning session. The two scanning operators were the same both times.

3.3. Statistics

Descriptive statistics of mean and range were used to present demographics. A t-test was performed on 11 questions regarding anxiety and well-being in conjunction with two consecutive 7 T MRI examinations. We had a targeted hypothesis, where we thought that the symptoms would decrease after an examination. Cronbach’s alpha (α) was = 0.261 after the first MRI examination and 0.511 after the MRI examination. One item stood out, “Do you feel tired after the examination?”, and when deleted, α changed to 0.454 and 0.729, respectively. The question “Do you feel upset after the examination?” was removed during the second calculation, since all participants scored 1. Spearman´s rank correlation was used for analyzing the ranked variables of dizziness and nervousness about the second MRI examination. Any p-value ≤ 0.05 was regarded as being statistically significant. We used SPSS version 28 (IBM, Armonk, NY, USA).

4. Results

The 42 participants, 26 females and 16 males with a mean age = 27 (range 20–41), answered questions regarding experiences in conjunction with 7T MRI examinations. A total of 29 of the 42 participants had not had a previous MRI examination. Eleven of the questions were compared between after the first examination and after the second examination on the same day in a paired t-test (

Table 1. Paired t-test with one-sided significance for detecting differences between first and second MRI examination. Questions in bold have a significant difference between the two MRI examinations.

Question	t-Test
	Mean	SD	t(41)	p
Did you feel worried before the MR examination?	0.357	0.533	4.343	<0.001
Did you feel well rested before the MR examination	−0.095	0.484	−1.274	0.105
Do you feel calm after the examination?	−0.095	0.617	−1.000	0.162
Do you feel tired after the examination?	−0.071	0.745	−0.621	0.269
Do you feel tense after the examination?	0.167	0.537	2.011	0.025
Do you feel upset after the examination?	0.024	0.154	1.000	0.162
Would you say that you are overall feeling fine after the MR examination?	0.095	0.370	1.667	0.052 *
Are you satisfied with how the MR examination went?	−0.071	0.463	−1.000	0.162
Did you feel that you had good contact between the staff and you during the examination?	0.095	0.431	1.432	0.080
Do you feel safe in the MR/hospital-environment?	0.071	0.342	1.355	0.091
Did you feel well informed before the MR examination?	−0.095	0.370	−1.667	0.052 *

* Borderline significant.

). To the question of whether they felt worried before the MR examination, significantly more people answered that they were worried before the first examination than the second examination (M = 0.357, SD = 0.533, p < 0,001). To the question of whether they felt tense after the examination, significantly more people answered that they did after the first examination than the second examination (M = 0.167, SD = 0.537, p = 0.03).

Significantly more people felt that they were better informed before the second examination than the first examination (M = −0.095, SD = 0.370, p = 0.05). However, significantly more people reported feeling fine overall after the first examination than after the second (M = 0.095, SD = 0.370, p = 0.05). All questions and significance are presented in Table 1. The questions with significant differences in the answers are also shown in bar charts (Figure 1). When the test was conducted on participants who had not previously undergone an MRI examination (n = 29), only the first question—whether they felt worried before the MRI examination—showed a significant difference between the first and second MR examinations.

Six people (14%) answered that they felt nervous about the second MRI examination after the first one was finished (Figure 2). Spearman’s rank correlation revealed no significant relationship (p = 0.07) between dizziness experienced when entering the magnet and nervousness before the second MRI examination.

The bar chart in Figure 3 shows that the feeling of anxiety before the examination was unnecessary in retrospect.

5. Discussion

When comparing anxiety levels between patients and healthy volunteers in a previous study, it was evident that patients experienced higher levels of anxiety. This is likely due to the additional stress of awaiting a diagnosis or monitoring disease progression, which naturally heightens their emotional response to the procedure [11]. The present study expands on these findings by demonstrating that even healthy volunteers who are not anticipating a diagnosis or monitoring a known condition experience some anxiety before undergoing an MRI examination. This indicates that the anxiety associated with MRI examination is not solely linked to medical concerns but also to the inherent apprehensions surrounding the procedure itself. Factors contributing to this anxiety might include fear of the unknown, discomfort with the confined space of the scanner, concerns about the procedure’s duration, and worries about potential findings, even in the absence of specific health issues. By acknowledging and actively working to alleviate these common anxieties, healthcare providers can improve the overall experience and compliance for both patients and healthy volunteers.

The level of anxiety decreases after completing the first MRI examination, and the participants are not as worried prior to the second MRI examination. A previous study provides evidence that anxiety levels decrease after the first MRI scan. This finding suggests that participants become more accustomed to the procedure, resulting in lower anxiety levels before their second MRI examination. Familiarity with the scanning process reduced the fear of the unknown, and the knowledge of what to expect contributed to this decrease in pre-examination anxiety. This reduced anxiety is important, as it can lead to better compliance and a more comfortable experience for patients undergoing repeated MRI examinations [6]. In our study, the majority of participants who initially felt anxious later reflected that their anxiety was unnecessary. This insight highlights an important aspect of patient preparation for MRI examinations. Communicating this to future participants could potentially help mitigate their anxiety. However, the challenge lies in how to effectively convey this reassurance. Simply informing patients beforehand that their anxiety is likely unfounded may not be sufficient for them to internalize and act upon this information. More effective strategies might include providing detailed information about the procedure and offering opportunities for patients to ask questions and express concerns prior to the scan. Tailoring the communication and information to individual patient needs and preferences might enhance their effectiveness in reassuring patients and minimizing unnecessary anxiety. Information regarding the side effects of the strong magnetic field is also important to minimize anxiety during the examination. The side effects of this scanner are reported in previous studies [11,14].

A perhaps surprising finding was that more individuals reported a better overall feeling after the first MRI examination compared with the second. This outcome might be attributed to several factors. Firstly, participants may experience a greater sense of relief after completing the initial examination, having confronted and navigated their initial anxieties about the unknown aspects of the procedure. The relief of having completed the first scan successfully might overshadow any discomfort they experienced, leading to a more positive overall feeling. In contrast, the second examination might not elicit the same level of relief. By this point, participants are familiar with the process, and while this familiarity reduces initial anxiety, it may also diminish the novelty and subsequent sense of accomplishment felt after the first scan. Additionally, participants might feel increasingly fatigued by the second examination, both physically and mentally, leading to a desire to complete the process quickly and leave the scanning facility.

6. Limitations

A limitation of this study might be the small sample size and the homogeneity of the young participants. Nevertheless, this was the population available to us through the language learning study. A study design limitation was that we did not have questions about anxiety before the participants went into the scanner the first time. Reliability was higher at the second time point and considerably higher when the question regarding tiredness was removed, indicating that more work needs to be conducted before the questionnaire can be used in healthcare. Additionally, a follow-up study should be performed using a mixed-methods design of quantitative and qualitative measures.

7. Conclusions

We can conclude that even after healthy participants have experienced a previous MRI examination, they still experience anxiety about subsequent ones. However, despite this initial anxiety, the majority of individuals reported feeling that their apprehension was unnecessary after undergoing the examination. Moreover, participants have expressed a desire for better pre-examination information. This sentiment implies that providing more comprehensive details about the MRI process could potentially alleviate anxiety, even among healthy volunteers participating in research studies. By offering a clearer understanding of what to expect during the examination, including the scanning procedure itself, potential sensations, and the overall environment, individuals may feel more prepared and less anxious. This highlights the importance of effective communication and informed consent procedures in research settings, as well as in clinical practice, to promote patient comfort and well-being throughout the MRI experience.