Preparing patients according to their individual coping style improves patient experience of magnetic resonance imaging

Magnetic resonance imaging (MRI) is a widely used diagnostic imaging method and generally well-tolerated (Dantendorfer et al., 1997; Mackenzie et al., 1995; Madl et al., 2022). Still, multiple studies have shown that MRI does induce stress and anxiety in up to one third of all patients; this can be seen in both psychological and physiological markers (Carlsson & Carlsson, 2013; Eatough et al., 2009; Eshed et al., 2007; Forshaw et al., 2018; Madl et al., 2022; Peters et al., 2011). Anxiety and stress in patients, in turn, may have a negative impact on clinical processes: A negative patient experience has been linked to a higher prevalence of motion artifacts and thus scan repetitions, longer scan duration, and more premature terminations (Dantendorfer et al., 1997; Dewey et al., 2007; Enders et al., 2011; Madl et al., 2022; Nguyen et al., 2020; Powell et al., 2015). Andre et al. (2015) calculated $115,000 lost revenue per scanner every year due to unexpected patient behavior, which at least partially seems to trace back to anxiety in patients.

Different approaches have been taken to reduce MRI-related anxiety and improve patient experience. Informational interventions aim to reduce feelings of uncertainty which can burden MRI patients (Carlsson & Carlsson, 2013; Mackenzie et al., 1995). However, such purely informational interventions have revealed mixed results (Munn & Jordan, 2013): While some authors found no or even a detrimental effect of additional information on anxiety (Quirk et al., 1989; Törnqvist et al., 2006), others did find the expected reduction of anxiety (Selim, 2001; Youssefzadeh et al., 1997). In contrast to that, other interventions aim to enhance the patients’ ability to cope with the aversive situation, for instance through relaxation, distraction, or reappraisal of the situation (Krohne & de Bruin, 1998; Miller et al., 1989), and have been shown to effectively reduce anxiety in patients; yet, the reported effect sizes vary considerably (Munn & Jordan, 2013).

Interindividual differences in personality traits may contribute to explaining these inconsistencies. In the broader field of medical procedures, the Model of Coping Modes (Krohne, 1993, 2003) has provided insights into this matter. It proposes that people differ in their habitual way of coping with stress-inducing situations; the two dimensions vigilance and cognitive avoidance describe how attention shifts when being confronted with aversive threats. Vigilance is characterized by an increased focus on aversive cues in order to reduce the uncertainty or ambiguity of a threatening situation (e.g., by searching for information or anticipating possible negative outcomes). Cognitive avoidance, on the contrary, means a tendency to distract attention from threatening cues in order to reduce the emotional arousal induced by these cues; this may be achieved via distraction or trivialization of the situation (Krohne, 1993, 2003). Depending on the individual manifestation of these dimensions, four coping styles can be differentiated (De Bruin et al., 2001; Krohne, 1993, 2003): Individuals of the coping style repression (low vigilance, high cognitive avoidance) generally aim to reduce the emotional arousal induced by threatening cues through diverting their attention from those. Rather than trying to generate a valid expectation of the threatening situation, they tend to disavow its’ aversive characteristics. Sensitization (high vigilance, low cognitive avoidance) is characterized by increased attention towards threatful cues in order to create a realistic picture of what to be expected and avoid “negative surprises”. By doing so, the uncertainty that renders a situation stressful can be reduced. Individuals with high scores on both dimensions (high vigilance, high cognitive avoidance) are considered highly anxious individuals. This coping pattern is characterized by a low tolerance for arousal as well as uncertainty; this evokes fluctuating coping behavior, as neither employment of vigilant nor avoiding coping strategies can meet all needs and both strategies cannot be employed simultaneously. Last, individuals with low scores on both dimensions (low vigilance, low cognitive avoidance) are postulated to tolerate uncertainty as well as arousal relatively well. This results in a non-defensive coping style which enables them to vary their coping strategy adaptively depending on the situational requirements (De Bruin et al., 2001; Krohne, 1993, 2003).

Findings on the sources of MRI-related anxiety support the hypothesis of different coping styles and patient needs. To begin with, uncertainty and lack of information seems to constitute a decisive factor for some patients, who report fear of being harmed by the machine and fear of pain (Carlsson & Carlsson, 2013; Dantendorfer et al., 1997; Katz et al., 1994; Thorpe et al., 2008). These fears seem to trace back to lacking knowledge and low tolerance of the related feelings of uncertainty, which may be founded in a vigilant coping style. Providing appropriate information could be suitable to address these concerns. Apart from these aspects, some patients have also reported to fear the physical properties of MRI (e.g. noise, duration, constriction), and to worry about the results to be expected from the examination and their health (Carlsson & Carlsson, 2013; Dantendorfer et al., 1997; Katz et al., 1994; Thorpe et al., 2008). These fears could trace back to a low tolerance for the arousal induced by MRI-related threatening cues, i.e., an avoidant coping style. The physical properties and potentially threatening results are inherent and unalterable characteristics of MRI. Accordingly, additional information does not seem to be capable of reducing these fears appropriately. Instead, a successful coping strategy could lie in distracting one’s attention thereof.

In the context of invasive diagnostic procedures and surgeries, preparing patients with interventions that are congruent with their coping style has been shown to produce desirable effects, especially for repressers and sensitizers. These groups are characterized by a clear preference for one coping strategy over the other which is why the clearest hypotheses can be formulated. Addressing the preferred strategy should meet their needs, whereas the situation is less clear when patients have a high or low tendency for both strategies like highly anxious and non-defensive individuals. Patients who strongly strive for threat-relevant information have been shown to search for more online health information (de Looper et al., 2021), to ask more questions in medical consultations—especially in highly-threatening situations (Ong et al., 1999; Timmermans et al., 2007), and to have a higher interest in learning about own cancer risk (Dahle Ommundsen et al., 2022). The opposite pattern is found for patients who strive to avoid threatening information: They tend to ask less questions which results in shorter consultations (Ong et al., 1999; Timmermans et al., 2007). Accordingly, patient preparation congruent with coping style has been associated with lower levels of behavioral indices of pain and self-reported anxiety, as well as shorter recovery times and better adaptation in patients undergoing coloscopy (Morgan et al., 1998), cardiac catheterization (Ludwick-Rosenthal & Neufeld, 1993), and oral surgery (Martelli et al., 1987). Krohne and El-Giamal (2008) found a significant increase of anxiety on the day of surgery when highly avoidant / vigilant patients had been prepared with information / relaxation; this increase was not visible when the intervention met the patients’ avoidant or vigilant needs. Similarly, de Rooij et al. (2019) found beneficial effects of detailed information provided in the context of a survivorship care plans only for those who sought for information about their disease, but to have detrimental effects for those who didn’t.

In sum, the different root causes for MRI-related anxiety suggest that patients have different needs to cope with the situation successfully. Building upon the findings regarding the interaction of patient preparation and coping style in other medical contexts, it is thus conceivable that the patients’ coping style may also impact the effectivity of interventions to prepare patients for MRI.

We aimed to answer two questions with this study:

In this study we sought to analyze the effect of two video-based interventions aimed at preparing patients for MRI on the patients’ psychological and physiological response to the MRI examination. In general, patients’ cortisol levels were higher on the day of MRI compared to an individual no-stress baseline, which indicates that patients experienced distress in anticipation of their examination. Neither the informational nor the relaxational intervention had a consistent positive effect on the patients’ response. Yet, when patients were prepared according to their coping style they tended to relax after the intervention and before the MRI scan already while those patients with no additional preparation only experienced this relief after the scan and results were ambiguous for the incongruent preparation group. Research on the connection of patient anxiety or stress and clinical processes suggests that improving patient experience may also have a positive impact for healthcare operations.

This is the first study to compare cortisol levels of MRI patients to an individual no-stress baseline; we found cortisol levels to be elevated at the day of MRI which mirrors the mild to moderate levels of psychological tension that patients reported on average. The fact that we also found decreasing cortisol levels from pre- to post-MRI contradicts previous research that reported a rise or no significant change (Derntl et al., 2015; Madl et al., 2022; Tazegul et al., 2014). Taken together, this indicates that patients in fact do experience distress in the context of MRI. Thereby distress seems to be greatest in anticipation of the examination. The fact that cortisol-levels decreased from pre- to post-MRI indicates that the stress induced by the examination itself seems to be of minor importance. This blends in with results regarding the well-established decrease of psychological distress and anxiety from pre- to post-MRI (Dantendorfer et al., 1997; Katz et al., 1994; Mackenzie et al., 1995); it also extends findings from previous studies which had not been able to ascertain whether a lacking change of cortisol throughout the examination was due to a lack of distress or caused by anticipation and maintenance effects (Derntl et al., 2015; Madl et al., 2022).

One major goal in this study was to determine whether the informational and relaxation intervention improved the patients’ psychological and physiological reaction to MRI. The data only partly supported this hypothesis: The information, relaxation, and control group did not differ in the response pattern of cortisol, agitation, or worry. All groups experienced relief after the examination. However, there was a trend that patients of the relaxation but not of the information or control group tended to experience a relief of anxiety after the intervention, already. Providing a relaxational intervention therefore might be somewhat beneficial in terms of calming patients during the waiting period, which is in line with previous findings (Munn & Jordan, 2013). Relaxational interventions may be more beneficial in terms of reducing stress and anxiety in MRI patients, at least at the time point directly before the examination. The informational intervention did not have a positive effect on the patients’ reaction, which is in line with other studies reporting a lacking or even negative effect of merely informational interventions (Munn & Jordan, 2013; Quirk et al., 1989; Törnqvist et al., 2006). Ahlander et al. (2018) suggested that patients might be in a suboptimal state of susceptibility for information when already in direct anticipation of the examination. This is supported by studies in children that showed that processing information takes a relatively long time until it can serve as a basis for successful coping (Manne et al., 1990, 1992). Thus, providing information in advance (e.g., when scheduling the upcoming MRI), might lead to different results in terms of reducing pre-examinational stress and anxiety. Similarly, Phillips and Deary (1995) suggested that relaxation techniques also require practice; therefore, providing patients with preparational material of any kind in sufficient advance might be a reasonable approach. Apart from these general considerations, a more detailed view on the underlying reasons for MRI-related anxiety and the individual coping style might be decisive and will be discussed in the following section.

We had hypothesized that patient preparation congruent to individual coping style would lead to the most pronounced decrease of stress and anxiety. This hypothesis was not supported in the detailed analysis for all coping styles, probably due to issues of statistical power. However, combining those who had been prepared congruently or not congruently fully supported our hypothesis for state anxiety; for agitation and worry results were less clear. All patients were less anxious after the examination, but the congruent group experienced a relief of anxiety during the waiting period already. These findings are in line with studies conducted in other medical settings which also reported the most positive outcomes regarding anxiety, pain, and adaptation in patients who had been prepared according to their coping style (Krohne & El-Giamal, 2008; Ludwick-Rosenthal & Neufeld, 1993; Martelli et al., 1987; Morgan et al., 1998). This finding contributes to explaining why previous studies on informational and relaxational interventions have revealed inconsistent results (Munn & Jordan, 2013): Fit of coping style with type of patient preparation might be crucial for the respective interventions to produce positive effects. Patients fear different aspects of MRI that may mirror different coping styles: For some, the uncertain situation and lack of knowledge about it is paramount (vigilance), whereas others rather fear the MRI scanner itself or the results of the examination (avoidance; Carlsson & Carlsson, 2013; Dantendorfer et al., 1997; Katz et al., 1994; Thorpe et al., 2008). Lastly, feelings of helplessness and lack of control could reflect both: Uncertainty due to lack of information or arousal tracing back to the unalterable circumstances of undergoing MRI (e.g., constriction, not being able to move). Building upon these considerations and our results, patient preparation congruent with coping style might indeed have the potential to alleviate stress and anxiety more effectively than standardized or no patient preparation. When targeting patient preparation is not possible, incongruent preparation by relaxation seems to be less detrimental than by information: Although mostly being reported to reduce anxiety (Munn & Jordan, 2013), Törnqvist et al. (2006) even found negative effects for merely informational preparation. This is in line with findings from other medical contexts, where additional information on one’s disease induced detrimental effects for those with an avoidant coping style (Dahle Ommundsen et al., 2022; de Rooij et al., 2019). In contrast, results for relaxational interventions are generally positive and only vary in effect size (Munn & Jordan, 2013). When analysis of coping style is not possible, relaxational interventions therefore might be the safer way to go. Yet, the best option might be to offer a broad variety of preparation material for patients to choose from and best in advance. This has even two advantages: 1) patients can choose what fits their needs best and through this, 2) their sense of control is strengthened. This is particularly important as loss of control is one of the factors associated with MRI-related anxiety (Carlsson & Carlsson, 2013). Anxiety and physiological stress markers have been linked to unexpected patient behaviors like motion artifacts and premature terminations, thereby impacting operational efficiency (Dewey et al., 2007; Dziuda et al., 2019; Enders et al., 2011; Madl et al., 2022; Nguyen et al., 2020; Powell et al., 2015). Thus, we hypothesize that if we manage to address each patients’ needs optimally, there also might be a positive effect on operational smoothness for the medical institutions.

Despite our sample size of 142 patients, missing responses and the random distribution of patients to the experimental groups lead to a relatively low number of patients of each coping style per group. This limited the statistical power for our analyses of congruence; the hypothesized effects could only be observed on a general level of congruent preparation but not for sensitizers and repressers individually. Further, despite thorough randomization, the congruent patient group had slightly higher levels of state anxiety than the other groups. One might criticize that the steeper decline throughout the waiting period might trace back to statistical regression. Yet, one might as well argue that congruent preparation even managed to achieve a significant decrease although the patients were most anxious beforehand. Lastly, we were able to distinguish patients with the four coping styles through cluster analysis. Still, the levels of cognitive avoidance were higher than those of sensitization in all clusters. This finding of higher levels of cognitive avoidance in the medical context has been described previously (Sturmbauer et al., 2019). Sturmbauer et al. (2019) postulate that engaging in avoidant coping strategies might be particularly adaptive in the medical setting where the individual possibilites to exert control on the situation are very limited, rendering vigilant behavior rather unsuitable. Accordingly, the sensitizers in our study still exhibited relatively high levels of cognitive avoidance which might have limited the potential positive effect of the informational intervention. This again speaks in favor of the notion that it is beneficial to provide information in advance when patients still perceive a greater scope of action.

Despite these limitations, this study makes an important contribution for exploring the importance of interindividual differences in patient preparation. Our findings imply that uniform approaches to enhance patient education on an exclusively informational level fall short for adequate patient preparation and improvements of patient experience. Instead, healthcare providers should also consider ways to meet patients’ tendency to engage in cognitive avoidance, especially bearing in mind the higher levels of this strategy in the medical context. Further, it should be emphasized that educational material should best be applied in sufficient advance when patients still are more receptive and the same might be advisable for other interventions, as well. Assessing potential differences depending on the timing of intervention therefore may constitute an important area for future research. Last, efforts to improve patient experience should always consider interindividual differences that influence the patients’ way of coping with stressful situations in the medical context. There probably is no “one-size-fits-all” solution for optimizing patient experience; instead, individual differences should be taken into account.