A conceptual structure and methodology for the systematic approach to the evaluation and treatment of patients with chronic dizziness

Anxiety Disorders 15 (2001) 95 ± 106

A conceptual structure and methodology for the systematic approach to the evaluation and treatment of patients with chronic dizziness Michael R. Clark*, Karen L. Swartz The Johns Hopkins University School of Medicine, Baltimore, MD, USA

Abstract The patient with chronic dizziness should never be labeled with psychogenic dizziness. Chronic does not mean psychogenic. Chronic means that health care has been unsuccessful. A systematic approach that yields a comprehensive formulation and rational treatment plan will increase the probability of a successful outcome and return to health. The four perspectives of diseases, life stories, dimensions, and behaviors provide a comprehensive yet flexible methodology for the evaluation of the patient in distress with chronic and disabling dizziness. The design of a comprehensive treatment plan involves the determination of each perspective's contribution to the patient's distress and to what relative degree. This process recognizes that the perspectives are distinct from one another but complementary in illuminating the various reasons for a patient's distress. The perspectives come together as the formulation of the patient's case and offer a recipe for treatment rather than just a list of ingredients such as bio, psycho, and social. D 2001 Elsevier Science Inc. All rights reserved. Keywords: Dizziness; Vertigo; Psychiatry; Somatization; Evaluation; Treatment; Disability; Rehabilitation

* Corresponding author. Department of Psychiatry and Behavioral Sciences, The Johns Hopkins Medical Institutions, Osler 320, 600 North Wolfe Street, Baltimore, MD 21287-5371, USA. Tel.: +1410-955-2126; fax: +1-410-614-8760. E-mail address: [email protected] (M.R. Clark). 0887-6185/01/$ ± see front matter D 2001 Elsevier Science Inc. All rights reserved. PII: S 0 8 8 7 - 6 1 8 5 ( 0 0 ) 0 0 0 4 4 - X

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1. Introduction Dizziness is a nonspecific symptom reported by patients to describe a variety of distressing sensory experiences and deficits in functioning (Kroenke, Arrington, & Mangelsdorff, 1990). The evaluation and differential diagnosis of patients with dizziness has been well described (Baloh, 1995; Drachman & Hart, 1972; Linstrom, 1992; Sloane, 1996). Unfortunately, a specific etiology is discovered in a minority of patients, and the patient is likely to remain ill for months, and even years (Kroenke & Mangelsdorff, 1989). Furman and Jacob have previously noted that if an etiology is not discovered after a routine evaluation with additional symptom-specific examinations, the patient with chronic dizziness is likely to receive a ``functional'' diagnosis such as psychogenic dizziness (Furman & Jacob, 1997; Jacob, Furman, Clark, Durrant, & Balaban, 1993). Similar diagnoses of last resort include imbalance, lightheadedness, presyncope, dysequilibrium, space phobia, functional dizziness, psychogenic disorder of stance and gait, and phobic postural vertigo (Brandt, 1996; Jacob et al., 1993; Jacob, Furman, & Balaban, 1996; Marks, 1981). The Diagnostic and Statistical Manual of Mental Disorders (DSM) established reliable criteria for the discipline of psychiatry (American Psychiatric Association, 1994). Unlike the diagnoses in many other medical fields, the criteria for a particular psychiatric diagnosis imply nothing about the etiology of the disorder. The psychiatric diagnoses are standardized, reliable descriptions that recharacterize and ``operationalize'' the patient's symptoms and sensory experiences. The descriptions associated with dizziness often come to masquerade as medical diagnoses with an implied understanding of etiology even though the diagnoses do not include any specific information about the etiology causing the patient's dizziness. In validated medical diagnoses with established etiologies, the treatments can target the factors precipitating and sustaining the condition. Given the lack of knowledge about their etiology, a particular psychiatric diagnosis, such as Somatoform Disorder, does not necessarily indicate a specific treatment. If the assessment of patients with dizziness is to guide treatment, the assessment needs to focus on the precipitants and sustaining factors for the symptoms. In contrast, the diagnosis of psychogenic dizziness perpetuates the use of symptomatic rather than rational treatments. Therefore, an individualized approach in the assessment that goes beyond mere labeling with a diagnosis is essential for treatment success. In the following sections, we describe a systematic approach for obtaining and conceptualizing treatment-relevant information concerning the patient with chronic dizziness. 2. The inherent conflict between `how' and `why' For any practitioner attempting to take care of patients with chronic disorders involving symptoms like dizziness, the principal question is usually whether to

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attribute the cause of the patient's distress and disability to mind or brain (Slavney, 1993). This form of dualism can be resolved by recognizing that both of these entities exist and problems arise from both realms. Although both require the basic sciences such as biochemistry for their existence, the connections between mind and brain are still unclear. Mind and brain remain distinct entities and they cannot be merged to form a ``unified field theory'' of mental life and behavior. The patient with chronic dizziness will likely suffer problems of both brain and mind. The conflict arises from the concepts of explanation and understanding (Jaspers, 1997; Peirce & Tomas, 1957; Slavney & McHugh, 1987). Explanation describes the linear reasoning of cause and effect. Many complex phenomena in the environment can be broken down into a series of two-component steps or dyads. A significant portion of the practice of medicine involves working backward through a series of dyads. This is the medical model being employed to find the cause or etiology of a particular clinical syndrome or effect with defined pathology. In contrast, understanding involves the process by which an aspect of the environment becomes meaningful in a person's world. Understanding first requires the person to experience some event. Then, he assigns a symbol such as a word, thought, or emotion that embodies the unique and personal qualities of the event (e.g., satisfaction with a personal achievement). All three components of this triad are essential to the formation of a meaningful connection (i.e., why it has relevance to his own personal life situation). The triad cannot be reduced to a dyad, and there is no way to close the gap between them. The triad is an interactive relationship between its components, while the dyad is a cause directly linked to its effect. Causality and meaning are still inadequate to describe the whole of human consciousness and behavior. Even though individuals can be affected by the external world and form an interpretation of that world, they still possess internal characteristics that shape their experience of distress and they take purposeful actions to express that distress. The practitioner's initial role in the evaluation of a patient with chronic dizziness is to produce a differential diagnosis attempting to sort out whether the patient is sick with a specific disease, demoralized by a particular sequence of meaningful events, frustrated by his own psychological trait vulnerabilities, or upset by repeatedly engaging in problematic behaviors (Clark, 1994). 3. The systematic approach The patient who presents with chronic dizziness is in distress and seeking help for a problem. Every approach to solving problems must have an underlying organization and methodology (McHugh, 1987a, 1987b, 1992; McHugh & Slavney, 1982). The biopsychosocial approach attempted to define a compre-

abnormal structure or function of a bodily part

prevent or correct the abnormality to restore function

all treatments can cause more damage predominance

Essence

Goal

Risk

Limitation

causal relationships define categories

Logic

Diseases

Table 1 Summary of the perspectives of psychiatry Life stories

forcing the one ``true'' story

all interpretations are hostile

meaningful connections between past events and present circumstances understand patterns and reinterpret meaning to restore mastery

accumulated events produce a unique narrative

all demands to stop behavior are stigmatizing ignoring self imposed and ideational goals for innate drives and conditioning

stop behavior to restore drives/goals and prevent relapse

altered drives and goals can produce problem behaviors

acts have design and purpose

Behaviors

arbitrary definition of abnormal vs. normal

personal features are described along spectrums of measurement the relative amount of a trait predisposes to inherent strengths and vulnerabilities guide toward strengths and avoid provocation of vulnerabilities to restore emotional stability all advice is paternalistic

Dimensions

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hensive model of the ``entire'' patient (Engel, 1977, 1979, 1980). Unfortunately, it defined only the elements of the systems of the patient and not a methodology that could be used to make a diagnosis, determine its causes, or direct treatments. If patients with chronic dizziness are going to improve, a comprehensive and systematic methodology for their evaluation and treatment is needed. The etiologies of their distress can be organized into four perspectives: diseases, life stories, dimensions, and behaviors (McHugh & Slavney, 1998). Each perspective offers its own logic and method of reasoning (Table 1). In this approach to patient care, diseases are what people have; life stories are what people want; dimensions are what people are; and behaviors are what people do. 3.1. Diseases The disease perspective utilizes the logic of cause and effect as described above. It is a linear or dyadic approach most often described as the medical model. The objective lies in using the patient's symptoms and signs to make a categorical and, therefore, mutually exclusive diagnosis of a clinical syndrome. The patient either has a particular disease or he does not. One diagnosis is ruled in and all other diagnoses are eventually ruled out. The disease perspective assumes an abnormality in the structure or function of a bodily part. This is an example of the power of Nature to ``break'' individuals. The broken part transforms physiology into pathophysiology and health into sickness. As a consequence, signs and symptoms of the disease emerge and cluster together as a recognizable clinical syndrome. The disease perspective demands searching for the broken part that results in the symptom of dizziness. For example, a patient with vertigo is examined and formulated as having the syndrome of unilateral vestibular nerve hypofunction. Further examination attempts to determine what pathology is present. The patient may have an inflammation, infarction, or compression of the vestibular nerve. Each of these pathologies, for example, compression, has an associated list of potential etiologies such as an acoustic neuroma caused by increased cell division, an aneurysm caused by weakened smooth muscle in a blood vessel, or excessive bone formation caused by osteoblast activation. Studies of patients presenting to clinics specializing in the evaluation of dizziness have systematically assessed the psychiatric disorders in these patients. Depression, panic disorder, and somatization disorder were more common in patients without evidence of peripheral vestibular disturbance when compared to patients with peripheral disorders (Sullivan et al., 1993). In a study of 100 consecutive outpatients presenting with dizziness as a chief complaint compared to 25 control patients, a higher lifetime prevalence of psychiatric disorders was found with the most striking differences in major depression, dysthymia, and somatization (Kroenke, Lucas, Rosenberg, & Scherokman, 1993). In longitudinal follow-up of this cohort, psychiatric disorders were the second most common cause of persistent dizziness with benign positional vertigo being the most

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common (Kroenke et al., 1992). The combination of chronic dizziness and a psychiatric disorder has been shown to produce greater disability than either condition alone (Clark, Sullivan, Katon, Russo, Fischl, Dobie, & Voorhees, 1993). The core symptoms of panic disorder include hyperventilation and dizziness. The relationship between panic and dizziness may have vestibular dysfunction as an underlying link (Asmundson, Larsen, & Stein, 1998). A high prevalence of abnormal vestibular test results has been found in twenty patients consecutively evaluated for panic disorder and not specifically complaining of dysequilibrium (Sklare, Stein, Pikus, & Uhde, 1990). Jacob, Furman, Durrant, and Turner (1996) recently addressed the issue of dizziness and panic disorder by testing the audiovestibular function of patients with and without panic disorder. While vestibular laboratory abnormalities were common in both groups, the highest prevalence was found in patients who had panic disorder with moderate to severe agoraphobia. The identification and treatment of psychiatric disorders such as major depression and panic disorder may result in a significant reduction of both dizziness and disability. Treatment for a disease involves finding a cure for the etiology and restoring function to premorbid levels. The cure may repair the broken part, prevent the initial damage from occurring, or rehabilitate the affected physiology. Definitive cures can be developed to combat specific etiologies when they are discovered. Unfortunately, the etiology of many conditions is elusive and treatments can only be approximations of a cure. In addition, every treatment has the potential for causing even more damage and making the patient worse. The disease perspective's limitations are its predominance in medical reasoning, rigid linear view of mutually exclusive conditions, and presumption that all mental distress and somatic symptoms emerge from broken parts in the brain or body. Although every human requires biochemistry, disorders with chronic symptoms are often the responses of perfectly intact individuals facing life's numerous difficulties. The other perspectives are necessary to comprehend these conditions and expand the process of evaluation, formulation, and treatment beyond the microscopic level. 3.2. Life stories As a person lives their life, he encounters and experiences a variety of events. As these events accumulate, a narrative envelops him. This narrative is a tapestry of meaningful connections specific to the individual that provides him with an understanding of his own existence in the world. At times, a person experiences the unintended consequences of past events. When a patient's life turns out differently from what was wanted, he then reaches the conclusion that he has failed. The outcome is demoralization and distress. This distress is due to a perceived loss of mastery over one's life. This loss is the result not of Nature's power but of an individual left wanting something better given his current set of life circumstances.

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Treatment within the domain of life stories involves appreciating the patient's meaningful understanding of events. Then, the patient is persuaded to try and avoid a similar outcome in the future or to give up his current interpretation of those events for another. A new interpretation is not necessarily the ``correct'' or ``true'' interpretation since any number of meanings can be generated for a given set of historical life events. Instead, the new interpretation is one that is useful and restores a sense of mastery. The patient now embraces a new understanding of his situation and why it has occurred. As a result, he goes forward with a renewed sense of control over his life that now has a potential for success. The patient who develops Meniere's disease can be persuaded that even though he has a serious illness, he can contribute to the future and maintain a sense of control in his life. This contribution may be in ways previously not considered such as starting a support group with educational programs for patients with Meniere's disease. Similarly, a patient who presents to a psychiatrist feeling overwhelmed by his third divorce would benefit from discussing each marriage to understand recurrent mistakes. Recognizing this pattern would allow for changes to avoid future mistakes of the same kind and restore the individual's desire for companionship. Chronic dizziness often raises issues of function and quality of life as individuals face a change in their degree of independence. The impact of this ``anticipatory disability'' includes a loss of valued personal roles, family conflict, demoralization, frustration, and restriction of social activities (Yardley, Luxon, & Haake, 1994). Addressing these fears and exploring the ways in which they affect the lives of individuals with dizziness can reduce the associated disability. In elderly individuals, the potential for significant injury from a fall is a common fear associated with dizziness. In a study of residents of Israel aged 65 and over, recent falls were associated with current negative subjective health ratings (Cwikel, Kaplan, & Barell, 1990). As an individual reflects on his life, he will try to integrate the role of an illness such as dizziness. This process should address the meaning of the illness and planning specific interventions to minimize any disability. Diseases are an example of dyads. A part breaks and causes an effect in the body that is manifested as a syndrome. The syndrome may be the result of a series of ``hits,'' but each one has the potential for being described as an individual dyad. Life stories, however, are examples of triads. The meaning cannot exist without all three components: the person, the event, and the symbol. Remove any one and no meaningful understanding can be sustained. If the disease perspective is utilized to answer how a patient becomes ill and the life story perspective is utilized to answer why a patient becomes ill, there still exists a gap between the functioning brain and the conscious mind. Although the gap cannot be closed until it is known by what mechanisms human consciousness is generated, the perspectives of dimensions and behaviors bridge the gap and allow patient care to advance.

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3.3. Dimensions The dimensional perspective is based on the logic of a continuous distribution of individual variation. Traits exist for many personal characteristics and bodily processes that can be quantified along a continuum. Traits are aspects of who people are. Most individuals possess an average amount of a particular trait; however, a few individuals will exist at both extremes. The trait itself conveys certain strengths and weaknesses upon the individual that vary depending on the quantity of the trait and the task at hand. At times, people will be vulnerable to distress by virtue of their individual ``dose'' of a characteristic that is inadequate to handle some stressor. The qualities inherent to the trait itself determine the type of susceptibility. Different settings provoke different difficulties for different traits. For example, the person with low levels of aldehyde dehydrogenase is usually unaware of his position along the continuum that quantifies this bodily enzyme. However, consuming a significant quantity of alcohol will ``stress'' and overwhelm the capacity to metabolize this substance. The result is poisoning. Similarly, the individual with poor muscular coordination may function without substantial difficulty in a highly structured and simple environment. However, when the person is placed on an escalator in a large, busy shopping mall, he will display his limitations in balance and need support to keep from falling. He will become distressed because too much is being asked of his deficient traits. The solution is often found in restoring structure to the environment or providing the person with new skills to improve balance. Another example of the dimensional perspective is found in the domain of affective temperament. Personality traits vary along spectrums of particular characteristics such as extroversion/introversion. Several studies have focused on the personality styles of patients with dizziness diagnosed with Meniere's disease. Previous studies have identified personality traits more common in patients with Meniere's disease such as obsessionality and ``psychosomatic type personality profiles,'' (Hinchcliffe, 1967; Stephens, 1975). These results have supported the characterization of Meniere's disease as a psychosomatic disorder emerging from the psychological vulnerabilities of individuals. However, Crary and Wexler demonstrated that while patients with Meniere's disease did differ from nonvertiginous controls in their scale profiles on the Minnesota Multiphasic Personality Inventory (MMPI), there were no significant differences when comparing Meniere's patients with patients with vertigo from ``organic'' ear diseases (Crary & Wexler, 1977). Personality may represent a sustaining or modifying factor rather than a causal one for an individual's response to a symptom such as dizziness. Traits of fear and anxiety have also been correlated with confidence in balance. Although they did not differ in measures of postural performance, the self-report of confidence in their balance was lower in a group of patients complaining of dizziness when compared to patients who had but did not

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complain of dizziness and a control group who denied significant dizziness (Hallam & Hinchcliffe, 1991). In a comparison of patients with relatively mild vertiginous symptoms, nonvertiginous symptoms, and a control group without medical complaints, the vertiginous group had significantly higher scores on the State-Trait Anxiety Index and a high prevalence of psychological morbidity (Alvord, 1991). The personality vulnerabilities, therefore, could be contributing to the degree of disability that individuals experience by influencing their response to symptoms. Treatments within the dimensional perspective focus on emphasizing the strengths and weaknesses that are the manifestations of particular characteristics and their provocations such as being anxious in unfamiliar situations. Practitioners not only help patients uncover their weaknesses but also point out their strengths so potential can be fulfilled through seeking out situations prone to success. With guidance, vulnerabilities can be avoided. However, the advice of practitioners can be excessively paternalistic if delivered as dogmatic orders. Specific methods should also be devised to compensate for an individual's vulnerabilities. The major weakness of the dimensional perspective is the arbitrary point along the continuum at which the difference between normal and abnormal is defined. 3.4. Behaviors Behaviors are goal-directed activities with both internal and external aspects. Internally, behaviors can be motivated by drives. These provoke the behavior and then abate after some action is performed that satisfies the drive, which then reemerges with the passage of time. Externally, behaviors can be meaningful because of the opportunities, self-imposed beliefs, and individual goals that lead to a person choosing to act. Similarly, behavior has external consequences that are reinforcing to the individual and involve learning over time how to accomplish one's goals more effectively. Traditional approaches to behavioral disorders have focused on innate drives and different types of conditioning. In patients with chronic dizziness, problematic behaviors include phobic avoidance or restricting their physical and social activity levels to avoid provoking symptoms of dizziness and to avoid potentially embarrassing situations (Yardley, Todd, Lacoudraye-Harter, & Ingham, 1992). Behavioral treatments promote the adaptation of a person to their symptoms of dizziness. Vestibular rehabilitation is a specific form of physical therapy directed at reducing dizziness by training the central nervous system to compensate for peripheral vestibular dysfunction. This ``balance retraining'' involves performing a series of head movements and postural changes with a goal of recovering normal vestibulo-ocular and vestibulo-spinal reflexes. These exercises may also have a psychological benefit as patients learn to take an active role in the treatment of their dizziness that increases functional capacity (Yardley & Luxon, 1994).

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Vestibular rehabilitation has been shown to reduce dizziness and improve balance significantly when compared to treatment with general conditioning exercises and vestibular suppressant medications (Horak, Jones-Rycewicz, Black, & Shumway-Cook, 1992). In addition to these specific exercises for dizziness and balance, more generalized balance training such as Tai Chi has been studied in relation to fears of falling. Subsequent avoidance may result from such fears and further limit a person's activities and worsen disability. In a study of elderly men and women living in the community, the group participating in Tai Chi had a reduction in their fear of falling as well as a reduction in actual fall rates when compared to a control group (Wolf et al., 1996). The emphasis of these behavioral treatments is to reduce disability by encouraging healthy, productive behaviors. Abnormal illness behavior such as unexplained disability or high utilization of health care services can be formulated in a similar fashion. The drives, behaviors, and goals of using excessive medications, pursuing diagnostic evaluations, or failing to work full-time must each be determined. Ultimately, treatment moves beyond stopping the dysfunctional actions to altering these associated drives and goals. These later steps focus on the components of behavior in order to prevent relapse so that productive behaviors are not subsequently overrun by the recurrence of problematic ones. If the patient with abnormal illness behavior stops seeking consultations and procedures for their symptoms, then they can be taught coping strategies for disturbing bodily sensations such as relaxation techniques. Demanding a behavior be stopped without appreciating these other components will only stigmatize the behavior and create arguments about being denied ``patient rights'' and access to care instead of taking responsibility and accepting the consequences of personal choices. 4. Summary Each perspective has a unique logic that defines specific methods for designing treatment and pursuing research hypotheses (Clark, 1994, 1996; Slavney, 1990). The patient does not have to fit into one theoretical approach or model in order to receive and accept treatment. The patient's diagnoses are based on the formulation, which then directs treatment along rational directions. The linkages and interactions of a patient's diagnoses can then be investigated within a framework that includes the entire person and not just their biochemistry. If a patient's distress continues, the practitioner must consider other factors that may have been overlooked before abandoning or modifying a treatment plan. Usually, these factors are within one of the perspectives initially thought to be less important. A new combination of approaches is then required to treat the patient successfully. The perspectives identify the patient as a person who is a composite of vulnerabilities and strengths but afflicted with diseases, struggling through important life events, and acting with many motivations.

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