CHICAGO – One doesn't immediately connect radiological innovation with mental health diagnosis or care. But two reports out of the annual meeting of the Radiological Society of North America (RSNA; Oak Brook, Illinois) this week highlighted, first, how one young radiologist astutely identified an emerging and disturbing psychiatric disorder among teens, and, second, the role functional magnetic resonance imaging (fMRI) is playing in future treatments of stress-related disorders.
The pain of adolescence combined with psychological disorders stemming from childhood abuse has propelled some teens to graduate to a new form of self injury coined self-embedding disorder, in which they jam objects into their bodies. The new trend was discovered by a radiology student working at Nationwide Children's Hospital (Columbus, Ohio) who saw several X-rays of children who presented in the emergency room in pain. This prompted William Shiels II, DO, chief of the department of radiology at Nationwide, to conduct a study which found that minimally invasive, image-guided treatment is a safe and precise method for removal of the self-inflicted foreign objects from the body.
"It's a previously unrecognized disorder and there's no literature on it," Shiels said. "Radiologists are in a unique position to be the first to detect self-embedding disorder, make the appropriate diagnosis and mobilize the healthcare system for early and effective intervention and treatment. This goes beyond traditional self-injury patterns such as bruising, burning or cutting. The percutaneous technique for removal allows us to treat patients through tiny openings, just one-quarter of an inch."
Teens typically show up in the emergency room when the pain becomes too much to bear. They don't always admit that they have inserted foreign objects in their bodies. But those objects show up on X-ray.
The prevalence of self-embedding disorder is as yet unknown because many cases go unreported. But Shiels said that 13% to 24% of high school students in the U.S. and Canada have practiced deliberate self-injury at least once.
Shiels and colleagues studied 19 episodes of self-embedding injury in 10 adolescent girls, age 15 to 18. Using ultrasound and/or fluoroscopic guidance, interventional pediatric radiologists removed 52 embedded foreign objects from nine of the patients.
The embedded objects included metal needles, metal staples, metal paperclips, glass, wood, plastic, graphite (pencil lead), crayon and stone. The objects were embedded during injuries to the arms, ankles, feet, hands and neck. One patient had self-embedded 11 objects, including an unfolded metal paperclip more than six inches in length.
Ultrasound guidance helped researchers to detect the presence and location of wood, crayons and plastic objects, not detectable on X-ray exams.
"This technique offers surgeons and emergency physicians a safe and effective alternative for removal of foreign bodies, including objects at risk for fragmentation during traditional operative techniques," said study co-author Adam Young. "The small incision minimizes scarring and deformity, which is key for the self-esteem of this unique, high-risk group of patients."
"It's a fascinating disorder; 90% demonstrate suicidal behavior," Shiels said. "Cutting isn't associated with suicidal behavior. Children who cut and bruise don't have this level of severe psychiatric disorders such as a combination of bipolar disorder, post-traumatic distress, obsessive compulsive disorder, depression and/or borderline personality disorder."
Shiels now is part of an interdisciplinary team led by psychiatric professionals and they have started a national registry to track the trend.
"It's fascinating to know that radiologists are the first healthcare providers in line to discover and treat this," he said. "The radiologist can take one look at the X-ray and mobilize an interdisciplinary approach to stop the cycle of self-harm."
fMRI highlights dysfunctional brain circuitry
In another psychiatric-related study out of RSNA this week, researchers reported using functional magnetic resonance imaging (fMRI) to reveal that circuitry in the area of the brain responsible for suppressing memory is dysfunctional in patients suffering from stress-related psychiatric disorders.
In other words, the source of these disorders is organic and fMRI pointed that out.
"How do traumatic memories in life affect adults who later develop stress-related psychiatric disorders? Our hypothesis is that there's an area of the brain that's dysfunctional that causes flashbacks and distressful symptoms," said Nivedita Agarwal, MD, radiology resident at the University of Udine (Italy), where the study is ongoing.
"Because traumatic memories are not adequately suppressed by the brain, they continue to interfere with the patient's life," said Agarwal, who also is a research fellow at the Brain Imaging Center of McLean Hospital (Belmont, Massachusetts), an affiliate of Harvard Medical School (Boston).
Agarwal and colleagues used brain fMRI to explore alterations in the neural circuitry that links the prefrontal cortex to the hippocampus, while study participants performed a memory task.
Study participants included 11 patients with major depression, 13 with generalized anxiety disorder, nine with panic attack disorders, five with borderline personality disorder and 21 healthy individuals.
All patients reported suffering varying degrees of stressful traumatic events, such as sexual or physical abuse, difficult relationships or harassment at some point in their lives.
"These people become hypersensitive and have flashbacks," Agarwal explained. "These patients exert a lot of effort to do the same thinking tasks compared to healthy controls."
All of this was illustrated with fMRI.
Agarwal was able to see the affected areas of the brains after patients reviewed a list of neutral word pairs. They then underwent fMRI. During imaging, they were presented with one of the words and asked to either recall or to suppress the memory of its associated word. fMRI images revealed that the prefrontal cortex, which controls the suppression and retrieval of memories processed by the hippocampus, showed abnormal activation in the patients with stress-related disorders compared to the healthy controls.
During the memory suppression phase of the test, patients with stress-related disorders showed greater activation in the hippocampus, suggesting that insufficient activation of the prefrontal cortex could be the basis for inadequate suppression of unwanted traumatic memories stored in the hippocampus.
"These data suggest that the mechanism for memory suppression is dysfunctional in patients with stress-related disorders primarily because of an alteration of the prefrontal cortex," she said. "These patients often complain of poor memory, which might in part be attributed to this altered circuitry.
"fMRI hold promise in understanding these disorders," said Agarwal. "If we know the prefrontal cortex is dysfunctional, is there anything we can do? Transcranial magnetic stimulation has an efficient antidepressant effect and then there are antidepressant medications too," she said.
Agarwal predicted that, in the next five to 10 years these modalities will be used to detect subtle difference in psychiatric illnesses so that physicians can personalize therapies. fMRI also will be used to test new drugs so that researchers can literally see the effects on the brain.