|
1
|
Simon E, Penzlin AI, Arndt M, Siepmann T, Barlinn K. Heart rate variability biofeedback in patients with functional dizziness. J Neurol 2025; 272:265. [PMID: 40072625 PMCID: PMC11903525 DOI: 10.1007/s00415-025-12988-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 01/20/2025] [Accepted: 02/23/2025] [Indexed: 03/14/2025]
Abstract
BACKGROUND Functional dizziness is one of the most common causes of chronic dizziness. Associated psychiatric diseases such as depression and anxiety lead to significant impairment, possibly due to autonomic nervous system imbalance. We investigated whether heart rate variability (HRV) biofeedback can modulate autonomic function in patients with functional dizziness. METHODS We performed a randomized controlled study in 24 patients diagnosed functional dizziness for the first time. Patients received six 20 min sessions of HRV biofeedback or no intervention. We assessed HRV (time and frequency domains), sympathetic vasomotor function, sympathetic skin response and psychometric assessments at baseline, immediately post-intervention (or control period) and another 3 and 6 weeks later. RESULTS Patients in the HRV biofeedback group showed improved cardiac autonomic function with elevated HRV time-dependent parameters immediately post-intervention [Root Mean Square of Successive Differences (RMSSD): 71.2 ms ± 38 ms vs. 38.2 ms ± 18.5 ms, p = 0.014; Standard Deviation of all NN Intervals (SDNN): 78.3 ms ± 35.9 ms vs. 48.1 ms ± 20.5 ms, p = 0.001], increased HRV frequency-dependent parameter [Low Frequency (LF): p = 0.001], as well as reduced depressiveness (BDI-II: p = 0.0236). None of these parameters were changed in control patients (p = ns). Dizziness-associated symptoms and sympathetic function of vasculature and sweat glands were unaltered in both study arms. CONCLUSION In a randomized controlled pilot study, HRV biofeedback led to improved autonomic cardiac function and alleviated symptoms of depression in patients with functional dizziness, most likely mediated by a predominantly parasympathetic effect.
Collapse
Affiliation(s)
- Erik Simon
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
| | - Ana Isabel Penzlin
- Department of Neurology, Rhön Klinikum, Campus Bad Neustadt, Bad Neustadt a.d. Saale, Germany
| | - Martin Arndt
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Timo Siepmann
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Kristian Barlinn
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| |
Collapse
|
|
2
|
Jia Y, Wang H, Li D, Wu X, Yang J, Min W, Ma T, Huang H, Li R. Repetitive transcranial magnetic stimulation as add-on the rapyin persistent postural-perceptual dizziness. IBRO Neurosci Rep 2024; 17:382-388. [PMID: 39559485 PMCID: PMC11570328 DOI: 10.1016/j.ibneur.2024.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2024] [Revised: 10/22/2024] [Accepted: 10/24/2024] [Indexed: 11/20/2024] Open
Abstract
Background This study aims to evaluate the clinical effectiveness of repetitive transcranial magnetic stimulation (rTMS) when used as an add-on therapy for individuals with persistent postural-perceptual dizziness (PPPD). Methods In this randomized controlled, double-blind trial conducted at Shangluo Central Hospital, patients with PPPD diagnosed in the neurology departments were included. Participants were randomized into a rTMS treatment group and a control group in a 1:1 ratio by the randomized grouping method. Patients in both groups received conventional treatment, with the rTMS treatment group underwent daily rTMS sessions, whereas the control group received sham rTMS treatments following the same schedule. The effectiveness of the treatments was primarily assessed using the Dizziness Handicap Inventory (DHI), Hamilton Anxiety Rating Scale (HAMA), and Hamilton Depression Rating Scale (HAMD), which measured symptoms of vertigo, anxiety, and depression at baseline, after two weeks, and at the end of four weeks. Findings Of the 46 participants recruited, 2 were excluded due to contraindications, 22 were randomly assigned to the rTMS treatment group, and 22 were assigned to the control group. Ultimately, 2 withdrew for personal reasons, and data from 42 participants were included in the outcome analysis. HAMA, HAMD and DHI scores were significantly lower in the rTMS treatment group than in the control group after 4 weeks of treatment (p<0.05). A positive correlation was also observed between DHI scores and HAMA or HAMD scores. Conclusions This pilot study demonstrated that rTMS is a beneficial add-on therapy for patients with PPPD.
Collapse
Affiliation(s)
- Yao Jia
- Department of Rehabilitation, Shangluo Central Hospital, Shaanxi 726000, PR China
| | - Hongbin Wang
- Department of Rehabilitation, Shangluo Central Hospital, Shaanxi 726000, PR China
| | - Dan Li
- Department of Rehabilitation, Shangluo Central Hospital, Shaanxi 726000, PR China
| | - Xingli Wu
- Department of Rehabilitation, Shangluo Central Hospital, Shaanxi 726000, PR China
| | - Jiawen Yang
- Department of Rehabilitation, Shangluo Central Hospital, Shaanxi 726000, PR China
| | - Weifei Min
- Department of Rehabilitation, Shangluo Central Hospital, Shaanxi 726000, PR China
| | - Ting Ma
- Department of Rehabilitation, Shangluo Central Hospital, Shaanxi 726000, PR China
| | - He Huang
- Department of Rehabilitation, Shangluo Central Hospital, Shaanxi 726000, PR China
| | - Rui Li
- Department of Neurology, Shaanxi Provincial People’s Hospital, Xi'an 710061, PR China
| |
Collapse
|
|
3
|
Suica Z, Behrendt F, Ziller C, Gäumann S, Schädler S, Hilfiker R, Parmar K, Gerth HU, Bonati LH, Schuster-Amft C. Comparative effectiveness of non- pharmacological treatments in patients with persistent postural-perceptual dizziness: a systematic review and effect sizes analyses. Front Neurol 2024; 15:1426566. [PMID: 39070052 PMCID: PMC11272556 DOI: 10.3389/fneur.2024.1426566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 07/01/2024] [Indexed: 07/30/2024] Open
Abstract
Introduction The patho-psychological mechanisms of persistent postural-perceptual dizziness (PPPD) appear to be very complex, and a multimodal, multidisciplinary approach is suggested for treating patients with PPPD. The aim of this review was to provide a comprehensive overview of non-pharmacological treatments and their comparative effectiveness in patients with PPPD. Methods Scopus, Web of Science, PsycINFO, Medline, Embase, CINAHL, Cochrane Library and ClinicalTrials.gov were searched in April 2022 with a search update in August 2023. Only randomized controlled trials (RCTs) were included. There was no restrictions regarding publication date. Two reviewers independently identified eligible trials, extracted data, double-checked all extracted information from the included articles and assessed the risk of bias using the Cochrane risk of bias tool. A qualitative synthesis was performed, considering methodological heterogeneity between trials. Finally, an effect size analysis was performed for each treatment comparison. The standardized mean differences (SMD) and their corresponding 95% confidence intervals (95%CI) were calculated for each trial using Review Manager 5.4. Results Thirteen RCTs (618 patients with moderate or mild dizziness) out of 1,362 references describing seven different non-pharmacological comparisons were selected. Nine trials included patients with PPPD, and four trials included patients with functional dizziness. The trials used different interventions that were classified as: (1) psychotherapeutic interventions (cognitive behavioral therapy, patient education), (2) physiotherapeutic interventions/training (vestibular rehabilitation, optokinetic stimulation), (3) stimulation procedures (vagus nerve stimulation, transcranial direct current stimulation) and (4) device application (visual desensitization using personalized glasses). However, most of the trials investigated the effects of single interventions, rather than multimodal interdisciplinary treatment of patients with PPPD. The SMD for dizziness handicap and severity was between 0.04 and 0.52 in most trials. In one trial using visual desensitization, the SMD was 1.09 (strong effect on the severity of dizziness) and 1.05 (strong effect on dizziness handicap). Discussion Several individual interventions have shown benefits in the treatment of patients with PPPD with small to moderate effects. However, the multimodal treatment or a combination of vestibular rehabilitation with visual desensitization, cognitive behavioral therapy including patient education, and medication support should be further investigated. Future trials should include a large sample size with severe dizziness, and provide a longer follow-up period. Clinical trial registration PROSPERO CRD42022320344.
Collapse
Affiliation(s)
- Zorica Suica
- Research Department, Reha Rheinfelden, Rheinfelden, Switzerland
| | - Frank Behrendt
- Research Department, Reha Rheinfelden, Rheinfelden, Switzerland
- School of Engineering and Computer Science, Bern University of Applied Sciences, Burgdorf, Switzerland
| | - Carina Ziller
- Research Department, Reha Rheinfelden, Rheinfelden, Switzerland
| | - Szabina Gäumann
- Research Department, Reha Rheinfelden, Rheinfelden, Switzerland
| | | | | | - Katrin Parmar
- Research Department, Reha Rheinfelden, Rheinfelden, Switzerland
- Translational Imaging in Neurology (ThINk) Basel, Departments of Head, Spine and Neuromedicine and Biomedical Engineering, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Hans Ulrich Gerth
- Research Department, Reha Rheinfelden, Rheinfelden, Switzerland
- Department of Medicine, University Hospital Münster, Münster, Germany
| | - Leo H. Bonati
- Research Department, Reha Rheinfelden, Rheinfelden, Switzerland
- Stroke Center and Department of Neurology, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Corina Schuster-Amft
- Research Department, Reha Rheinfelden, Rheinfelden, Switzerland
- School of Engineering and Computer Science, Bern University of Applied Sciences, Burgdorf, Switzerland
- Department for Sport, Exercise, and Health, University of Basel, Basel, Switzerland
| |
Collapse
|
|
4
|
Zang J, Zheng M, Chu H, Yang X. Additional cognitive behavior therapy for persistent postural-perceptual dizziness: a meta-analysis. Braz J Otorhinolaryngol 2024; 90:101393. [PMID: 38350404 PMCID: PMC10867767 DOI: 10.1016/j.bjorl.2024.101393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/18/2023] [Indexed: 02/15/2024] Open
Abstract
OBJECTIVE To investigate whether additional Cognitive Behavior Therapy (CBT) combined with conventional therapy improves outcomes for patients with Persistent Postural-Perceptual Dizziness (PPPD) compared with conventional therapy alone. METHODS Two reviewers independently searched PubMed, Embase, Web of Science, Cochrane Library, and ClinicalTrials.gov for relevant Randomized Controlled Trials (RCTs) examining CBT for PPPD which were conducted and published in English from January 2002 to November 2022. RCTs reporting any indicators for assessing corresponding symptoms of PPPD were included, such as Dizziness Handicap Inventory (DHI), Hamilton Anxiety Scale (HAMA), Hamilton Depression Scale (HAMD), Hospital Anxiety and Depression Scale (HADS), and Patient Health Questionnaire-9 (PHQ-9). Two independent reviewers conducted extraction of relevant information and evaluation of risk of bias. The Cochrane Collaboration risk of bias tool version 1.0 was used to evaluate risks and assess the quality of the included studies, and Cochrane Review Manager 5.3 software (RevMan 5.3) was used to perform meta-analyses. RESULTS The results of six RCTs indicated that combining additional CBT with conventional therapy significantly improved outcomes for PPPD patients compared with conventional therapy alone, especially in DHI-Total scores (Mean Difference [MD = -8.17], 95% Confidence Interval [95% CI: -10.26, -6.09], p < 0.00001), HAMA scores (MD = -2.76, 95% CI: [-3.57, -1.94], p < 0.00001), GAD-7 scores (MD = -2.50, 95% CI [-3.29, -1.70], p < 0.00001), and PHQ-9 scores (MD = -2.29, 95% CI [-3.04, -1.55], p < 0.00001). Subgroup analysis revealed a significant benefit of additional CBT compared with conventional therapies alone, including Vestibular Rehabilitation Therapy (VRT) (MD = -8.70, 95% CI: [-12.17, -5.22], p < 0.00001), Selective Serotonin Reuptake Inhibitor (SSRI) (with controlled SSRI: MD = -10.70, 95% CI: [-14.97, -6.43], p < 0.00001), and VRT combined with SSRI (MD = -6.08, 95% CI [-9.49, -2.67], p = 0.0005) in DHI-Total scores. CONCLUSION Additional CBT combined with conventional therapy may provide additional improvement for patients with PPPD compared with conventional therapy alone. However, more RCTs are needed to support and guide the application of CBT in treating PPPD. LEVEL OF EVIDENCE I; Systematic review of RCTs.
Collapse
Affiliation(s)
- Jialin Zang
- Department of Neurology, Peking University Aerospace School of Clinical Medicine (Aerospace Center Hospital), Beijing, China
| | - Mohan Zheng
- Department of Neurology, Peking University Aerospace School of Clinical Medicine (Aerospace Center Hospital), Beijing, China
| | - Hongyuan Chu
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Xu Yang
- Department of Neurology, Peking University Aerospace School of Clinical Medicine (Aerospace Center Hospital), Beijing, China.
| |
Collapse
|
|
5
|
Dunlap PM, Alradady FA, Costa CM, Delitto A, Terhorst L, Sparto PJ, Furman JM, Marchetti GF, Staab JP, Chueh J, Whitney SL. The Psychometric Properties of the 9-Item Vestibular Activities Avoidance Instrument. Phys Ther 2023; 103:pzad094. [PMID: 37459243 DOI: 10.1093/ptj/pzad094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 04/24/2023] [Accepted: 07/02/2023] [Indexed: 12/29/2023]
Abstract
OBJECTIVE The purpose of this study was to establish the psychometric properties of the 9-Item Vestibular Activities Avoidance Instrument (VAAI-9), a patient-reported outcome measure developed to identify fear avoidance beliefs in persons with vestibular disorders. METHODS This prospective cohort study included 100 participants 18 years and older seeking care at a balance disorders clinic for dizziness. Participants completed the VAAI-9, the Dizziness Handicap Inventory (DHI), and other patient-reported outcomes at the initial visit and the 3-month follow-up. To measure test-retest reliability, the VAAI-9 was completed again 5 days after the initial visit and was analyzed using a 2-way mixed ICC for absolute agreement. Internal consistency was determined using the Cronbach alpha. The Spearman correlation coefficient was used to assess convergent validity of the VAAI-9 with other outcomes. Receiver operating characteristic curves were used to identify baseline VAAI-9 cutoff scores for those who reported mild (DHI ≤ 30) or moderate or severe (DHI > 30) perceived disability at the 3-month follow-up. RESULTS The mean age of the study cohort was 49 (SD = 16) years; 73 (73%) were women. Seventy-one participants completed the 5-day follow-up, and 68 completed the 3-month follow-up. The VAAI-9 demonstrated excellent internal consistency (α = 0.91) and test-retest reliability (ICC = 0.90). Baseline VAAI-9 scores had moderate to strong associations with other outcome measures at baseline and 3 months. A baseline VAAI-9 score of 26 or higher had a sensitivity of 80.6% and a specificity of 78.4% for identifying a DHI score of >30 at 3 months (area under the curve = 0.86). CONCLUSIONS The results provide evidence of excellent reliability and validity for the 9-item VAAI in persons with vestibular disorders. A baseline VAAI-9 score of ≥26 identified individuals at risk of persistent moderate to severe disability due to dizziness. IMPACT Initial levels of fear avoidance beliefs measured using the VAAI-9 provided important prognostic information about outcomes for persons with vestibular symptoms.
Collapse
Affiliation(s)
- Pamela M Dunlap
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Fai A Alradady
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Anthony Delitto
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lauren Terhorst
- School of Health and Rehabilitation Sciences Data Center and Department of Occupational Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Patrick J Sparto
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joseph M Furman
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Gregory F Marchetti
- Department of Physical Therapy, Duquesne University, Pittsburgh, Pennsylvania, USA
| | - Jeffrey P Staab
- Departments of Psychiatry and Psychology and Otorhinolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jasmine Chueh
- School of Health Professions, Stony Brook University, Stony Brook, New York, USA
| | - Susan L Whitney
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
|
6
|
Candreia C, Rust HM, Honegger F, Allum JHJ. The Effects of Vibro-Tactile Biofeedback Balance Training on Balance Control and Dizziness in Patients with Persistent Postural-Perceptual Dizziness (PPPD). Brain Sci 2023; 13:brainsci13050782. [PMID: 37239254 DOI: 10.3390/brainsci13050782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/18/2023] [Accepted: 05/05/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Patients with persistent postural-perceptual dizziness (PPPD) frequently report having problems with balance control. Artificial systems providing vibro-tactile feedback (VTfb) of trunk sway to the patient could aid recalibration of "falsely" programmed natural sensory signal gains underlying unstable balance control and dizziness. Thus, the question we examine, retrospectively, is whether such artificial systems improve balance control in PPPD patients and simultaneously reduce the effects of dizziness on their living circumstances. Therefore, we assessed in PPPD patients the effects of VTfb of trunk sway on balance control during stance and gait tests, and on their perceived dizziness. METHODS Balance control was assessed in 23 PPPD patients (11 of primary PPPD origin) using peak-to-peak amplitudes of trunk sway measured in the pitch and roll planes with a gyroscope system (SwayStar™) during 14 stance and gait tests. The tests included standing eyes closed on foam, walking tandem steps, and walking over low barriers. The measures of trunk sway were combined into a Balance Control Index (BCI) and used to determine whether the patient had a quantified balance deficit (QBD) or dizziness only (DO). The Dizziness Handicap Inventory (DHI) was used to assess perceived dizziness. The subjects first underwent a standard balance assessment from which the VTfb thresholds in eight directions, separated by 45 deg, were calculated for each assessment test based on the 90% range of the trunk sway angles in the pitch and roll directions for the test. A headband-mounted VTfb system, connected to the SwayStar™, was active in one of the eight directions when the threshold for that direction was exceeded. The subjects trained for 11 of the 14 balance tests with VTfb twice per week for 30 min over a total of 2 consecutive weeks. The BCI and DHI were reassessed each week and the thresholds were reset after the first week of training. RESULTS On average, the patients showed an improved balance control in the BCI values after 2 weeks of VTfb training (24% p = 0.0001). The improvement was greater for the QBD patients than for the DO patients (26 vs. 21%), and greater for the gait tests than the stance tests. After 2 weeks, the mean BCI values of the DO patients, but not the QBD patients, were significantly less (p = 0.0008) than the upper 95% limit of normal age-matched reference values. A subjective benefit in balance control was spontaneously reported by 11 patients. Lower (36%), but less significant DHI values were also achieved after VTfb training (p = 0.006). The DHI changes were identical for the QBD and DO patients and approximately equal to the minimum clinical important difference. CONCLUSIONS These initial results show, as far as we are aware for the first time, that providing VTfb of trunk sway to PPPD subjects yields a significant improvement in balance control, but a far less significant change in DHI-assessed dizziness. The intervention benefitted the gait trials more than the stance trials and benefited the QBD group of PPPD patients more than the DO group. This study increases our understanding of the pathophysiologic processes underlying PPPD and provides a basis for future interventions.
Collapse
Affiliation(s)
- Claudia Candreia
- Department of ORL, Cantonal Hospital, CH-6016 Luzern, Switzerland
| | - Heiko M Rust
- Department of Neurology, University of Basel Hospital, CH-4031 Basel, Switzerland
| | - Flurin Honegger
- Department of ORL, University of Basel Hospital, CH-4031 Basel, Switzerland
| | - John H J Allum
- Department of ORL, Cantonal Hospital, CH-6016 Luzern, Switzerland
- Department of ORL, University of Basel Hospital, CH-4031 Basel, Switzerland
| |
Collapse
|
|
7
|
Maywald M, Pogarell O, Levai S, Paolini M, Tschentscher N, Rauchmann BS, Krause D, Stöcklein S, Goerigk S, Röll L, Ertl-Wagner B, Papazov B, Keeser D, Karch S, Chrobok A. Neurofunctional differences and similarities between persistent postural-perceptual dizziness and anxiety disorder. Neuroimage Clin 2023; 37:103330. [PMID: 36696807 PMCID: PMC9879992 DOI: 10.1016/j.nicl.2023.103330] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Persistent postural-perceptual dizziness (PPPD) (ICD-11) and anxiety disorders (ANX) share behavioural symptoms like anxiety, avoidance, social withdrawal, hyperarousal, or palpitation as well as neurological symptoms like vertigo, stance and gait disorders. Furthermore, previous studies have shown a bidirectional link between vestibulo-spatial and anxiety neural networks. So far, there have been no neuroimaging-studies comparing these groups. OBJECTIVES The aim of this explorative study was to investigate differences and similarities of neural correlates between these two patient groups and to compare their findings with a healthy control group. METHODS 63 participants, divided in two patient groups (ANX = 20 and PPPD = 14) and two sex and age matched healthy control groups (HC-A = 16, HC-P = 13) were included. Anxiety and dizziness related pictures were shown during fMRI-measurements in a block-design in order to induce emotional responses. All subjects filled in questionnaires regarding vertigo (VSS, VHQ), anxiety (STAI), depression (BDI-II), alexithymia (TAS), and illness-perception (IPQ). After modelling the BOLD response with a standard canonical HRF, voxel-wise t-tests between conditions (emotional-negative vs neutral stimuli) were used to generate statistical contrast maps and identify relevant brain areas (pFDR < 0.05, cluster size >30 voxels). ROI-analyses were performed for amygdala, cingulate gyrus, hippocampus, inferior frontal gyrus, insula, supramarginal gyrus and thalamus (p ≤ 0.05). RESULTS Patient groups differed from both HC groups regarding anxiety, dizziness, depression and alexithymia scores; ratings of the PPPD group and the ANX group did differ significantly only in the VSS subscale 'vertigo and related symptoms' (VSS-VER). The PPPD group showed increased neural responses in the vestibulo-spatial network, especially in the supramarginal gyrus (SMG), and superior temporal gyrus (STG), compared to ANX and HC-P group. The PPPD group showed increased neural responses compared to the HC-P group in the anxiety network including amygdala, insula, lentiform gyrus, hippocampus, inferior frontal gyrus (IFG) and brainstem. Neuronal responses were enhanced in visual structures, e.g. fusiform gyrus, middle occipital gyrus, and in the medial orbitofrontal cortex (mOFC) in healthy controls compared to patients with ANX and PPPD, and in the ANX group compared to the PPPD group. CONCLUSIONS These findings indicate that neuronal responses to emotional information in the PPPD and the ANX group are comparable in anxiety networks but not in vestibulo-spatial networks. Patients with PPPD revealed a stronger neuronal response especially in SMG and STG compared to the ANX and the HC group. These results might suggest higher sensitivity and poorer adaptation processes in the PPPD group to anxiety and dizziness related pictures. Stronger activation in visual processing areas in HC subjects might be due to less emotional and more visual processing strategies.
Collapse
Affiliation(s)
- Maximilian Maywald
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany.
| | - Oliver Pogarell
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Susanne Levai
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Marco Paolini
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Nadja Tschentscher
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Boris Stephan Rauchmann
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany; Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Daniela Krause
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Sophia Stöcklein
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Stephan Goerigk
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Lukas Röll
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Birgit Ertl-Wagner
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Boris Papazov
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Daniel Keeser
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany; Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Susanne Karch
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| | - Agnieszka Chrobok
- Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany
| |
Collapse
|
|
8
|
Tripathi S, Tripathi S, Shantha N, Goyal S. Beyond Vertigo- Perceptual Postural Phobic Dizziness (PPPD): Our experience. Indian J Otolaryngol Head Neck Surg 2022; 74:4455-4459. [PMID: 36742640 PMCID: PMC9895483 DOI: 10.1007/s12070-021-02984-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 11/08/2021] [Indexed: 02/07/2023] Open
Abstract
Notwithstanding current understanding of vertigo, there are various clinical scenarios which are intriguing for clinicians, where patients have been too symptomatic but the presentation does not fit into any diagnosis. We stumbled upon a new entity during literature search known as Persistent Postural Perceptual Dizziness (PPPD). It fills the lacuna where we are often left wanting for diagnosis in the existing pool of knowledge. This case series has been prepared keeping in view the lack of data regarding PPPD in Indian population. For better understanding we present the illustration of our patients in this case series. We presented the details of three patients who were diagnosed as PPPD and managed effectively and followed up for one year. The nomenclature portrays the core concept of dizziness. The diagnostic criteria clearly define PPPD. It should not be used as escape or exclusion diagnosis. Our case series highlights various presentation of, not so uncommon, PPPD in Indian population. The case series has been brought out to address the deficiency of knowledge in dealing with intriguing vertigo. Careful thorough history is important to reach a diagnosis and avoids unwarranted vestibular sedatives. It highlights that proper counselling and vestibular rehabilitation can help the patients overcome their chronic disability.
Collapse
Affiliation(s)
| | | | - N. Shantha
- Dept of ENT, Military Hospital, Ferozpur, Punjab India
| | - Sunil Goyal
- Dept of ENT, Command Hospital, Kolkata, West Bengal India
| |
Collapse
|
|
9
|
Yamaguchi T, Miwa T, Tamura K, Inoue F, Umezawa N, Maetani T, Hara M, Kanemaru SI. Temporal virtual reality-guided, dual-task, trunk balance training in a sitting position improves persistent postural-perceptual dizziness: proof of concept. J Neuroeng Rehabil 2022; 19:92. [PMID: 35987778 PMCID: PMC9392908 DOI: 10.1186/s12984-022-01068-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 08/12/2022] [Indexed: 11/30/2022] Open
Abstract
Background Persistent postural-perceptual dizziness (PPPD) is a newly defined disorder characterized by functional dizziness. Due to its recent discovery, definitive treatment for PPPD has not been established; therefore, this study aimed to assess the effectiveness of virtual reality (VR)-guided, dual-task, trunk balance training for the management of PPPD using the mediVR KAGURA system. Methods We analyzed data of patients who presented with PPPD from January 1, 2021, to February 28, 2021. The VR group included patients who underwent mediVR KAGURA-guided training for 100 tasks (10 min). Patients with PPPD who received standard treatment and rehabilitation were assigned to the control group. Equilibrium tests were performed at baseline and immediately after mediVR KAGURA-guided training to examine its effectiveness in improving static and dynamic balance. Additionally, clinical questionnaires related to balance disorders were administered at baseline and 1 week after mediVR KAGURA-guided training to examine its effects on balance-related symptoms. The primary outcome was improvements in static and dynamic balance and Niigata PPPD Questionnaire (NPQ) scores. Results VR-guided training using mediVR KAGURA improved objective outcomes, including static and dynamic postural stability, after a single 10-min training session. Additionally, mediVR KAGURA-guided training improved scores on the Hospital Anxiety and Depression Scale and NPQ 1 week after the 10-min training session. Conclusion VR-guided training using mediVR KAGURA represents a viable method for managing balancing ability, anxiety, and symptoms in patients with PPPD. Such training provides a safe and cost-effective solution for PPPD management. Further studies are required to evaluate the clinical efficacy of this strategy. Trial registration: Institutional Ethics Committee of Kitano Hospital, approval number: 1911003. Registered 18 December 2019, https://kitano.bvits.com/rinri/publish_document.aspx?ID=426. Supplementary Information The online version contains supplementary material available at 10.1186/s12984-022-01068-6.
Collapse
|
|
10
|
Miwa T, Kanemaru SI. Effects of Kampo medicine hangebyakujutsutemmato on persistent postural-perceptual dizziness: A retrospective pilot study. World J Clin Cases 2022; 10:6811-6824. [PMID: 36051127 PMCID: PMC9297410 DOI: 10.12998/wjcc.v10.i20.6811] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 03/17/2022] [Accepted: 04/24/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Persistent postural-perceptual dizziness (PPPD) is a functional disorder, typically preceded by acute vestibular disorders. It is characterized by a shift in processing spatial orientation information, to favor visual over vestibular and somatosensory inputs, and a failure of higher cortical mechanisms. To date, no therapies for PPPD have been approved. Kampo medicine hangebyakujutsutemmato (HBT) has been reported to alleviate disturbances of equilibrium. We hypothesized that HBT would be a beneficial treatment for PPPD.
AIM To examine the efficacy of HBT for the treatment of PPPD.
METHODS Patients with PPPD were enrolled and divided into two groups: The HBT group (n = 24) and the non-HBT group (n = 14). The participants completed questionnaire surveys [Niigata PPPD questionnaire (NPQ), dizziness handicap inventory, hospital anxiety and depression scale (HADS), orthostatic dysregulation questionnaire, pittsburg sleep quality index (PSQI), and motion sickness scores] before and after HBT treatment. Additionally, to identify HBT responders, multivariate regression analysis was performed using the results of the questionnaire surveys and equilibrium tests; including stabilometry, and caloric, vestibular evoked myogenic response, and head-up tilt tests.
RESULTS Thirty-eight outpatients were included in this study, of which 14 patients (3 men, 11 women; mean age, 63.5 ± 15.9 years) received treatment without HBT, and 24 (1 man, 23 women; mean age, 58.2 ± 18.7 years) received combination treatment with HBT. Following HBT treatment, NPQ scores decreased significantly (baseline 40.1 ± 10.0 vs 2 mo 24.6 ± 17.7, P < 0.001). No statistically significant changes were observed in the NPQ scores in the non-HBT group (baseline 38.6 ± 12.2 vs 2 mo 39.4 ± 14.4, P = 0.92). Multivariable regression analysis revealed that the results of stabilometry (P = 0.02) and the caloric (P = 0.03), and head-up tilt tests (P < 0.001), HADS (P = 0.003), and PSQI (P = 0.01) were associated with HBT responsiveness in PPPD patients.
CONCLUSION HBT may be an effective adjunct therapy for PPPD. Patients with autonomic dysfunction, unstable balance, semicircular canal paresis, anxiety, and poor sleep quality may be high responders to HBT.
Collapse
Affiliation(s)
- Toru Miwa
- Department of Otolaryngology-Head and Neck Surgery, Osaka Metropolitan University, Osaka 5458585, Japan
- Department of Otolaryngology-Head and Neck Surgery, Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka 5308480, Japan
- Department of Otolaryngology-Head and Neck Surgery, Kyoto University, Kyoto 7507501, Japan
| | - Shin-ichi Kanemaru
- Department of Otolaryngology-Head and Neck Surgery, Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka 5308480, Japan
- Department of Otolaryngology-Head and Neck Surgery, Kyoto University, Kyoto 7507501, Japan
| |
Collapse
|
|
11
|
Persistent Postural-Perceptual Dizziness Interventions—An Embodied Insight on the Use Virtual Reality for Technologists. ELECTRONICS 2022. [DOI: 10.3390/electronics11010142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Persistent and inconsistent unsteadiness with nonvertiginous dizziness (persistent postural-perceptual dizziness (PPPD)) could negatively impact quality of life. This study highlights that the use of virtual reality (VR) systems offers bimodal benefits to PPPD, such as understanding symptoms and providing a basis for treatment. The aim is to develop an understanding of PPPD and its interventions, including current trends of VR involvement to extrapolate and re-evaluate VR design strategies. Therefore, recent virtual-reality-based research work that progressed in understanding PPPD is identified, collected, and analysed. This study proposes a novel approach to the understanding of PPPD, specifically for VR technologists, and examines the principles of effectively aligning VR development for PPPD interventions.
Collapse
|
|
12
|
Wang A, Fleischman KM, Kawai K, Corcoran M, Brodsky JR. Persistent Postural-Perceptual Dizziness in Children and Adolescents. Otol Neurotol 2021; 42:e1093-e1100. [PMID: 34191779 DOI: 10.1097/mao.0000000000003212] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Persistent postural-perceptual dizziness (PPPD) is a recently defined diagnostic syndrome characterized by chronic symptoms of dizziness, unsteadiness, and/or non-spinning vertigo. Although PPPD has been studied in adults, reports in the pediatric population are few. The goal of this study was to describe the presentation and treatment of PPPD in a group of pediatric patients. STUDY DESIGN Retrospective chart review. SETTING Tertiary referral center. PATIENTS ≤21 years old, who met Bárány Society consensus criteria for a diagnosis of PPPD and were followed for ≥6 months or until symptom resolution. MAIN OUTCOME MEASURESS Patient demographics, comorbidities, symptom chronicity, and response to treatment(s). RESULTS Of the 53 patients identified, 44 (83.0%) were women. Mean age at the time of initial evaluation was 14.6 years old. Common diagnoses in addition to PPPD included benign paroxysmal positional vertigo (64.2%), vestibular migraine (56.6%), and anxiety (28.3%). A high proportion of patients (43.4%) reported initially missing school or work due to their symptoms. Eighteen patients (34.0%) reported symptom resolution ranging from 2 to 48 months after diagnosis (median 9 mo). Of these patients, 15 of 18 attended physical therapy (PT), 11 of 18 attended cognitive behavioral therapy (CBT) and/or biofeedback therapy, and 10 of 18 took selective serotonin reuptake inhibitor (SSRI) medications, and 7 of 18 (40%) did a combination of all three therapies. CONCLUSION PPPD can impact patients at a young age, and prolonged symptoms present a significant burden to children and adolescents, many of whom are unable to attend school. Treatments such as PT, CBT, and SSRI medication may be effective.
Collapse
Affiliation(s)
- Alicia Wang
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital
| | - Katie M Fleischman
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital
- Harvard Medical School, Boston, Massachusetts
| | - Kosuke Kawai
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital
- Harvard Medical School, Boston, Massachusetts
| | - Meghan Corcoran
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital
| | - Jacob R Brodsky
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital
- Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
|
13
|
Limburg K, Radziej K, Sattel H, Henningsen P, Dieterich M, Probst T, Dale R, Lahmann C. A Randomized Controlled Trial Evaluating Integrative Psychotherapeutic Group Treatment Compared to Self-Help Groups in Functional Vertigo/Dizziness. J Clin Med 2021; 10:jcm10102215. [PMID: 34065517 PMCID: PMC8161006 DOI: 10.3390/jcm10102215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 05/16/2021] [Accepted: 05/17/2021] [Indexed: 11/20/2022] Open
Abstract
We tested the efficacy of an integrative psychotherapeutic group treatment (IPGT) in reducing vertigo/dizziness-related impairment along with depression, anxiety, and somatization by conducting a randomized controlled superiority trial comparing IPGT to self-help groups moderated by a clinical psychologist (SHG). Adult patients with functional vertigo and dizziness symptoms were randomly allocated to either the IPGT or SHG as active control group. Outcomes were assessed at baseline (t0), after treatment lasting 16 weeks (t1), and 12 months after treatment (t2). A total of 81 patients were assigned to IPGT and 78 patients were assigned to SHG. Vertigo-related impairment was reduced in both conditions (IPGT: t0–t1: d = 1.10, t0–t2: d = 1.06; SHG: t0–t1: d = 0.86, t0–t2: d = 1.29), showing the efficiency of both IPGT and SHG. Clinically relevant improvements were also obtained for depression in both groups. Linear mixed model analyses revealed no differences between groups for all outcomes (effect of group for the primary outcome: b = −1.15, SE = 2.13, t = −0.54, p = 0.59). Attrition rates were higher in SHG (52.6%) than in IPGT (28.4%). Both conditions improved primary and secondary outcomes while IPGT was better accepted by patients than SHG. Trial registration: ClinicalTrials.gov, Identifier: NCT02320851.
Collapse
Affiliation(s)
- Karina Limburg
- Department of Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar, Technical University Munich, 81675 Munich, Germany; (K.R.); (H.S.); (P.H.)
- Correspondence: (K.L.); (C.L.); Tel.: +49-761-270-68060 (C.L.)
| | - Katharina Radziej
- Department of Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar, Technical University Munich, 81675 Munich, Germany; (K.R.); (H.S.); (P.H.)
| | - Heribert Sattel
- Department of Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar, Technical University Munich, 81675 Munich, Germany; (K.R.); (H.S.); (P.H.)
| | - Peter Henningsen
- Department of Psychosomatic Medicine and Psychotherapy, Klinikum rechts der Isar, Technical University Munich, 81675 Munich, Germany; (K.R.); (H.S.); (P.H.)
| | - Marianne Dieterich
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-University, University Hospital, 81377 Munich, Germany;
- Department of Neurology, Ludwig-Maximilians-University, University Hospital, 81677 Munich, Germany
- Cluster of Systems Neurology-SyNergy, 81377 Munich, Germany
| | - Thomas Probst
- Department for Psychotherapy and Biopsychosocial Health, Danube University Krems, 3500 Krems, Austria; (T.P.); (R.D.)
| | - Rachel Dale
- Department for Psychotherapy and Biopsychosocial Health, Danube University Krems, 3500 Krems, Austria; (T.P.); (R.D.)
| | - Claas Lahmann
- Department of Psychosomatic Medicine and Psychotherapy, Faculty of Medicine, Medical Center-University of Freiburg, 79104 Freiburg, Germany
- Correspondence: (K.L.); (C.L.); Tel.: +49-761-270-68060 (C.L.)
| |
Collapse
|
|
14
|
Axer H, Finn S, Wassermann A, Guntinas-Lichius O, Klingner CM, Witte OW. Multimodal treatment of persistent postural-perceptual dizziness. Brain Behav 2020; 10:e01864. [PMID: 32989916 PMCID: PMC7749543 DOI: 10.1002/brb3.1864] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 09/12/2020] [Accepted: 09/13/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Persistent postural-perceptual dizziness (PPPD) is a chronic disorder with fluctuating symptoms of dizziness, unsteadiness, or vertigo for at least three months. Its pathophysiological mechanisms give theoretical support for the use of multimodal treatment. However, there are different therapeutic programs and principles available, and their clinical effectiveness remains elusive. METHODS A database of patients who participated in a day care multimodal treatment program was analyzed regarding the therapeutic effects on PPPD. Vertigo Severity Scale (VSS) and Hospital Anxiety and Depression Scale (HADS) were assessed before and 6 months after therapy. RESULTS Of a total of 657 patients treated with a tertiary care multimodal treatment program, 46.4% met the criteria for PPPD. PPPD patients were younger than patients with somatic diagnoses and complained more distress due to dizziness. 63.6% completed the follow-up questionnaire. All patients showed significant changes in VSS and HADS anxiety, but the PPPD patients generally showed a tendency to improve more than the patients with somatic diagnoses. The change in the autonomic-anxiety subscore of VSS only reached statistical significance when comparing PPPD with somatic diagnoses (p = .002). CONCLUSIONS Therapeutic principles comprise cognitive-behavioral therapy, vestibular rehabilitation exercises, and serotonergic medication. However, large-scale, randomized, controlled trials are still missing. Follow-up observations after multimodal interdisciplinary therapy reveal an improvement in symptoms in most patients with chronic dizziness. The study was not designed to detect diagnosis-specific effects, but patients with PPPD and patients with other vestibular disorders benefit from multimodal therapies.
Collapse
Affiliation(s)
- Hubertus Axer
- Center for Vertigo and Dizziness, Department of Neurology, Jena University Hospital, Jena, Germany
| | - Sigrid Finn
- Center for Vertigo and Dizziness, Department of Neurology, Jena University Hospital, Jena, Germany
| | - Alexander Wassermann
- Center for Vertigo and Dizziness, Department of Neurology, Jena University Hospital, Jena, Germany
| | | | - Carsten M Klingner
- Center for Vertigo and Dizziness, Department of Neurology, Jena University Hospital, Jena, Germany.,Biomagnetic Center, Jena University Hospital, Jena, Germany
| | - Otto W Witte
- Center for Vertigo and Dizziness, Department of Neurology, Jena University Hospital, Jena, Germany
| |
Collapse
|
|
15
|
Toshishige Y, Kondo M, Kabaya K, Watanabe W, Fukui A, Kuwabara J, Nakayama M, Iwasaki S, Furukawa TA, Akechi T. Cognitive-behavioural therapy for chronic subjective dizziness: Predictors of improvement in Dizziness Handicap Inventory at 6 months posttreatment. Acta Otolaryngol 2020; 140:827-832. [PMID: 32543959 DOI: 10.1080/00016489.2020.1772994] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background: Chronic subjective dizziness (CSD), which was superseded by persistent postural-perceptual dizziness as of 2017, has a great impact on patients' quality of life. Cognitive-behavioural therapy (CBT) is a promising treatment, with demonstrated effectiveness as a CSD treatment; however, no studies have examined positive predictors of its effectiveness in the long term.Aims/objectives: This study aimed to examine predictors of improvement in the Dizziness Handicap Inventory (DHI) in patients with CSD at 6 months after CBT.Materials and methods: Thirty-seven patients with CSD who were recruited from April 2012 to November 2014 and completed group CBT were analysed. Single and multiple regression analyses with forward-backward stepwise model selection method was used to examine the independent predictors of long-term improvement in the change score of DHI.Results: Presence or absence of comorbid anxiety disorders (p = .023) was a significant positive predictive factor for improvement of DHI from pretreatment to 6-month follow-up.Conclusions and significance: The presence of comorbid anxiety disorders predicted considerable improvement of DHI from pretreatment to 6-month follow-up. Group therapy including interoceptive exposure using vestibular rehabilitation, along with psychoeducation and behavioural experiments with graded exposure, may be particularly suitable in treating patients with CSD.
Collapse
Affiliation(s)
- Yuko Toshishige
- Department of Psychiatry and Cognitive-Behavioural Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masaki Kondo
- Department of Psychiatry and Cognitive-Behavioural Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Kayoko Kabaya
- Department of Otolaryngology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Wakako Watanabe
- Department of Psychiatry and Cognitive-Behavioural Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
- Kikuchi Mental Clinic, Toyokawa, Japan
| | - Ayako Fukui
- Good Sleep Center, Nagoya City University Hospital, Nagoya, Japan
| | - Junya Kuwabara
- Department of Psychiatry and Cognitive-Behavioural Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Meiho Nakayama
- Department of Otolaryngology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
- Good Sleep Center, Nagoya City University Hospital, Nagoya, Japan
| | - Shinichi Iwasaki
- Department of Otolaryngology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Toshi A. Furukawa
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Tatsuo Akechi
- Department of Psychiatry and Cognitive-Behavioural Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| |
Collapse
|
|
16
|
Schmid DA, Allum JHJ, Sleptsova M, Welge-Lüssen A, Schaefert R, Meinlschmidt G, Langewitz W. Relation of anxiety and other psychometric measures, balance deficits, impaired quality of life, and perceived state of health to dizziness handicap inventory scores for patients with dizziness. Health Qual Life Outcomes 2020; 18:204. [PMID: 32590995 PMCID: PMC7320574 DOI: 10.1186/s12955-020-01445-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 06/09/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND An important question influencing therapy for dizziness is whether the strengths of the relationships of emotional and functional aspects of dizziness to 1) anxiety and other mental states, 2) perceived state of health (SoH) and quality of life (QoL) are different in patients with and without normal balance control. We attempted to answer this question by examining these dimensions' regression strengths with Dizziness Handicap Inventory (DHI) scores. METHODS We divided 40 patients receiving group cognitive behavioural therapy (CBT) and vestibular rehabilitation for dizziness, into 2 groups: dizziness only (DO) and normal balance control; dizziness and a quantified balance deficit (QBD). Group-wise, we first performed stepwise multivariate regression analysis relating total DHI scores with Brief Symptom Inventory (BSI) sub-scores obtained pre- and post-therapy. Then, regression analysis was expanded to include SoH, QoL, and balance scores. Finally, we performed regressions with DHI sub-scores. RESULTS In both groups, the BSI phobic anxiety state score was selected first in the multivariate regression analysis. In the DO group, obsessiveness/compulsiveness was also selected. The correlation coefficient, R, was 0.74 and 0.55 for the DO and QBD groups, respectively. When QoL and SoH scores were included, R values increased to 0.86 and 0.74, explaining in total 74, and 55% of the DHI variance for DO and QBD groups, respectively. Correlations with balance scores were not significant (R ≤ 0.21). The psychometric scores selected showed the strongest correlations with emotional DHI sub-scores, and perceived QoL and SoH scores with functional DHI sub-scores. CONCLUSIONS Our findings suggest that reducing phobic anxiety and obsessiveness/compulsiveness during CBT may improve emotional aspects of dizziness and targeting perceived SoH and QoL may improve functional aspects of dizziness for those with and without normal balance control.
Collapse
Affiliation(s)
- D A Schmid
- Department of Psychosomatic Medicine, Faculty of Medicine, University of Basel and University Hospital Basel, Hebelstr 2, CH-4031, Basel, Switzerland
- Department of Psychosomatic Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - J H J Allum
- Department of Psychosomatic Medicine, Faculty of Medicine, University of Basel and University Hospital Basel, Hebelstr 2, CH-4031, Basel, Switzerland.
- Department of ORL, Faculty of Medicine, University of Basel and University Hospital Basel, Basel, Switzerland.
| | - M Sleptsova
- Department of Psychosomatic Medicine, Faculty of Medicine, University of Basel and University Hospital Basel, Hebelstr 2, CH-4031, Basel, Switzerland
| | - A Welge-Lüssen
- Department of ORL, Faculty of Medicine, University of Basel and University Hospital Basel, Basel, Switzerland
| | - R Schaefert
- Department of Psychosomatic Medicine, Faculty of Medicine, University of Basel and University Hospital Basel, Hebelstr 2, CH-4031, Basel, Switzerland
| | - G Meinlschmidt
- Department of Psychosomatic Medicine, Faculty of Medicine, University of Basel and University Hospital Basel, Hebelstr 2, CH-4031, Basel, Switzerland
- Division of Clinical Psychology and Cognitive Behavioral Therapy, International Psychoanalytic University, Berlin, Germany
- Division of Clinical Psychology and Epidemiology, Department of Psychology, University of Basel, Basel, Switzerland
| | - W Langewitz
- Department of Psychosomatic Medicine, Faculty of Medicine, University of Basel and University Hospital Basel, Hebelstr 2, CH-4031, Basel, Switzerland
| |
Collapse
|
|
17
|
Biomarkers of Oxidative Stress and Endogenous Antioxidants for Patients with Chronic Subjective Dizziness. Sci Rep 2020; 10:1478. [PMID: 32001745 PMCID: PMC6992639 DOI: 10.1038/s41598-020-58218-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 01/08/2020] [Indexed: 12/18/2022] Open
Abstract
As a neurotologic disorder of persistent non-vertiginous dizziness, chronic subjective dizziness (CSD) arises unsteadily by psychological and physiological imbalance. The CSD is hypersensitivity reaction due to exposure to complex motions visual stimuli. However, the pathophysiological features and mechanism of the CSD still remains unclearly. The present study was purposed to establish possible endogenous contributors of the CSD using serum samples from patients with the CSD. A total 199 participants were gathered and divided into two groups; healthy (n = 152, male for 61, and female for 91) and CSD (n = 47, male for 5, female for 42), respectively. Oxidative stress parameters such as, hydrogen peroxide and reactive substances were significantly elevated (p < 0.01 or p < 0.001), whereas endogenous antioxidant components including total glutathione contents, and activities of catalase and superoxide dismutase were significantly deteriorated in the CSD group (p < 0.01 or p < 0.001) as comparing to the healthy group, respectively. Serum levels of tumor necrosis factor -α and interferon-γ were significantly increased in the CSD participants (p < 0.001). Additionally, emotional stress related hormones including cortisol, adrenaline, and serotonin were abnormally observed in the serum levels of the CSD group (p < 0.01 or p < 0.001). Our results confirmed that oxidative stress and antioxidants are a critical contributor of pathophysiology of the CSD, and that is first explored to establish features of redox system in the CSD subjects compared to a healthy population.
Collapse
|
|
18
|
Shapovalova MV, Zamergrad MV. [Persistent postural perceptual dizziness of the elderly]. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:5-9. [PMID: 31825383 DOI: 10.17116/jnevro20191190925] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Persistent postural perceptual dizziness (PPPD) is a common cause of complaints to dizziness and unitability among patients of all-ages. The disease is characterized by a permanent feeling of non-rotatory dizziness or unsteadiness that at first can be caused by an acute vestibular dizziness, somatic disturbance that causes sudden unsteadiness and loss of balance or, for example, by a panic attack. Despite the permanent feeling of unsteadiness and dizziness, a regular instrumental examination cannot reveal important changes that can explain personal feeling. The diagnosis can be made according to the diagnostic criteria developed by the International Barani Society. Treatment consists of psychotherapy, drug therapy and vestibular rehabilitation.
Collapse
Affiliation(s)
- M V Shapovalova
- Russian Medical Academy for Continuing Professional Education, Moscow, Russia
| | - M V Zamergrad
- Pirogov Russian National Research Medical University, Russian Gerontology Clinical Research Center, Moscow, Russia
| |
Collapse
|
|
19
|
Reduced cortical folding in multi-modal vestibular regions in persistent postural perceptual dizziness. Brain Imaging Behav 2019; 13:798-809. [PMID: 29860587 PMCID: PMC6538588 DOI: 10.1007/s11682-018-9900-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Persistent postural perceptual dizziness (PPPD) is a common functional vestibular disorder that is triggered and sustained by a complex interaction between physiological and psychological factors affecting spatial orientation and postural control. Past functional neuroimaging research and one recent structural (i.e., voxel-based morphometry-VBM) study have identified alterations in vestibular, visuo-spatial, and limbic brain regions in patients with PPPD and anxiety-prone normal individuals. However, no-one thus far has employed surface based morphometry (SBM) to explore whether cortical morphology in patients with PPPD differs from that of healthy people. We calculated SBM measures from structural MR images in 15 patients with PPPD and compared them to those from 15 healthy controls matched for demographics, personality traits known to confer risk for PPPD as well as anxiety and depressive symptoms that are commonly comorbid with PPPD. We tested for associations between SBM measures and dizziness severity in patients with PPPD. Relative to controls, PPPD patients showed significantly decreased local gyrification index (LGI) in multi-modal vestibular regions bilaterally, specifically the posterior insular cortices, supra-marginal gyri, and posterior superior temporal gyri (p < 0.001). Within the PPPD group, dizziness severity positively correlated with LGI in visual areas and negatively with LGI in the right superior parietal cortex. These findings demonstrate abnormal cortical folding in vestibular cortices and correlations between dizziness severity and cortical folding in visual and somatosensory spatial association areas in PPPD patients, which provides new insights into the pathophysiological mechanisms underlying this disorder.
Collapse
|
|
20
|
Persistent Postural-Perceptual Dizziness-A Systematic Review of the Literature for the Balance Specialist. Otol Neurotol 2019; 39:1291-1303. [PMID: 30289841 DOI: 10.1097/mao.0000000000002010] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To present a systematic review of the current data on persistent postural-perceptual dizziness (PPPD), a useful and relatively new diagnosis for a disorder that has previously been known by many different names. In addition, to discuss diagnostic criteria and management strategies for this condition with the otologist in mind. DATA SOURCES CINAHL, Embase, PubMed, Medline, PsycINFO, PubMed, Google Scholar. REVIEW METHOD The phrase "persistent postural-perceptual dizziness" and its acronym "PPPD" were used. RESULTS From 318 articles, 15 were selected for full analysis with respect to PPPD. Most were case-control studies, with one consensus paper from the Bárány Society available. Overall, the pathophysiology of PPPD remains relatively poorly understood, but is likely to be a maladaptive state to a variety of insults, including vestibular dysfunction and not a structural or psychiatric one. Cognitive behavioral therapy, vestibular rehabilitation, selective serotonin uptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs) all seem to have a role in its management. CONCLUSIONS PPPD is useful as a diagnosis for those treating dizziness as it helps to define a conglomeration of symptoms that can seem otherwise vague and allows for more structured management plans in those suffering from it.
Collapse
|
|
21
|
Kristiansen L, Magnussen LH, Wilhelmsen KT, Mæland S, Nordahl SHG, Clendaniel R, Hovland A, Juul-Kristensen B. Efficacy of intergrating vestibular rehabilitation and cognitive behaviour therapy in persons with persistent dizziness in primary care- a study protocol for a randomised controlled trial. Trials 2019; 20:575. [PMID: 31590692 PMCID: PMC6781377 DOI: 10.1186/s13063-019-3660-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/14/2019] [Indexed: 01/13/2023] Open
Abstract
Background Dizziness is a common complaint, and the symptom often persists, together with additional complaints. A treatment combining Vestibular Rehabilitation (VR) and Cognitive Behaviour Therapy (CBT) is suggested. However, further research is necessary to evaluate the efficacy of such an intervention. The objective of this paper is to present the design of a randomised controlled trial aiming at evaluating the efficacy of an integrated treatment of VR and CBT on dizziness, physical function, psychological complaints and quality of life in persons with persistent dizziness. Methods/design The randomised controlled trial is an assessor-blinded, block-randomised, parallel-group design, with a 6- and 12-month follow-up. The study includes 125 participants from Bergen (Norway) and surrounding areas. Included participants present with persistent dizziness lasting for at least 3 months, triggered or exacerbated by movement. All participants receive a one-session treatment (Brief Intervention Vestibular Rehabilitation; BI-VR) with VR before being randomised into a control group or an intervention group. The intervention group will further be offered an eight-session treatment integrating VR and CBT. The primary outcomes in the study are the Dizziness Handicap Inventory and preferred gait velocity. Discussion Previous studies combining these treatments have been of varying methodological quality, with small samples, and long-term effects have not been maintained. In addition, only the CBT has been administered in supervised sessions, with VR offered as home exercises. The current study focusses on the integrated treatment, a sufficiently powered sample size, and a standardised treatment programme evaluated by validated outcomes using a standardised assessment protocol. Trial registration www.clinicaltrials.gov, ID: NCT02655575. Registered on 14 January 2016. Electronic supplementary material The online version of this article (10.1186/s13063-019-3660-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Lene Kristiansen
- Department of Health and Functioning, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway.
| | - L H Magnussen
- Department of Health and Functioning, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - K T Wilhelmsen
- Department of Health and Functioning, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - S Mæland
- Department of Health and Functioning, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - S H G Nordahl
- Norwegian National Advisory Unit on Vestibular Disorders, Department of Otorhinolaryngology and Head Neck Surgery, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - R Clendaniel
- Doctor of Physical Therapy Division, Department of Orthopedics, Duke University School of Medicine, Durham, NC, USA
| | - A Hovland
- Department of Clinical Psychology, University of Bergen, Bergen, Norway.,Solli District Psychiatric Centre (DPS), Nesttun, Norway
| | - B Juul-Kristensen
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
|
22
|
Sezier AEI, Saywell N, Terry G, Taylor D, Kayes N. Working-age adults' perspectives on living with persistent postural-perceptual dizziness: a qualitative exploratory study. BMJ Open 2019; 9:e024326. [PMID: 30940754 PMCID: PMC6500355 DOI: 10.1136/bmjopen-2018-024326] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 01/16/2019] [Accepted: 02/26/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To (a) explore the experiences of persistent postural-perceptual dizziness (PPPD), formerly chronic subjective dizziness on the personal, work and social lives of working-age adults; (b) enhance current understandings of the condition and its impact on the lives of working-age adults and (c) highlight points for consideration and importance to clinical practice. METHODS This qualitative exploratory study drew on interpretive descriptive methodology. Working-age adults (n=8) diagnosed with PPPD were recruited from a single New Zealand community-based specialist clinic. Data from interviews (n=8) and postinterview reflections (n=2) were analysed using thematic analysis. RESULTS Three themes were constructed: (1) It sounds like I'm crazy-referring to the lack of medical, social and self-validation associated with PPPD; (2) I'm a shadow of my former self-representing the impact of the condition on sense of self and life trajectory and (3) How will I survive?- highlighting individual coping processes. CONCLUSION This study contributed to the existing body of knowledge by highlighting the complexity and fluidity of experiencing PPPD. It also drew attention to the tension between the acute illness framework that forms the basis of many therapeutic interactions and the enduring psychosocial support needs of the person experiencing PPPD. The findings highlighted that contextual factors need to be taken into account and that a person-centred and biopsychosocial approach, rather than a condition-specific biomedical approach, is needed for care to be perceived as meaningful and satisfactory.
Collapse
Affiliation(s)
| | - Nicola Saywell
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand
| | - Gareth Terry
- Centre for Person Centred Research, Auckland University of Technology, Auckland, New Zealand
| | - Denise Taylor
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand
| | - Nicola Kayes
- Centre for Person Centred Research, Auckland University of Technology, Auckland, New Zealand
| |
Collapse
|
|
23
|
Nada EH, Ibraheem OA, Hassaan MR. Vestibular Rehabilitation Therapy Outcomes in Patients With Persistent Postural-Perceptual Dizziness. Ann Otol Rhinol Laryngol 2019; 128:323-329. [DOI: 10.1177/0003489418823017] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objectives: Persistent postural-perceptual dizziness (PPPD) represents an important category of vertigo. Medical treatment and psychotherapy provide convenient control of symptoms. However, these management strategies can have inconvenient side effects and short-term relief, respectively. Vestibular rehabilitation therapy (VRT) is a self-conducted habituation program that can be personalized to the subject’s needs to give adequate symptom relief without side effects. The present study aims to test the effect of VRT on patients with PPPD. Methods: Participants were diagnosed as having PPPD by the exclusion of organic vestibular lesions. The study involved 2 groups with PPPD: Group I, treated with the VRT, and Group II, treated with the VRT plus placebo. The Dizziness Handicap Inventory (DHI), a self-assessment scale, was used to evaluate the VRT outcomes. Results: There was a significant decrease in functional, physical, and total scores on the DHI in both groups after VRT. Adding the placebo did not have supplementary outcomes. The patients who did not benefit from the VRT had a significantly longer duration of PPPD, more complex aggravating factors, more composite VRT exercises, and a higher DHI score than the patients who benefited from VRT. Conclusions: Customized VRT adequately reduced symptoms and improved quality of life in subjects with PPPD.
Collapse
Affiliation(s)
- Ebtessam H. Nada
- Audio-Vestibular Medicine Unit, Department of Otolaryngology–Head and Neck Surgery, Faculty of Medicine, University of Zagazig, Zagazig, Egypt
| | - Ola A. Ibraheem
- Audio-Vestibular Medicine Unit, Department of Otolaryngology–Head and Neck Surgery, Faculty of Medicine, University of Zagazig, Zagazig, Egypt
| | - Mohammad R. Hassaan
- Audio-Vestibular Medicine Unit, Department of Otolaryngology–Head and Neck Surgery, Faculty of Medicine, University of Zagazig, Zagazig, Egypt
| |
Collapse
|
|
24
|
Popkirov S, Stone J, Holle-Lee D. Treatment of Persistent Postural-Perceptual Dizziness (PPPD) and Related Disorders. Curr Treat Options Neurol 2018; 20:50. [PMID: 30315375 DOI: 10.1007/s11940-018-0535-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Persistent postural-perceptual dizziness (PPPD) is a newly defined disorder of functional dizziness that in the International Classification of Diseases in its 11th revision (ICD-11) supersedes phobic postural vertigo and chronic subjective dizziness. Despite efforts to unify the diagnosis of functional (somatoform) dizziness, patients will present with a variety of triggers, perpetuating factors, and comorbidities, requiring individualized treatment. This article will review different treatment strategies for this common functional neurological disorder and provide practical recommendations for tailored therapy. RECENT FINDINGS An emerging understanding of the underlying pathophysiology that considers vestibular, postural, cognitive, and emotional aspects can enable patients to profit from vestibular rehabilitation, as well as cognitive-behavioral therapy (CBT). Crucially, approaches from CBT should inform and augment physiotherapeutic techniques, and, on the other hand, vestibular exercises or relaxation techniques can be integrated into CBT programs. Antidepressant medication might further facilitate rehabilitation, though the mechanisms are yet to be elucidated, and the level of evidence is low. In PPPD and related disorders, vestibular rehabilitation combined with CBT, and possibly supported by medication, can help patients escape a cycle of maladaptive balance control, recalibrate vestibular systems, and regain independence in everyday life.
Collapse
Affiliation(s)
- Stoyan Popkirov
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany.
| | - Jon Stone
- Centre for Clinical Brain Sciences, Western General Hospital, University of Edinburgh, Edinburgh, UK
| | - Dagny Holle-Lee
- Dizziness and Vertigo Center Essen and Department of Neurology, University of Duisburg-Essen, Essen, Germany
| |
Collapse
|
|
25
|
Morisod B, Mermod M, Maire R. Posturographic pattern of patients with chronic subjective dizziness before and after vestibular rehabilitation. J Vestib Res 2018; 27:305-311. [PMID: 29125531 DOI: 10.3233/ves-170628] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Chronic subjective dizziness (CSD) is frequently encountered in neurotology clinics. This diagnosis is mainly clinical, but computerized dynamic posturography (CDP) could be a helpful instrumental tool in the identification of these patients and validation of the treatment. This study was aimed to look for a specific posturographic pattern among patients diagnosed with CSD, and to eventually visualize improvement after vestibular rehabilitation. METHODS Single center, retrospective review from 2009 to 2014. We included patients diagnosed with CSD who underwent CDP in their neurotologic assessment. For those patients who benefited from vestibular rehabilitation, we compared their pre- and post-rehabilitation posturographies. RESULTS We included 114 patients, of whom 74% had known anxiety disorders and 33% a history of past vestibular disorder. 62% of the assessment posturographies were abnormal. The most affected sub-items were limit of stability, composite score of sensory organization tests and condition 5 in respectively 34%, 23% and 20% of the cases. In univariate analysis, only pathologic videonystagmography and history of unilateral vestibular dysfunction were significantly related to abnormal posturography. In the 42 patients who had vestibular rehabilitation and a post rehabilitation posturography, the proportion of abnormal posturography significantly dropped from 79% to 33% (p < 0.001). When it was assessed, 79% of the patients reported a subjective improvement. CONCLUSION Patients with CSD have a high rate of abnormal posturography, but without a specific pattern. Vestibular rehabilitation is an effective tool in the therapeutic armamentarium.
Collapse
Affiliation(s)
- Benoît Morisod
- Department of Otorhinolaryngology, Head and Neck Surgery, Neurotology Unit, Lausanne University Hospital, Switzerland
| | - Maxime Mermod
- Department of Otorhinolaryngology, Head and Neck Surgery, Neurotology Unit, Lausanne University Hospital, Switzerland
| | - Raphaël Maire
- Department of Otorhinolaryngology, Head and Neck Surgery, Neurotology Unit, Lausanne University Hospital, Switzerland
| |
Collapse
|
|
26
|
Menant JC, Migliaccio AA, Sturnieks DL, Hicks C, Lo J, Ratanapongleka M, Turner J, Delbaere K, Titov N, Meinrath D, McVeigh C, Close JCT, Lord SR. Reducing the burden of dizziness in middle-aged and older people: A multifactorial, tailored, single-blind randomized controlled trial. PLoS Med 2018; 15:e1002620. [PMID: 30040818 PMCID: PMC6057644 DOI: 10.1371/journal.pmed.1002620] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 06/21/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Dizziness is common among older people and is associated with a cascade of debilitating symptoms, such as reduced quality of life, depression, and falls. The multifactorial aetiology of dizziness is a major barrier to establishing a clear diagnosis and offering effective therapeutic interventions. Only a few multidisciplinary interventions of dizziness have been conducted to date, all of a pilot nature and none tailoring the intervention to the specific causes of dizziness. Here, we aimed to test the hypothesis that a multidisciplinary dizziness assessment followed by a tailored multifaceted intervention would reduce dizziness handicap and self-reported dizziness as well as enhance balance and gait in people aged 50 years and over with dizziness symptoms. METHODS AND FINDINGS We conducted a 6-month, single-blind, parallel-group randomized controlled trial in community-living people aged 50 years and over who reported dizziness in the past year. We excluded individuals currently receiving treatment for their dizziness, those with degenerative neurological conditions including cognitive impairment, those unable to walk 20 meters, and those identified at baseline assessment with conditions that required urgent treatment. Our team of geriatrician, vestibular neuroscientist, psychologist, exercise physiologist, study coordinator, and baseline assessor held case conferences fortnightly to discuss and recommend appropriate therapy (or therapies) for each participant, based on their multidisciplinary baseline assessments. A total of 305 men and women aged 50 to 92 years (mean [SD] age: 67.8 [8.3] years; 62% women) were randomly assigned to either usual care (control; n = 151) or to a tailored, multifaceted intervention (n = 154) comprising one or more of the following: a physiotherapist-led vestibular rehabilitation programme (35% [n = 54]), an 8-week internet-based cognitive-behavioural therapy (CBT) (19% [n = 29]), a 6-month Otago home-based exercise programme (24% [n = 37]), and/or medical management (40% [n = 62]). We were unable to identify a cause of dizziness in 71 participants (23% of total sample). Primary outcome measures comprised dizziness burden measured with the Dizziness Handicap Inventory (DHI) score, frequency of dizziness episodes recorded with monthly calendars over the 6-month follow-up, choice-stepping reaction time (CSRT), and gait variability. Data from 274 participants (90%; 137 per group) were included in the intention-to-treat analysis. At trial completion, the DHI scores in the intervention group (pre and post mean [SD]: 25.9 [19.2] and 20.4 [17.7], respectively) were significantly reduced compared with the control group (pre and post mean [SD]: 23.0 [15.8] and 21.8 [16.4]), when controlling for baseline scores (mean [95% CI] difference between groups [baseline adjusted]: -3.7 [-6.2 to -1.2]; p = 0.003). There were no significant between-group differences in dizziness episodes (relative risk [RR] [95% CI]: 0.87 [0.65 to 1.17]; p = 0.360), CSRT performance (mean [95% CI] difference between groups [baseline adjusted]: -15 [-40 to 10]; p = 0.246), and step-time variability during gait (mean [95% CI] difference between groups [baseline adjusted]: -0.001 [-0.002 to 0.001]; p = 0.497). No serious intervention-related adverse events occurred. Study limitations included the low initial dizziness severity of the participants and the only fair uptake of the falls clinic (medical management) and the CBT interventions. CONCLUSIONS A multifactorial tailored approach for treating dizziness was effective in reducing dizziness handicap in community-living people aged 50 years and older. No difference was seen on the other primary outcomes. Our findings therefore support the implementation of individualized, multifaceted evidence-based therapies to reduce self-perceived disability associated with dizziness in middle-aged and older people. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12612000379819.
Collapse
Affiliation(s)
- Jasmine C. Menant
- Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Americo A. Migliaccio
- Neuroscience Research Australia, Sydney, New South Wales, Australia
- Graduate School of Biomedical Engineering, University of New South Wales, Sydney, New South Wales, Australia
| | - Daina L. Sturnieks
- Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Cameron Hicks
- Neuroscience Research Australia, Sydney, New South Wales, Australia
| | - Joanne Lo
- Neuroscience Research Australia, Sydney, New South Wales, Australia
| | | | - Jessica Turner
- Neuroscience Research Australia, Sydney, New South Wales, Australia
| | - Kim Delbaere
- Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Nickolai Titov
- Department of Psychology, Macquarie University, Sydney, New South Wales, Australia
| | - Daniela Meinrath
- Department of Physiotherapy, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Catherine McVeigh
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Jacqueline C. T. Close
- Neuroscience Research Australia, Sydney, New South Wales, Australia
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Stephen R. Lord
- Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
- * E-mail:
| |
Collapse
|
|
27
|
Kelm Z, Klapchar K, Kieliszak CR, Selinsky C. Psychogenic Dizziness: An Important but Overlooked Differential Diagnosis in the Workup of the Dizzy Patient. J Osteopath Med 2018; 118:e22-e27. [DOI: 10.7556/jaoa.2018.066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Abstract
Chronic dizziness can be challenging for both patients and physicians, as a variety of specialists may be consulted and tests ordered before a diagnosis is established. The various potential etiologic processes involved in chronic dizziness require an interdisciplinary approach to care. Common causes include neurologic, vestibular, and cardiac diseases. Psychiatric disorders, however, may be overlooked when establishing a differential diagnosis. This case report illustrates some of the complexities in diagnosing and effectively managing chronic dizziness and serves as a reminder that psychiatric disorders should be considered in the differential diagnosis.
Collapse
|
|
28
|
Effects of a program of cognitive-behavioural group therapy, vestibular rehabilitation, and psychoeducational explanations on patients with dizziness and no quantified balance deficit, compared to patients with dizziness and a quantified balance deficit. J Psychosom Res 2018; 105:21-30. [PMID: 29332630 DOI: 10.1016/j.jpsychores.2017.11.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 11/29/2017] [Accepted: 11/29/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND We examined whether a program combining cognitive-behavioural therapy (CBT), vestibular rehabilitation (VR) and psychoeducation is equally effective in improving psychometric measures in patients with dizziness independent of a balance deficit. Measures of patients with dizziness only (DO) were compared to those of patients also having a quantified balance deficit (QBD). METHODS 32 patients (23 female, 9 male) with persistent dizziness were analysed as 2 groups based on stance and gait balance control: those with QBD (pathological balance) or DO (normal balance). Dizziness Handicap Inventory (DHI) and Brief Symptom Inventory (BSI) questionnaires were used pre- and post-therapy to assess psychometric measures. Patients then received the same combination therapy in a group setting. RESULTS The QBD group mean age was 60.6, SD 8.3, and DO group mean age 44.8, SD 12.1, years. Pre-therapy, questionnaire scores were pathological but not different between groups. Balance improved significantly for the QBD group (p=0.003) but not for the DO group. DHI and BSI scores improved significantly in the DO group (0.001<p<0.045), some BSI sub-scores reaching normal levels. These scores were unchanged for the QBD group. Phobic anxiety scores changed most for both groups, being significantly correlated with DHI scores, higher (R=0.71 vs. 0.57) for the DO group. CONCLUSIONS A combination of CBT, VR, and psychoeducation improves psychological measures in DO patients but not significantly in QBD patients, despite their balance control improving to near normal. Possibly, greater focus on phobic anxiety during the group therapy program would have improved psychological measures of QBD patient.
Collapse
|
|
29
|
Functional dizziness: from phobic postural vertigo and chronic subjective dizziness to persistent postural-perceptual dizziness. Curr Opin Neurol 2018; 30:107-113. [PMID: 28002123 DOI: 10.1097/wco.0000000000000417] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW Functional dizziness is the new term for somatoform or psychogenic dizziness. The aim of this study is to review arguments for the new nomenclature, clinical features, possible pathomechanisms, and comorbidities of functional dizziness. RECENT FINDINGS The prevalence of functional dizziness as a primary cause of vestibular symptoms amounts to 10% in neuro-otology centers. Rates of psychiatric comorbidity in patients with structural vestibular syndromes are much higher with nearly 50% and with highest rates in patients with vestibular migraine, vestibular paroxysmia, and Ménière's disease. Pathophysiologic processes seem to include precipitating events that trigger anxiety-related changes in postural strategies with an increased attention to head and body motion and a cocontraction of leg muscles. Personality traits with high levels of neuroticism and low levels of extraversion appear as risk factors for anxiety and depressive disorders and increased morbidity in functional disorders. SUMMARY Correct and early diagnosis of functional dizziness, as primary cause or secondary disorder after a structural vestibular syndrome, is very important to prevent further chronification and enable adequate treatment. Treatment plans that include patient education, vestibular rehabilitation, cognitive and behavioral therapies, and medications substantially reduce morbidity and offer the potential for sustained remission when applied systematically.
Collapse
|
|
30
|
Popkirov S, Staab JP, Stone J. Persistent postural-perceptual dizziness (PPPD): a common, characteristic and treatable cause of chronic dizziness. Pract Neurol 2017; 18:5-13. [PMID: 29208729 DOI: 10.1136/practneurol-2017-001809] [Citation(s) in RCA: 158] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2017] [Indexed: 01/13/2023]
Abstract
Persistent postural-perceptual dizziness (PPPD) is a newly defined diagnostic syndrome that unifies key features of chronic subjective dizziness, phobic postural vertigo and related disorders. It describes a common chronic dysfunction of the vestibular system and brain that produces persistent dizziness, non-spinning vertigo and/or unsteadiness. The disorder constitutes a long-term maladaptation to a neuro-otological, medical or psychological event that triggered vestibular symptoms, and is usefully considered within the spectrum of other functional neurological disorders. While diagnostic tests and conventional imaging usually remain negative, patients with PPPD present in a characteristic way that maps on to positive diagnostic criteria. Patients often develop secondary functional gait disorder, anxiety, avoidance behaviour and severe disability. Once recognised, PPPD can be managed with effective communication and tailored treatment strategies, including specialised physical therapy (vestibular rehabilitation), serotonergic medications and cognitive-behavioural therapy.
Collapse
Affiliation(s)
- Stoyan Popkirov
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Jeffrey P Staab
- Department of Psychiatry and Psychology and Otorhinolaryngology - Head and Neck Surgery, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Jon Stone
- Centre for Clinical Brain Sciences, University of Edinburgh, Western General Hospital, Edinburgh, UK
| |
Collapse
|
|
31
|
A Cognitive-Behavioral Model of Persistent Postural-Perceptual Dizziness. COGNITIVE AND BEHAVIORAL PRACTICE 2017. [DOI: 10.1016/j.cbpra.2016.03.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
|
32
|
Diukova GM, Zamergrad MV, Golubev VL, Adilova SM, Makarov SA. Functional (psychogenic) vertigo. Zh Nevrol Psikhiatr Im S S Korsakova 2017; 117:91-98. [DOI: 10.17116/jnevro20171176191-98] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
|
33
|
Saman Y, Mclellan L, Mckenna L, Dutia MB, Obholzer R, Libby G, Gleeson M, Bamiou DE. State Anxiety Subjective Imbalance and Handicap in Vestibular Schwannoma. Front Neurol 2016; 7:101. [PMID: 27468274 PMCID: PMC4942454 DOI: 10.3389/fneur.2016.00101] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 06/15/2016] [Indexed: 11/29/2022] Open
Abstract
Introduction Evidence is emerging for a significant clinical and neuroanatomical relationship between balance and anxiety. Research has suggested a potentially priming effect with anxiety symptoms predicting a worsening of balance function in patients with underlying balance dysfunction. We propose to show that a vestibular stimulus is responsible for an increase in state anxiety, and there is a relationship between increased state anxiety and worsening balance function. Aims (1) To quantify state anxiety following a vestibular stimulus in patients with a chronic vestibular deficit. (2) To determine if state anxiety during a vestibular stimulus would correlate with the severity of chronic balance symptoms and handicap. Methods Two separate cohorts of vestibular schwannoma (VS) patients underwent vestibular tests (electronystagmography, cervical and ocular vestibular evoked myogenic potentials, and caloric responses) and questionnaire assessments [vertigo handicap questionnaire (VHQ), vertigo symptom scale (VSS), and state-trait anxiety inventory (STAIY)]. Fifteen post-resection VS patients, with complete unilateral vestibular deafferentation, were assessed at a minimum of 6 months after surgery in Experiment 1 (Aim 1). Forty-five patients with VS in situ formed the cohort for Experiment 2 (Aim 2). Experiment 1: VS subjects (N = 15) with a complete post-resection unilateral vestibular deafferentation completed a state anxiety questionnaire before caloric assessment and again afterward with the point of maximal vertigo as the reference (Aim 1). Experiment 2: state anxiety measured at the point of maximal vertigo following a caloric assessment was compared between two groups of patients with VS in situ presenting with balance symptoms (Group 1, N = 26) and without balance symptoms (Group 2, N = 11) (Aim 2). The presence of balance symptoms was defined as having a positive score on the VSS–VER. Results In Experiment 1, a significant difference (p < 0.01) was found when comparing STAIY at baseline and at the peak of the subjective vertiginous response in post-resection patients with a unilateral vestibular deafferentation. In Experiment 2, VS in situ patients with balance symptoms had significantly worse state anxiety at the peak vertiginous response than patients without balance symptoms (p < 0.001), as did patients with a balance-related handicap (p < 0.001). Conclusion Anxiety symptoms during a vestibular stimulus may contribute to a priming effect that could explain worsening balance function.
Collapse
Affiliation(s)
- Yougan Saman
- Institute of Neurology, National Hospital for Neurology and Neurosurgery, UCL, London, UK; Nelson R. Mandela School of Medicine, UKZN, Durban, South Africa
| | - Lucie Mclellan
- Neuro-otology Department, National Hospital for Neurology and Neurosurgery , London , England
| | | | - Mayank B Dutia
- Centre for Integrative Physiology, University of Edinburgh , Edinburgh , UK
| | - Rupert Obholzer
- ENT and Skull Base Department, Guys Hospital, London, UK; ENT and Skull Base Department, Kings College Hospital, London, UK
| | - Gerald Libby
- Neurogastroenterology Group, Queen Mary University of London , London , UK
| | - Michael Gleeson
- Neuro-otology and Skull Base Department, National Hospital for Neurology and Neurosurgery , London , UK
| | - Doris-Eva Bamiou
- Neuro-otology Department, National Hospital for Neurology and Neurosurgery, London, England; Ear Institute, UCL, London, UK
| |
Collapse
|
|
34
|
Abstract
Functional and psychiatric disorders that cause vestibular symptoms (i.e., vertigo, unsteadiness, and dizziness) are common. In fact, they are more common than many well-known structural vestibular disorders. Neurologists and otologists are more likely to encounter patients with vestibular symptoms due to persistent postural-perceptual dizziness or panic disorder than Ménière's disease or bilateral vestibular loss. Successful approaches to identifying functional and psychiatric causes of vestibular symptoms can be incorporated into existing practices without much difficulty. The greatest challenge is to set aside dichotomous thinking that strongly emphasizes investigations of structural diseases in favor of a three-pronged approach that assesses structural, functional, and psychiatric disorders simultaneously. The pathophysiologic mechanisms underlying functional and psychiatric causes of vestibular symptoms are better understood than many clinicians realize. Research methods such as advanced posturographic analysis and functional brain imaging will push this knowledge further in the next few years. Treatment plans that include patient education, vestibular rehabilitation, cognitive and behavioral therapies, and medications substantially reduce morbidity and offer the potential for sustained remission when applied systematically. Diagnostic and therapeutic approaches are necessarily multidisciplinary in nature, but they are well within the purview of collaborative care teams or networks of clinicians coordinated with the neurologists and otologists whom patients consult first.
Collapse
Affiliation(s)
- M Dieterich
- Department of Neurology, Ludwig-Maximilians-University Munich, Klinikum Grosshadern, Munich, Germany; German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-University Munich, Klinikum Grosshadern, Munich, Germany.
| | - J P Staab
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - T Brandt
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-University Munich, Klinikum Grosshadern, Munich, Germany
| |
Collapse
|
|
35
|
Abstract
Behavioral factors have long been recognized as affecting spatial orientation and balance function. Neuroanatomic and neurophysiologic studies conducted worldwide over the last 30 years have substantially advanced our knowledge about the inherently strong connectivity among threat/anxiety, vestibular, visual, and somatosensory systems in the brain. Clinical investigations have shed greater light on the nature of functional and psychiatric disorders that manifest or magnify vestibular morbidity. Concepts of these syndromes have changed over 150 years. Even their nomenclature has had different meanings in different eras. This chapter will review functional and psychiatric vestibular disorders. Terminology will follow the International Classification of Diseases, 11th edition, beta draft and the International Classification of Vestibular Disorders. Anxiety plays a central role in behavioral vestibular morbidity. Anxiety, traumatic stress, obsessive, and depressive disorders may be primary causes of episodic and chronic vestibular symptoms or secondary complications of other vestibular disorders. These psychiatric illnesses affect 30-50% of patients who consult neurologists or otologists for vestibular symptoms. Coexisting psychiatric disorders adversely affect treatment for patients with structural vestibular diseases, especially when unrecognized. Persistent postural-perceptual dizziness is the leading cause of long-term vestibular disability. Fortunately, pharmacologic, psychotherapeutic, and rehabilitative treatments of these illnesses have improved in recent years.
Collapse
Affiliation(s)
- J P Staab
- Department of Psychiatry and Psychology, and Department of Otorhinolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
|
36
|
STEADFAST: Psychotherapeutic Intervention Improves Postural Strategy of Somatoform Vertigo and Dizziness. Behav Neurol 2015; 2015:456850. [PMID: 26843786 PMCID: PMC4710932 DOI: 10.1155/2015/456850] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 11/23/2015] [Accepted: 11/25/2015] [Indexed: 11/17/2022] Open
Abstract
Patients with somatoform vertigo and dizziness (SVD) disorders often report instability of stance or gait and fear of falling. Posturographic measurements indeed indicated a pathological postural strategy. Our goal was to evaluate the effectiveness of a psychotherapeutic and psychoeducational short-term intervention (PTI) using static posturography and psychometric examination. Seventeen SVD patients took part in the study. The effects of PTI on SVD were evaluated with quantitative static posturography. As primary endpoint a quotient characterizing the relation between horizontal and vertical sway was calculated (QH/V), reflecting the individual postural strategy. Results of static posturography were compared to those of age- and gender-matched healthy volunteers (n = 28); baseline measurements were compared to results after PTI. The secondary endpoint was the participation-limiting consequences of SVD as measured by the Vertigo Handicap Questionnaire (VHQ). Compared to the healthy volunteers, the patients with SVD showed a postural strategy characterized by stiffening-up that resulted in a significantly reduced body sway quotient before PTI (patients: QH/V = 0.31 versus controls: QH/V = 0.38; p = 0.022). After PTI the postural behavior normalized, and psychological distress was reduced. PTI therefore appears to modify pathological balance behaviour. The postural strategy of patients with SVD possibly results from anxious anticipatory cocontraction of the antigravity muscles.
Collapse
|
|
37
|
Strupp M, Dieterich M, Zwergal A, Brandt T. [Peripheral, central and functional vertigo syndromes]. DER NERVENARZT 2015; 86:1573-84; quiz 1585-6. [PMID: 26643594 DOI: 10.1007/s00115-015-4425-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Depending on the temporal course, three forms of vertigo syndrome can be differentiated: 1) vertigo attacks, e.g. benign paroxysmal positional vertigo (BPPV), Menière's disease and vestibular migraine, 2) acute spontaneous vertigo lasting for days, e.g. acute unilateral vestibulopathy, brainstem or cerebellar infarction and 3) symptoms lasting for months or years, e.g. bilateral vestibulopathy and functional vertigo. The specific therapy of the various syndromes is based on three principles: 1) physical treatment with liberatory maneuvers for BPPV and balance training for vestibular deficits, 2) pharmacotherapy, e.g. for acute unilateral vestibulopathy (corticosteroids) and Menière's disease (transtympanic administration of gentamicin or steroids and high-dose betahistine therapy); placebo-controlled pharmacotherapy studies are currently being carried out for acute unilateral vestibulopathy, vestibular paroxysmia, prophylaxis of BPPV, vestibular migraine, episodic ataxia type 2 and cerebellar ataxia; 3) psychotherapy for functional dizziness.
Collapse
Affiliation(s)
- M Strupp
- Neurologische Klinik, Klinikum der Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland. .,Deutsches Schwindel- und Gleichgewichtszentrum, Klinikum der Universität München, Campus Großhadern, München, Deutschland.
| | - M Dieterich
- Neurologische Klinik, Klinikum der Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland.,Deutsches Schwindel- und Gleichgewichtszentrum, Klinikum der Universität München, Campus Großhadern, München, Deutschland.,SyNergy, Munich Cluster for Systems Neurology, München, Deutschland
| | - A Zwergal
- Neurologische Klinik, Klinikum der Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland.,Deutsches Schwindel- und Gleichgewichtszentrum, Klinikum der Universität München, Campus Großhadern, München, Deutschland
| | - T Brandt
- Deutsches Schwindel- und Gleichgewichtszentrum, Klinikum der Universität München, Campus Großhadern, München, Deutschland.,Institut für Klinische Neurowissenschaften, Klinikum der Universität München, Campus Großhadern, München, Deutschland
| |
Collapse
|
|
38
|
Piker EG, Kaylie DM, Garrison D, Tucci DL. Hospital Anxiety and Depression Scale: Factor Structure, Internal Consistency and Convergent Validity in Patients with Dizziness. Audiol Neurootol 2015; 20:394-9. [PMID: 26460986 DOI: 10.1159/000438740] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 07/15/2015] [Indexed: 11/19/2022] Open
Abstract
Psychiatric comorbidities, particularly anxiety-related pathologies, are often observed in dizzy patients. The Hospital Anxiety and Depression Scale (HADS) is a widely used self-report instrument used to screen for anxiety and depression in medical outpatient settings. The purpose of this study was to assess the factor structure, internal consistency and convergent validity of the HADS in an unselected group of patients with dizziness. The HADS and the Dizziness Handicap Inventory (DHI) were administered to 205 dizzy patients. An exploratory factor analysis was conducted and indicated a 3-factor structure, inconsistent with the 2-subscale structure (i.e. anxiety and depression) of the HADS. The total scale was found to be internally consistent, and convergent validity, as assessed using the DHI, was acceptable. Overall findings suggest that the HADS should not be used as a tool for psychiatric differential diagnosis, but rather as a helpful screener for general psychiatric distress in the two domains of psychiatric illness most germane in dizzy patients.
Collapse
Affiliation(s)
- Erin G Piker
- Division of Otolaryngology, Head and Neck Surgery, Duke University Medical Center, Durham, N.C., USA
| | | | | | | |
Collapse
|
|
39
|
Psychological traumatization and adverse life events in patients with organic and functional vestibular symptoms. J Psychosom Res 2015; 79:123-9. [PMID: 26094009 DOI: 10.1016/j.jpsychores.2015.05.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Revised: 05/07/2015] [Accepted: 05/10/2015] [Indexed: 11/20/2022]
Abstract
OBJECTIVE . A relationship has frequently been found between a history of traumatization and the existence of somatoform symptoms. The objective of this study was to examine whether this relationship is also observed for functional, i.e. medically not sufficiently explained, vestibular symptoms (FVS). We tested whether patients with FVS and organically explained vestibular symptoms (OVS) differ with regard to frequencies of previous traumatic experiences and posttraumatic stress symptoms. We also explored whether the impact of previous trauma was associated with characteristics of vestibular symptoms and handicap. METHODS . Patients with a diagnosis of OVS (N=185) or FVS (N=158) completed questionnaires about potentially traumatizing experiences (e.g., Childhood Trauma Questionnaire, Impact of Events Scale) and vertigo-related symptoms and handicap (Vertigo Symptom Scale, Vertigo Handicap Questionnaire). RESULTS . We found no differences between the two patient groups with regard to number or impact of traumatic life events. However, regression analyses across groups revealed that, regardless of their diagnosis, prior traumatic experiences and the presence of posttraumatic stress symptoms including avoidance and intrusion predicted to some extent higher overall balance symptoms and autonomic symptoms of vertigo-related anxiety. CONCLUSION . Exposure to trauma and symptoms of posttraumatic stress can contribute to symptom severity and handicap experienced by patients with vestibular symptoms irrespective of their original cause, most likely serving as predisposing, modulating or perpetuating factors.
Collapse
|
|
40
|
Tailored care for somatoform vertigo/dizziness: study protocol for a randomised controlled trial evaluating integrative group psychotherapy. J Neurol 2015; 262:1867-75. [PMID: 26001913 DOI: 10.1007/s00415-015-7784-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 05/07/2015] [Accepted: 05/08/2015] [Indexed: 12/12/2022]
Abstract
UNLABELLED Vertigo/dizziness (VD) ranks high in lifetime prevalence and clinical relevance. Nearly half of the complex VD disorders presenting at specialised units for vertigo or otoneurological disorders are not fully explained by an identifiable medical illness, but instead are related to anxiety, depressive, or somatoform disorders. Although there is some evidence that psychotherapy may be effective for these patients, therapeutic options remain unsatisfactory. This report describes the objectives, design and methods of a randomised, controlled clinical trial, evaluating the efficacy of manualised, multimodal group psychotherapy, based on integrative psychotherapy (IPT) and tailored to subgroups of mental disorders in medically unexplained VD. This psychotherapeutic approach will be compared to self-help groups (n = 172; n = 86 per study arm). Improvements with regard to handicap due to VD at 12 months follow-up will serve as primary outcome. Additionally, measures of generic quality of life, severity of vertigo, depression, anxiety, somatisation as well as Head Impulse Test and Computerized Static Posturography will be applied. We will also analyse the cost-effectiveness of this trial. The study aims to improve treatment of this therapeutically underserved population who are often severely impaired in their working and daily lives. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02320851. TRIAL STATUS This is an on-going study; recruitment for the study is about to start.
Collapse
|
|
41
|
Coelho CM, Balaban CD. Visuo-vestibular contributions to anxiety and fear. Neurosci Biobehav Rev 2014; 48:148-59. [PMID: 25451199 DOI: 10.1016/j.neubiorev.2014.10.023] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 08/25/2014] [Accepted: 10/28/2014] [Indexed: 12/30/2022]
Abstract
The interactive roles of the visual and vestibular systems allow for postural control within boundaries of perceived safety. In specific circumstances, visual vestibular and postural interactions act as a cue that trigger fear, similarly to what occurs in motion sickness. Unusual patterns of visuo-vestibular interaction that emerge without warning can elicit fear, which can then become associated to a certain stimuli or situation, creating a CS-US association, (i.e., phobia), or can emerge without warning but also without becoming associated to a particular concomitant event (i.e., panic). Depending on the individual sensitivity to visuo-vestibular unusual patterns and its impact in postural control, individuals will be more or less vulnerable to develop these disorders. As such, the mechanism we here propose is also sufficient to explain the lack of certain fears albeit exposure. Following this rationale, a new subcategory of anxiety disorders, named visuo-vestibular fears can be considered. This model brings important implications for developmental and evolutionary psychological science, and invites to place visuo-vestibular fears in a particular subtype or specification within the DSM-5 diagnostic criteria.
Collapse
Affiliation(s)
- Carlos M Coelho
- University of Minho, School of Engineering, Centro Algoritmi, Guimarães, Portugal; University of Queensland, Queensland Brain Institute, Brisbane, Australia.
| | - Carey D Balaban
- University of Pittsburgh, School of Med, Department of Otolaryngology, Eye & Ear Inst., Pittsburgh, PA, USA; University of Pittsburgh, Department of Neurobiology, Pittsburgh, PA, USA; University of Pittsburgh, Department of Communication Sciences & Disorders, Pittsburgh, PA, USA; University of Pittsburgh, Department of Bioengineering, Pittsburgh, PA, USA
| |
Collapse
|
|
42
|
Whitney SL, Sparto PJ, Alahmari K, Redfern MS, Furman JM. The use of virtual reality for people with balance and vestibular disorders: the Pittsburgh experience. PHYSICAL THERAPY REVIEWS 2014. [DOI: 10.1179/108331909x12488667117294] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
|
|
43
|
Abstract
The aim of this study was to perform a 3-year follow-up of primary somatoform vertigo and dizziness (SVD) regarding health care use and treatment. Ninety-two patients with dizziness underwent detailed vestibular neurophysiological testing and a Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Psychometric assessments comprised the Vertigo Symptom Scale, the Vertigo Handicap Questionnaire, the SCL-90-R, and the Short-Form-36 Health Survey. At the 3-year follow-up, 65 patients with primary SVD (anxiety, n = 29; depression, n = 14; somatoform disorders, n = 22) were reassessed (70.7% response). The patients improved in symptom severity (p < 0.05), handicap (p < 0.01), and physical quality of life (QoL; p < 0.05) but showed no change in emotional distress. A total of 63.1% (of n = 65) had ongoing SVD. A total of 69.2% (of n = 65) received different forms of treatments. A total of 46.1% (of n = 65) searched redundant medical diagnostic procedures. The patients with decreased coping capacity over time obtained the best prognosis. Primary SVD is an ineffectively treated disorder. Recommendations for specific complaint-oriented psychotherapy programs were given.
Collapse
|
|
44
|
E.J. Mahoney A, Edelman S, D. Cremer P. Cognitive behavior therapy for chronic subjective dizziness: longer-term gains and predictors of disability. Am J Otolaryngol 2013. [PMID: 23177378 DOI: 10.1016/j.amjoto.2012.09.013] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE The study sought to evaluate the longer-term effects of a brief cognitive behavior therapy (CBT) intervention for patients with chronic subjective dizziness (CSD). In addition, it sought to identify predictors of longer-term disability in this group. MATERIALS AND METHODS Forty-four patients with CSD referred by a neuro-otological clinic were followed-up six months after completing a brief treatment program based on the CBT model of panic disorder. Patients completed the following measures: Dizziness Handicap Inventory, Depression, Anxiety and Stress Scales, Dizziness Symptoms Inventory, and the Safety Behaviours Inventory. Measures were completed at pre and post-treatment, as well as at one and six months post-treatment. RESULTS Treatment gains observed immediately after treatment were maintained at one and six months post-treatment. High levels of pre-treatment anxiety predicted higher levels of disability at six months post-treatment. Duration and severity of dizziness, and medical or psychiatric comorbidity did not predict disability at six month follow-up. CONCLUSIONS A brief CBT intervention for patients with CSD produced improvements in physical symptoms, disability, and functional impairment which were sustained at one month and six months post intervention. Patients with high levels of anxiety prior to treatment had higher levels of disability at six months post-treatment. It is possible that more focused interventions that specifically target anxiety might produce further benefits for this cohort.
Collapse
|
|
45
|
Winter L, Wollmer MA, Laurens J, Straumann D, Kruger THC. Cox's Chair Revisited: Can Spinning Alter Mood States? Front Psychiatry 2013; 4:132. [PMID: 24133463 PMCID: PMC3796758 DOI: 10.3389/fpsyt.2013.00132] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 09/30/2013] [Indexed: 11/17/2022] Open
Abstract
Although there is clinical and historical evidence for a vivid relation between the vestibular and emotional systems, the neuroscientific underpinnings are poorly understood. The "spin doctors" of the nineteenth century used spinning chairs (e.g., Cox's chair) to treat conditions of mania or elevated arousal. On the basis of a recent study on a hexapod motion-simulator, in this prototypic investigation we explore the impact of yaw stimulation on a spinning chair on mood states. Using a controlled experimental stimulation paradigm on a unique 3-D-turntable at the University of Zurich we included 11 healthy subjects and assessed parameters of mood states and autonomic nervous system activity. The Multidimensional Mood State Questionnaire and Visual Analog Scales (VAS) were used to assess changes of mood in response to a 100 s yaw stimulation. In addition heart rate was continuously monitored during the experiment. Subjects indicated feeling less "good," "relaxed," "comfortable," and "calm" and reported an increased alertness after vestibular stimulation. However, there were no objective adverse effects of the stimulation. Accordingly, heart rate did not significantly differ in response to the stimulation. This is the first study in a highly controlled setting using the historical approach of stimulating the vestibular system to impact mood states. It demonstrates a specific interaction between the vestibular system and mood states and thereby supports recent experimental findings with a different stimulation technique. These results may inspire future research on the clinical potential of this method.
Collapse
Affiliation(s)
- Lotta Winter
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Division of Clinical Psychology, Medical School Hannover , Hannover , Germany
| | | | | | | | | |
Collapse
|
|
46
|
Translation and validation of the vertigo symptom scale into German: A cultural adaption to a wider German-speaking population. BMC EAR, NOSE, AND THROAT DISORDERS 2012; 12:7. [PMID: 22747644 PMCID: PMC3441555 DOI: 10.1186/1472-6815-12-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 06/26/2012] [Indexed: 01/31/2023]
Abstract
Background Dizziness and comorbid anxiety may cause severe disability of patients with vestibulopathy, but can be addressed effectively with rehabilitation. For an individually adapted treatment, a structured assessment is needed. The Vertigo Symptom Scale (VSS) with two subscales assessing vertigo symptoms (VSS-VER) and associated symptoms (VSS-AA) might be used for this purpose. As there was no validated VSS available in German, the aim of the study was the translation and cross-cultural adaptation in German (VSS-G) and the investigation of its reliability, internal and external validity. Methods The VSS was translated into German according to recognized guidelines. Psychometric properties were tested on 52 healthy controls and 202 participants with vestibulopathy. Internal validity and reliability were investigated with factor analysis, Cronbach’s α and ICC estimations. Discriminant validity was analysed with the Mann–Whitney-U-Test between patients and controls and the ROC-Curve. Convergent validity was estimated with the correlation with the Hospital Anxiety Subscale (HADS-A), Dizziness Handicap Inventory (DHI) and frequency of dizziness. Results Internal validity: factor analysis confirmed the structure of two subscales. Reliability: VSS-G: α = 0.904 and ICC (CI) =0.926 (0.826, 0.965). Discriminant validity: VSS-VER differentiate patients and controls ROC (CI) =0.99 (0.98, 1.00). Convergent validity: VSS-G correlates with DHI (r = 0.554) and frequency (T = 0.317). HADS-A correlates with VSS-AA (r = 0.452) but not with VSS-VER (r = 0.186). Conclusions The VSS-G showed satisfactory psychometric properties to assess the severity of vertigo or vertigo-related symptoms. The VSS-VER can differentiate between healthy subjects and patients with vestibular disorders. The VSS-AA showed some screening properties with high sensitivity for patients with abnormal anxiety.
Collapse
|
|
47
|
Edelman S, Mahoney AE, Cremer PD. Cognitive behavior therapy for chronic subjective dizziness: a randomized, controlled trial. Am J Otolaryngol 2012; 33:395-401. [PMID: 22104568 DOI: 10.1016/j.amjoto.2011.10.009] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Accepted: 10/08/2011] [Indexed: 02/07/2023]
Abstract
PURPOSE The aim of this study was to evaluate the effects of a brief cognitive behavior therapy (CBT) intervention on the physical symptoms, illness-related disability, and psychologic distress of patients with chronic subjective dizziness. MATERIALS AND METHODS Forty-one patients with chronic subjective dizziness referred by a neurootologic clinic were randomly assigned to immediate treatment or a wait-list control. Three weekly treatment sessions based on the CBT model of panic disorder, adapted for patients with dizziness, were administered by a clinical psychologist. Treatment included psychoeducation, behavioral experiments, exposure to feared stimuli, and attentional refocusing. Outcomes were measured on the Dizziness Handicap Inventory and the Depression, Anxiety and Stress Scales. Two further measures developed for this study; the Dizziness Symptoms Inventory and the Safety Behaviours Inventory were used to measure physical symptoms and safety behaviors. RESULTS The intervention was associated with significant reductions in disability on the Dizziness Handicap Inventory, reduced dizziness and related physical symptoms on the Dizziness Symptoms Inventory, and reduced avoidance and safety behaviors as measured by the Safety Behaviours Inventory. Pre- to posteffect sizes ranged from 0.98 to 1.15. There was no change in psychologic outcomes measured on the Depression, Anxiety and Stress Scales. CONCLUSIONS A 3-session psychologic intervention based on the CBT model can produce significant improvements in dizziness-related symptoms, disability, and functional impairment among patients with chronic subjective dizziness. This suggests that treatment of this condition may be reasonably simple and cost-effective for most of the patients.
Collapse
|
|
48
|
Naber CM, Water-Schmeder O, Bohrer PS, Matonak K, Bernstein AL, Merchant MA. Interdisciplinary treatment for vestibular dysfunction: the effectiveness of mindfulness, cognitive-behavioral techniques, and vestibular rehabilitation. Otolaryngol Head Neck Surg 2011; 145:117-24. [PMID: 21493331 DOI: 10.1177/0194599811399371] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To investigate whether an interdisciplinary program for vestibular patients improved health outcomes and health care utilization. STUDY DESIGN Case series with chart review. SETTING Outpatient neurotology clinic. SUBJECTS AND METHODS Patients (N = 167) with dizziness attended an interdisciplinary neurotology clinic; 129 were offered group treatment. After an introductory session, group treatment included 5 sessions incorporating mindfulness, cognitive-behavioral techniques, and vestibular rehabilitation. Physical and emotional functioning, depression,anxiety, dizziness, impairment, coping, skill use, and patient satisfaction were measured with rating scales pre- and post-group treatment. Data from 51 patients (male/female = 14/37; age range, 25-82 years) were analyzed with paired t tests or nonparametric tests. Logistic regression analyzed predictors of outcome and utilization for 116 patients (male/female = 81/35; age range, 11-86 years) attending the interdisciplinary clinic, introductory session, and/or group. RESULTS After group treatment, patients reported better mood (P = .0482); better physical (P = .0006) and mental (P = .0183) health; better functionality, coping, and skill use (Ps< .0001); less impairment (P < .0001); and fewer limitations from dizziness (P < .0001). Higher pretreatment levels of depression (P = .0216), poorer initial mental (P = .0164) or physical (P = .0059) health, and peripheral diagnosis (P = .0220) predicted better outcome. Group treatment decreased utilization more than the interdisciplinary clinic with (P = .0183) or without (P = .0196) the introductory session; 78% of patients with any level of participation showed less utilization. Clinic patients had fewer radiology procedures than group patients (P = .0365). Patients were highly satisfied with the program and found it more effective than previous treatment. CONCLUSION Interdisciplinary treatment improves patient coping, functionality, and satisfaction and decreases overall health care utilization in vestibular patients.
Collapse
Affiliation(s)
- Christine M Naber
- Department of Neurology, Kaiser Permanente, Santa Rosa, California USA.
| | | | | | | | | | | |
Collapse
|
|
49
|
Honaker JA, Gilbert JM, Staab JP. Chronic Subjective Dizziness Versus Conversion Disorder: Discussion of Clinical Findings and Rehabilitation. Am J Audiol 2010; 19:3-8. [DOI: 10.1044/1059-0889(2009/09-0013)] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Purpose
Audiologists frequently encounter patients who complain of chronic dizziness or imbalance, in the absence of active vestibular or neurological deficits. Knowledge about conditions that cause this clinical presentation will allow audiologists to make important contributions to accurate diagnosis and effective management of these patients. This article reviews 2 such conditions, chronic subjective dizziness (CSD) and conversion disorder.
Method
A case of CSD and another of conversion disorder are presented, with a literature review of their clinical presentations, key diagnostic features, and treatment strategies. The role of the audiologist in assessing patients with these conditions and facilitating appropriate treatment referrals is discussed.
Conclusions
The audiologist is in a key position to identify individuals with CSD and conversion disorder, 2 conditions that can be effectively managed if properly recognized. The authors demonstrate an effective team approach program that includes the audiologist’s contribution to differential diagnosis, education of patients and other clinicians about these conditions, and development of recommendations for neurological, psychiatric, otologic, and physical therapy referrals.
Collapse
|
|
50
|
Ferreira LSDS, Pereira CB, Rossini S, Kanashiro AMK, Adda CC, Scaff M. Psychological assessment in patients with phobic postural vertigo. ARQUIVOS DE NEURO-PSIQUIATRIA 2010; 68:224-227. [PMID: 20464289 DOI: 10.1590/s0004-282x2010000200013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2009] [Accepted: 11/17/2009] [Indexed: 05/29/2023]
Abstract
UNLABELLED Phobic postural vertigo (PPV) is a frequent diagnosis which can be challenging to treat. OBJECTIVE To investigate the presence of psychiatric disturbances in patients with PPV; to assess the psychological status of patients using adaptive diagnosis; to verify possible correlations between severity of psychiatric disturbance and adaptive efficacy. METHOD A total of nineteen subjects were assessed and two instruments applied: the Primary Care Evaluation of Mental Disorders Questionnaire (PRIME-MD) and the Adaptive Operationalized Diagnostic Scale (AODS), and results from both tests were compared. RESULTS Fourteen patients presented with mood disorder and thirteen with anxiety. All patients presented compromised adaptive efficacy. Correlation was found between overall outcome on the PRIME and the AODS (tau= -0.42, p=0.027), Separate analysis revealed correlation between results of the AODS and anxiety disorders (tau= -0.45, p=0.018) but not with mood disorders (tau= -0.36, p=0.054). CONCLUSION Adaptive compromise was observed in individuals with PPV which was shown to be associated to psychiatric disorders.
Collapse
|