Underlying Mechanisms of Psychological Interventions in Magnetic Resonance Imaging and Image-Guided Radiology Procedures.

Positive patient care and healthcare facility outcomes are associated with using various psychological interventions during magnetic resonance imaging and interventional radiology procedures. Interventions such as hypnosis, relaxation, guided imagery, and empathic communication can improve anxiety, pain, and hemodynamic stability during procedures, as well as improve claustrophobia and anxiety during magnetic resonance imaging. Little is understood as to the potential underlying mechanisms of how these interventions operate and contribute to positive outcomes. Thus, this article seeks to address that question by integrating autonomic nervous system functioning, neuropsychological concepts, and common factors theory of psychotherapy as potential underlying mechanisms. Opportunities for future directions in the field are also included.

Easing anxiety in preparation for pediatric magnetic resonance imaging: a pilot study using animal-assisted therapy.

BACKGROUND: Children undergoing magnetic resonance imaging (MRI) can experience negative emotions both before and during their scan, causing them to move and often necessitating the use of procedural sedation. Several strategies to improve patient compliance have been attempted. OBJECTIVE: This study was designed to evaluate the effectiveness of a non-pharmacological intervention to reduce anxiety in pediatric patients preparing for MRI using animal-assisted therapy. MATERIALS AND METHODS: An animal intervention pilot study was performed in patients who agreed in advance to interact with a dog. Patients and caregivers filled out questionnaires, including questions designed to capture changes in patient emotion before and after the intervention. MRI diagnostic quality was compared to age- and gender-matched control groups with and without general anesthesia. RESULTS: The intervention in 21 patients comparing pre- and post-scan surveys demonstrated a statistically significant improvement in patient anxiety levels (P<0.01). Diagnostic MRI scans were achieved in 19/21 (90%), with no significant difference in exam quality or times compared against control groups. The majority of caregivers and staff members agreed strongly that patients benefited from the therapy dog's presence. CONCLUSION: The use of animal-assisted therapy in a pilot group in our MRI division resulted in a beneficial effect on patients' emotional status, easing anxiety in preparation for scheduled scans, without impacting MRI quality or duration. Further randomized studies will be needed to demonstrate its significance in reducing sedation rates in children undergoing MRI.

Alternatives to Sedation and General Anesthesia in Pediatric Magnetic Resonance Imaging: A Literature Review.

PURPOSE: To assess alternatives to sedation and general anesthesia to prepare children for magnetic resonance (MR) imaging examinations. METHODS: Online databases were searched for articles discussing methods of preparing children for MR imaging procedures. Because of the large number of articles returned, criteria were limited to only studies that prepared patients without the use of sedation or general anesthesia. RESULTS: Twenty-four studies were deemed appropriate for inclusion in the review. The following methods emerged as alternatives to pediatric sedation: mock scanners, MR-compatible audiovisual systems, feed-sleep manipulation, play therapy, infant incubators/immobilizers, photo diaries, sucrose solutions, and guided imagery. The approaches with the most extensive research were mock MR scanners and feed-sleep manipulation. DISCUSSION: Evidence supports the use of these alternative techniques as valid substitutes for pediatric sedation and general anesthesia. CONCLUSION: To reduce the risks associated with sedation of pediatric patients, institutions could implement the alternatives discussed in this review. Cost analyses should be conducted first because some methods are more expensive than others. Finally, further research is needed to better assess the effectiveness of lesser-practiced methods, including photo diaries, sucrose solutions, and guided imagery.

Interventions to reduce anxiety, distress and the need for sedation in adult patients undergoing magnetic resonance imaging: a systematic review.

PURPOSE: Adults undergoing MRI scans can experience anxiety, claustrophobia and fear during the scanning experience and, in some cases, require sedation. The aim of this systematic review was to determine what strategies are effective in reducing fear, anxiety and claustrophobia, and the need for sedation in adults undergoing MRI. METHODS: A quantitative systematic review, according to the methodology of the Joanna Briggs Institute, was carried out. A systematic search of a number of databases was performed. Studies were then screened and critically appraised by two independent reviewers before being included in the review. RESULTS: In total, 21 studies met the inclusion criteria for the review, which assessed the following interventions: MRI design features, cognitive-behavioural strategies, prone positioning, information, fragrance administration and team training. All of these had some positive impact on outcomes. CONCLUSION: Healthcare professionals working with adults undergoing MRI may consider some of the strategies included in this review to implement in their practice to reduce anxiety and increase patient comfort while reducing the need for sedation.

How silent is silent reading? Intracerebral evidence for top-down activation of temporal voice areas during reading.

As you might experience it while reading this sentence, silent reading often involves an imagery speech component: we can hear our own "inner voice" pronouncing words mentally. Recent functional magnetic resonance imaging studies have associated that component with increased metabolic activity in the auditory cortex, including voice-selective areas. It remains to be determined, however, whether this activation arises automatically from early bottom-up visual inputs or whether it depends on late top-down control processes modulated by task demands. To answer this question, we collaborated with four epileptic human patients recorded with intracranial electrodes in the auditory cortex for therapeutic purposes, and measured high-frequency (50-150 Hz) "gamma" activity as a proxy of population level spiking activity. Temporal voice-selective areas (TVAs) were identified with an auditory localizer task and monitored as participants viewed words flashed on screen. We compared neural responses depending on whether words were attended or ignored and found a significant increase of neural activity in response to words, strongly enhanced by attention. In one of the patients, we could record that response at 800 ms in TVAs, but also at 700 ms in the primary auditory cortex and at 300 ms in the ventral occipital temporal cortex. Furthermore, single-trial analysis revealed a considerable jitter between activation peaks in visual and auditory cortices. Altogether, our results demonstrate that the multimodal mental experience of reading is in fact a heterogeneous complex of asynchronous neural responses, and that auditory and visual modalities often process distinct temporal frames of our environment at the same time.

Improving visual perception through neurofeedback.

Perception depends on the interplay of ongoing spontaneous activity and stimulus-evoked activity in sensory cortices. This raises the possibility that training ongoing spontaneous activity alone might be sufficient for enhancing perceptual sensitivity. To test this, we trained human participants to control ongoing spontaneous activity in circumscribed regions of retinotopic visual cortex using real-time functional MRI-based neurofeedback. After training, we tested participants using a new and previously untrained visual detection task that was presented at the visual field location corresponding to the trained region of visual cortex. Perceptual sensitivity was significantly enhanced only when participants who had previously learned control over ongoing activity were now exercising control and only for that region of visual cortex. Our new approach allows us to non-invasively and non-pharmacologically manipulate regionally specific brain activity and thus provide "brain training" to deliver particular perceptual enhancements.

Altered processing of sweet taste in the brain of diet soda drinkers.

Artificially sweetened beverage consumption has been linked to obesity, and it has been hypothesized that considerable exposure to nonnutritive sweeteners may be associated with impaired energy regulation. The reward system plays an integral role in modulating energy intake, but little is known about whether habitual use of artificial sweetener (i.e., diet soda consumption) may be related to altered reward processing of sweet taste in the brain. To investigate this, we examined fMRI response after a 12-hour fast to sucrose (a nutritive sweetener) and saccharin (a nonnutritive sweetener) during hedonic evaluation in young adult diet soda drinkers and non-diet soda drinkers. Diet soda drinkers demonstrated greater activation to sweet taste in the dopaminergic midbrain (including ventral tegmental area) and right amygdala. Saccharin elicited a greater response in the right orbitofrontal cortex (Brodmann Area 47) relative to sucrose in non-diet soda drinkers. There was no difference in fMRI response to the nutritive or nonnutritive sweetener for diet soda drinkers. Within the diet soda drinkers, fMRI activation of the right caudate head in response to saccharin was negatively associated with the amount of diet sodas consumed per week; individuals who consumed a greater number of diet sodas had reduced caudate head activation. These findings suggest that there are alterations in reward processing of sweet taste in individuals who regularly consume diet soda, and this is associated with the degree of consumption. These findings may provide some insight into the link between diet soda consumption and obesity.

Food motivation circuitry hypoactivation related to hedonic and nonhedonic aspects of hunger and satiety in women with active anorexia nervosa and weight-restored women with anorexia nervosa.

BACKGROUND: Previous studies have provided evidence of food motivation circuitry dysfunction in individuals with anorexia nervosa. However, methodological limitations present challenges to the development of a cohesive neurobiological model of anorexia nervosa. Our goal was to investigate the neural circuitry of appetite dysregulation across states of hunger and satiety in active and weight-restored phases of anorexia nervosa using robust methodology to advance our understanding of potential neural circuitry abnormalities related to hedonic and nonhedonic state and trait. METHODS: We scanned women with active anorexia nervosa, weight-restored women with anorexia nervosa and healthy-weight controls on a 3-T Siemens magnetic resonance scanner while they viewed images of high- and low-calorie foods and objects before (premeal) and after (postmeal) eating a 400 kcal meal. RESULTS: We enrolled 12 women with active disease, 10 weight-restored women with anorexia nervosa and 11 controls in our study. Compared with controls, both weight-restored women and those with active disease demonstrated hypoactivity premeal in the hypothalamus, amygdala and anterior insula in response to high-calorie foods (v. objects). Postmeal, hypoactivation in the anterior insula persisted in women with active disease. Percent signal change in the anterior insula was positively correlated with food stimuli ratings and hedonic and nonhedonic appetite ratings in controls, but not women with active disease. LIMITATIONS: Our findings are limited by a relatively small sample size, which prevented the use of an analysis of variance model and exploration of interaction effects, although our substantial effect sizes of between-group differences suggest adequate power for our statistical analysis approach. Participants taking psychotropic medications were included. CONCLUSION: Our data provide evidence of potential state and trait hypoactivations in food motivation regions involved in the assessment of food's reward value and integration of these with interoceptive signalling of one's internal state of well-being, with important relations between brain activity and homeostatic and hedonic aspects of appetite. Our findings give novel evidence of disruption in neurobiological circuits and stress the importance of examining both state and trait characteristics in the investigation of brain phenotypes in individuals with anorexia nervosa.

Neural correlates of stress-induced and cue-induced drug craving: influences of sex and cocaine dependence.

OBJECTIVE: Although stress and drug cue exposure each increase drug craving and contribute to relapse in cocaine dependence, no previous research has directly examined the neural correlates of stress-induced and drug cue-induced craving in cocaine-dependent women and men relative to comparison subjects. METHOD: Functional MRI was used to assess responses to individualized scripts for stress, drug/alcohol cue and neutral-relaxing-imagery conditions in 30 abstinent cocaine-dependent individuals (16 women, 14 men) and 36 healthy recreational-drinking comparison subjects (18 women, 18 men). RESULTS: Significant three-way interactions between diagnostic group, sex, and script condition were observed in multiple brain regions including the striatum, insula, and anterior and posterior cingulate. Within women, group-by-condition interactions were observed involving these regions and were attributable to relatively increased regional activations in cocaine-dependent women during the stress and, to a lesser extent, neutral-relaxing conditions. Within men, group main effects were observed involving these same regions, with cocaine-dependent men demonstrating relatively increased activation across conditions, with the main contributions from the drug and neutral-relaxing conditions. In men and women, subjective drug-induced craving measures correlated positively with corticostriatal-limbic activations. CONCLUSIONS: In cocaine dependence, corticostriatal-limbic hyperactivity appears to be linked to stress cues in women, drug cues in men, and neutral-relaxing conditions in both. These findings suggest that sex should be taken into account in the selection of therapies in the treatment of addiction, particularly those targeting stress reduction.

Real-time fMRI: a tool for local brain regulation.

Real-time fMRI permits simultaneous measurement and observation of brain activity during an ongoing task. One of the most challenging applications of real-time fMRI in neuroscientific and clinical research is the possibility of acquiring volitional control of localized brain activity using real-time fMRI-based neurofeedback protocols. Real-time fMRI allows the experimenter to noninvasively manipulate brain activity as an independent variable to observe the effects on behavior. Real-time fMRI neurofeedback studies demonstrated that learned control of the local brain activity leads to specific changes in behavior. Here, the authors describe the implementation and application of real-time fMRI with particular emphasis on the self-regulation of local brain activity and the investigation of brain-function relationships. Real-time fMRI represents a promising new approach to cognitive neuroscience that could complement traditional neuroimaging techniques by providing more causal insights into the functional role of circumscribed brain regions in behavior.

Investigation of anatomical thalamo-cortical connectivity and FMRI activation in schizophrenia.

The purpose of this study was to examine measures of anatomical connectivity between the thalamus and lateral prefrontal cortex (LPFC) in schizophrenia and to assess their functional implications. We measured thalamocortical connectivity with diffusion tensor imaging (DTI) and probabilistic tractography in 15 patients with schizophrenia and 22 age- and sex-matched controls. The relationship between thalamocortical connectivity and prefrontal cortical blood-oxygenation-level-dependent (BOLD) functional activity as well as behavioral performance during working memory was examined in a subsample of 9 patients and 18 controls. Compared with controls, schizophrenia patients showed reduced total connectivity of the thalamus to only one of six cortical regions, the LPFC. The size of the thalamic region with at least 25% of model fibers reaching the LPFC was also reduced in patients compared with controls. The total thalamocortical connectivity to the LPFC predicted working memory task performance and also correlated with LPFC BOLD activation. Notably, the correlation with BOLD activation was accentuated in patients as compared with controls in the ventral LPFC. These results suggest that thalamocortical connectivity to the LPFC is altered in schizophrenia with functional consequences on working memory processing in LPFC.

Neural correlates and predictive power of trait resilience in an acutely traumatized sample: a pilot investigation.

OBJECTIVE: Resilience refers to the ability to thrive despite adversity and is defined as a multidimensional phenomenon, spanning internal locus of control, sense of meaning, social problem-solving skills, and self-esteem. We aimed to investigate the predictive value of resilience for the development of posttraumatic stress disorder (PTSD) and to examine the neural correlates mediating the relationship between resilience and recovery from a traumatic event in acutely traumatized subjects. We hypothesized that resilience would mediate the relationship between childhood trauma and posttraumatic recovery. METHOD: We conducted a prospective study with 70 acutely traumatized subjects with DSM-IV PTSD recruited at the emergency department, assessing PTSD symptom severity at 3 time points within the first 3 months posttrauma. Scores for childhood trauma as assessed with the Childhood Trauma Questionnaire and trait resilience as assessed with the Connor-Davidson Resilience Scale were used as predictors of symptom severity. A subsample of 12 subjects additionally underwent a functional 4 Tesla magnetic resonance imaging scan 2 to 4 months posttrauma. We employed the traumatic script-driven imagery paradigm to assess the correlations between trait resilience and blood oxygen level-dependent (BOLD) response. The study was conducted from 2003 to 2007. RESULTS: Resilience predicted PTSD symptom severity at 5 to 6 weeks (ß = -0.326, P = .01) as well as at 3 months (ß = -0.423, P = .003) posttrauma better than childhood trauma. Resilience essentially mediated the relationship between childhood trauma and posttraumatic adjustment. Resilience scores were positively correlated with BOLD signal strength in the right thalamus as well as the inferior and middle frontal gyri (Brodmann area 47). CONCLUSIONS: This pilot investigation revealed a significant relationship between resilience and emotion regulation areas during trauma recall in an acutely traumatized sample. Resilience was established as a significant predictor of PTSD symptom severity and mediated the influence of childhood trauma on posttraumatic adjustment.

Beyond alcoholism: Wernicke-Korsakoff syndrome in patients with psychiatric disorders.

OBJECTIVE: Wernicke encephalopathy and Korsakoff syndrome (the combined disorder is named Wernicke-Korsakoff syndrome [WKS]) are preventable, life-threatening neuropsychiatric syndromes resulting from thiamine deficiency. WKS has historically been associated with alcoholism; more recently, it has been recognized in patients who have anorexia nervosa or have undergone bariatric surgery for obesity. However, patients with nutritional deficiencies of any origin are at risk for WKS. We present clinical histories and neuroimaging data on 2 young adults with underlying psychiatric disorders who became malnourished and developed WKS. METHODS: A young woman with bipolar disorder and somatization disorder was hospitalized for intractable vomiting. A young man with chronic paranoid schizophrenia developed delusions that food and water were harmful, and was hospitalized after subsisting for 4 months on soda pop. RESULTS: Acute, life-threatening Wernicke encephalopathy was confirmed in both patients by brain magnetic resonance imaging showing classic thalamic injury. The patients were left with persistent cognitive and physical disabilities that were consistent with Korsakoff syndrome. CONCLUSIONS: Failure to suspect a vitamin deficiency led to permanent cognitive and physical disabilities that may necessitate lifelong care for these patients. The neuropsychiatric consequences could have been prevented by prompt recognition of their thiamine deficiency.

Not pitch perfect: sensory contributions to affective communication impairment in schizophrenia.

BACKGROUND: Schizophrenia patients have vocal affect (prosody) deficits that are treatment resistant and associated with negative symptoms and poor outcome. The neural correlates of this dysfunction are unclear. Prior study has suggested that schizophrenia vocal affect perception deficits stem from an inability to use acoustic cues, notably pitch, in decoding emotion. METHODS: Functional magnetic resonance imaging was performed in 24 schizophrenia patients and 28 healthy control subjects, during the performance of a four-choice (happiness, fear, anger, neutral) vocal affect identification task in which items for each emotion varied parametrically in affective salient acoustic cue levels. RESULTS: We observed that parametric increases in cue levels in schizophrenia failed to produce the same identification rate increases as in control subjects. These deficits correlated with diminished reciprocal activation changes in superior temporal and inferior frontal gyri and reduced temporo-frontal connectivity. Task activation also correlated with independent measures of pitch perception and negative symptom severity. CONCLUSIONS: These findings illustrate the interplay between sensory and higher-order cognitive dysfunction in schizophrenia. Sensory contributions to vocal affect deficits also suggest that this neurobehavioral marker could be targeted by pharmacological or behavioral remediation of acoustic feature discrimination.

Neurolinguistic programming used to reduce the need for anaesthesia in claustrophobic patients undergoing MRI.

The purpose of this study was to assess the success of neurolinguistic programming in reducing the need for general anaesthesia in claustrophobic patients who require MRI and to consider the financial implications for health providers. This was a prospective study performed in 2006 and 2007 at a teaching hospital in England and comprised 50 adults who had unsuccessful MR examinations because of claustrophobia. The main outcome measures were the ability to tolerate a successful MR examination after neurolinguistic programming, the reduction of median anxiety scores produced by neurolinguistic programming, and models of costs for various imaging pathways. Neurolinguistic programming allowed 38/50 people (76%) to complete the MR examination successfully. Overall, the median anxiety score was significantly reduced following the session of neurolinguistic programming. In conclusion, neurolinguistic programming reduced anxiety and subsequently allowed MRI to be performed without resorting to general anaesthesia in a high proportion of claustrophobic adults. If these results are reproducible, there will be major advantages in terms of patient safety and costs.

Effect of live music therapy for patients undergoing magnetic resonance imaging.

The purpose of the current study was to identify the effects of live music therapy interventions compared with preferred recorded music for patients undergoing MRI scans. To date, there has not been a published study involving the use of live music therapy during MRI scans. The current study investigated the differences between teenage through adult patients receiving live music therapy intervention during outpatient MRI scans versus the standard protocol of care listening to recorded music (N = 88). Subjects ranged in age from 15 to 93 years old. Results indicated subjects who received the live music therapy protocol reported significantly better perception of the MRI procedure (p < 0.05). Additionally, subjects receiving the live music therapy protocol had fewer scans repeated due to movement. Of the repeated images, 26% occurred in the live music group and 73% occurred in the recorded music group. Subjects receiving live music therapy also requested less breaks from the scan. Two percent of the live music subjects requested a break and 17.6% of the control patients requested breaks. When comparing the same type of scan between groups, subjects receiving the live music protocol required less time to complete the scans. For lumbar scans without contrast (N = 14, n = 7, n = 7), live music subjects spent an average of 4.63 less min per scan for a total of 32 less min for 7 subjects. For brain scans (N = 8, n = 4, n = 4), live music subjects spent an average of 5.8 less min per scan for a total of 23 less min for 4 subjects. Results of the current study supports the use of live music therapy intervention for teenage and adult patients undergoing MRI scans to reduce patient anxiety and improve patient perception of the scan experience. Additionally, live music therapy has the potential to shorten the length of time required for patients to complete MRI scans due to decreased patient movements and fewer breaks requested during the scans. The cost savings impact of reduced procedure time can positively impact the facility productivity by allowing more scans to be scheduled daily.

FMRI indices of auditory attention in schizophrenia.

The present study sought to identify abnormalities in activation in several brain regions in response to an auditory attention task in patients with schizophrenia. Ten patients and twenty healthy control participants were examined using Functional Magnetic Resonance Imaging (FMRI) measures acquired during an auditory attention task. Region of interest analyses of activation of targeted regions implicated in attention included: anterior cingulate cortex (ACC), dorsolateral prefrontal cortex (DLPFC), hippocampus, parahippocampal gyrus (PHG), and superior temporal gyrus (STG). The results indicated over-activation in patients with schizophrenia. While the control group showed notable coherence in activation within and across hemispheres the schizophrenia group showed relatively less coherence overall that was only present in the right hemisphere. These findings suggest that patients with schizophrenia show both an over-engagement of brain regions during attention task as well as a lack of communication among neural regions involved.

It's like being in another world--patients' lived experience of magnetic resonance imaging.

AIM: The aim of this study was to illuminate patients' lived experience during magnetic resonance imaging. BACKGROUND: Magnetic resonance imaging has increased in importance since the early 1980s and is today a common useful diagnostic tool. Although magnetic resonance imaging are non-invasive and considered painless, many patients experience anxiety, sometimes so strong that the scan has to be terminated. DESIGN AND METHODS: The study had an inductive design and a hermeneutic phenomenological methodology was used. RESULTS: The essential theme of going through magnetic resonance imaging was a feeling of being in another world. The strange environment and isolation inside the scanner made the participants' experiences unusual, with varying degrees of difficulty dealing with it. Being in the other world caused a threat to the participants' self-control. There was a relation between threat to self-control, effort and need for support in the sense that the magnitude of threat to self-control had an impact on the effort it took to handle the situation and on the need for support, and conversely that the support received could affect the effort and threat to self-control. CONCLUSIONS: The study shows that the information received and the interaction between patients and staff have a significant influence on patients' lived experiences. The individual experience of threat to self-control requires the need for support to be individualized and care need to be adjusted for each patient.

Functional MRI for neurofeedback: feasibility study on a hand motor task.

We present an fMRI-based method that enables subjects to monitor and actively modulate their own brain activity as a form of biofeedback. On a 1.5 T clinical MR scanner, functional areas during a simple hand motor task were delineated by detecting signal variations associated with the brain activity. Then, the subject adopted a different strategy to expand the activation in motor and somatosensory areas that were not activated previously. Statistical maps of brain activity were visually presented back to the subject, being updated at the end of each segmented rest-task block in near real-time manner. Our results suggest that the visual feedback of the functional brain activation maps guided subjects to adjust their task performance to achieve the desired modulation of cortical activity. This method may offer a potential utility for fMRI-based neurofeedback.