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Beliefs and emotional reactions in patients with benign paroxysmal positional vertigo: a longitudinal study
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American Journal of Otolaryngology–Head and Neck Medicine and Surgery 33 (2012) 221 – 225 www.elsevier.com/locate/amjoto
Beliefs and emotional reactions in patients with benign paroxysmal positional vertigo: a longitudinal study☆ Lea Pollak, MD a,⁎, Perri Segal, MS a , Rafael Stryjer, MD b , Hadassah Goldberg Stern, MD c a
Department of Neurology, Assaf Harofeh Medical Center affiliated to Sackler Faculty of Medicine, Tel Aviv University, Israel b Mental Health Hospital, Beer Yaacov, Israel c Department of Neurology, Schneider Children's Medical center of Israel, Petach Tikva, Israel Received 19 March 2011
Abstract
Objective: Psychologic studies in patients with benign paroxysmal positional vertigo (BPPV) are scarce, considering the high frequency of the disorder. We performed a repeated-measures design questionnaire study in a cohort of patients with BPPV before and after treatment to investigate the dynamics of the psychologic findings and possible treatment consequences. Methods: Thirty-seven consecutive patients with idiopathic BPPV participated in the study. During the first visit and 2 to 3 months after therapy, the patients completed 4 questionnaires: the Dizziness Handicap Inventory, the Illness Perception Questionnaire-Revised, the Intolerance of Uncertainty Scale, and the State-Trait Anxiety Inventory. Results: The scores for all questioned items did not change before and after treatment except for the physical handicap scores. Correlation was found between the grade of functional and emotional impact of the disease and belief in consequences as well as anxiety levels of the patients. Moreover, uncertainty scores were in correlation with emotional impact, anxiety levels, and perceived consequences of the disease. The belief in personal control of the condition was correlated with the belief in treatment control and understanding of the disease. Conclusion: The main finding in this study is the lack of a significant change in beliefs and emotional reactions in patients with BPPV after treatment of their condition. Physicians dealing with BPPV should be aware that the disease is not solely a somatic condition but has a serious impact on the patient's mental state. Selected patients might benefit from anxiolytic medication. © 2012 Elsevier Inc. All rights reserved.
1. Introduction One of the most common and treatable causes of vertigo in the adult population is benign paroxysmal positional vertigo (BPPV) [1,2]. It is characterized by rotational vertigo induced by head position changes in the plane of one of the semicircular canals of the vestibular labyrinth. The diagnosis is confirmed by positioning testing that reveals a characteristic nystagmus. Benign paroxysmal positional vertigo is considered to be caused by canalithiasis
☆
The authors report no conflict of interest or financial support for this work. ⁎ Corresponding author. Department of Neurology, Assaf Harofeh Medical Center, Zerifin, Israel. Tel.: +972 8 9404747; fax: +972 8 9401995. E-mail address: [email protected] (L. Pollak). 0196-0709/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.amjoto.2011.07.002
and cupulolithiasis. Otoconial debris, derived from the utricular macula, loosens and becomes trapped in one of the semicircular canals or its cupula. This causes inappropriate stimulation of the sensory hair cells of the affected canal and results in vertigo and nystagmus. Particle repositioning maneuvers, aimed to remove the otoconial debris from the particular semicircular canal, are a simple and highly effective treatment of the condition [3,4]. Complete resolution of the symptoms can be achieved in 75% to 100% of patients after a single or couple of treatments. However, the condition recurs in up to 50% of patients within 5 years of follow-up [5]. The close relationship of dizziness or vertigo and psychiatric disturbances has been readily recognized [6-9]. Dizziness or vertigo can be a complaint in depression, generalized anxiety disorder, somatization disease, and panic
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L. Pollak et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 33 (2012) 221–225
disorder. The link between psychic changes and dizziness is supported by neurophysiologic studies that showed the influence of increased arousal and hyperventilation, associated with anxiety, on various vestibular laboratory parameters [10,11]. On the other hand, vestibular lesions of distinct etiologies can trigger the onset of a psychiatric illness especially in predisposed individuals. They typically provoke an exaggerated emotional reaction sometimes persisting for a long period after the vestibular symptoms have resolved [7,8]. Anatomical and functional connections between the vestibular system and structures involved in the pathogenesis of panic disorder or conditioning of fear responses, such as locus coeruleus and raphe nucleus of the brainstem, further support this concept [9-12]. Although psychologic findings in some vestibular disorders, such as Ménière disease, vestibular migraine, and vestibular neuronitis, have been extensively reported, psychologic studies in patients with BPPV are surprisingly scarce, considering the high frequency of the disorder [1319]. In one study where the Hospital Anxiety-Depression scoring was applied, anxiety was found in 73.5% and depression in 41% of patients with BPPV [20,21]. We performed a repeated-measures design study in a cohort of patients with BPPV before and after treatment to investigate the dynamics of the psychologic findings and possible treatment consequences.
2. Methods 2.1. Patients Thirty-seven consecutive patients with idiopathic BPPV, diagnosed and treated at an outpatient clinic during the years 2008 and 2009, participated in the study. Their mean age was 59.2 ± 14.5 years; 14 were men, and 23 were women. Thirtytwo patients had a posterior canal BPPV, and 5 had a horizontal canal involvement. Patients with a physical disorder such as orthopedic disorders, surgical disorders, grave internal diseases, aphasia, agraphia, alexia, dementia and severe depression or psychosis, or previous otological disease were excluded. Patients with a history of mental illness, regardless to present medication intake, were also excluded. After the diagnostic test (Dix-Hallpike maneuver for the posterior and roll test for the horizontal canal type of BPPV), the patients received a detailed explanation of their condition and were treated by an appropriate particle repositioning maneuver during the same session. Patients were seen again within 1 week after the treatment. If necessary, the treatment was repeated in 3- to 7-day intervals until the nystagmus disappeared. The study was performed in accordance with the Helsinki declaration and approved by the local ethics committee of the Assaf Harofeh Medical Center.
2.2. Methods Four questionnaires were administered: 1. The Dizziness Handicap Inventory (DHI) was developed to measure self-perceived levels of handicap associated with the symptoms of dizziness. It has 25 items, with 3 response levels subgrouped into 3 domains: functional (DHI-f), emotional (DHI-e), and physical (DHI-p). The possible score ranges from 0 to 100, a higher score indicating worse handicap. The maximum possible scores are 28 for DHI-p, 36 for DHI-f, and 36 for DHI-e subscores. Test-retest reliability (r = 0.92–0.97) and internal consistency (α = .72–.89) have been demonstrated to be high [22,23]. 2. The Illness Perception Questionnaire-Revised (IPQ-R) (second part) measures patients' cognitive and emotional representations of their illness. It consists of 38 statements using 5-point Likert scales (“strongly agree” to “strongly disagree”). It gives separate scores for the timeline (short- vs long-term IPQ-R-1), unpredictability (IPQ-R-2), consequences (IPQ-R-3), personal and treatment control (IPQ-R-4 and IPQ-R-5), illness coherence (IPQ-R-6), and emotional representation (IPQ-R-7). High scores indicate strong beliefs in serious consequences of the disease, chronicity and/or recurrence of the disease, the patients' own ability to control symptoms, and effectiveness of treatment in controlling the disease. High scores on the illness coherence scale indicate a high degree of patients' belief in a good understanding of their medical condition, and high scores on the emotional representation scale indicate a strong emotional response to the illness. The internal reliability of the test has been shown to range from 0.71 to 0.90 for the distinct subscales [24,25]. 3. The Intolerance of Uncertainty Scale (IUS) is a 27-item measure that assesses emotional, cognitive, and behavioral responses to ambiguous situations, implications of being uncertain, and attempts to control the future. Items are scored on a 5-point scale. The responses are summed as a total scale score, ranging from 27 to 135. The test has demonstrated a good internal consistency (α = .94) and a good test-retest reliability (r = 0.74) [26-29]. 4. The State-Trait Anxiety Inventory (STAI) consists of 40 items: 20 designed to assess state anxiety, that is, anxiety level at the time of examination (S scale), and further 20 items to assess trait anxiety, that is, general anxiety of the individual (T scale). High scores mean more trait or state anxiety. The reliability of the tests has been reported to range from 0.65 to 0.86 for the trait anxiety subscale and from 0.16 to 0.62 for the state anxiety subscale [30-32]. Patients completed the questionnaires twice: the first time during their first visit and the second time 2 to 3 months later while free of vertigo symptoms.
L. Pollak et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 33 (2012) 221–225
2.3. Statistical methods Paired samples test (paired t test) was applied to investigate the differences of questionnaires' results before and after treatment. Pearson correlation coefficient investigated for internal consistency as well as interrelations between scores and subscores of the distinct questionnaires. The statistical power (P) was considered significant if less than .05.
3. Results The scores for all questioned items did not change before and after treatment except for the physical handicap subscores (Table 1). For example, the mean DHI total score was 29.6 before and 24.3 after treatment (P = .1). The DHI-f subscores changed from 11.2 to 9.4 (P = .1), and the DHI-e subscores, from 6.5 to 6.2 (P = .7). Significant change could be demonstrated only for the DHI-p subscores that decreased from 11.7 to 8.7 (P = .01). Good intrapersonal consistency was found for all items except for disease predictability (IPQ-R-2) and belief in personal control (IPQ-R-4) (Table 2). Correlation was found between the grade of functional and emotional impact (DHI) and belief in consequences (IPQ-R-3) of the disease as well as anxiety levels of the patients (STAI). A significant interrelation was also found between state and trait anxiety subscores (STAI-S, STAI-T). Moreover, uncertainty scores (IUS) were in correlation with emotional impact as well as anxiety levels and perceived consequences of BPPV. A belief in personal control of the condition (IPQ-R-4) was correlated with the belief in treatment control (IPQ-R-5) and understanding of the disease (IPQ-R-6) (Table 3).
Table 1 Questionnaires' results in patients with BPPV before and after treatment Questionnaire Mean score before SD2 Mean score after SD treatment treatment
P
DHI, total DHI-f DHI-p DHI-e IPQ-R, total IPQ-R-1 IPQ-R-2 IPQ-R-3 IPQ-R-4 IPQ-R-5 IPQ-R-6 IPQ-R-7 IUS STAI-S STAI-T
.105 .151 .019 .752 .942 .807 .818 .218 .9 .301 .583 .524 .191 .524 .347
29.6 11.2 11.7 6.5 109.3 17.9 12.5 13.4 15.6 17.8 15.1 16.8 73.8 39.4 39.7
17.1 24.3 7.7 9.4 5.6 8.7 6 6.2 16.7 109.2 2.4 18 3.2 12.3 4.3 12.7 4.4 15.7 4 18.6 3.4 15.5 6.9 16.1 20.6 70 14.2 38 11.1 38.5
19.7 8.9 6.3 6.8 12.1 2 3.4 3.5 4.9 2.3 2.3 5.8 20.2 13.4 10.5
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Table 2 Pearson correlation coefficients for questionnaires' scores before and after treatment Questionnaire
Correlation coefficient
P
DHI, total DHI-f DHI-p DHI-e IPQ-R, total IPQ-R-1 IPQ-R-2 IPQ-R-3 IPQ-R-4 IPQ-R-5 IPQ-R-6 IPQ-R-7 IUS STAI-S STAI-T
0.4 0.5 0.1 0.3 0.5 0.6 0.1 0.7 0.3 0.4 0.4 0.5 0.6 0.5 0.7
.06 .001 .239 .19 .001 .001 .323 .001 .023 .792 .13 .001 .001 .001 .001
4. Discussion The main finding in this study is the lack of a significant change in personal beliefs and emotional reactions in patients with BPPV before and after successful treatment. The scores of dizziness handicap (DHI) were comparable with previous reports [33] but did not improve after treatment except for perceived physical handicap. The physical handicap score reflects the direct impact of the disease on physical activity such as constraints in bending, getting up, or turning in bed, and the change in this parameter was therefore expectable after the disease has been cured and positional vertigo has cleared. Illness perception (IPQ-R), intolerance uncertainty (IUS), as well as anxiety (STAI) also remained unchanged after treatment. The individuals were consistent in their responses for all items before and after treatment except for feeling of predictability of their condition and belief in personal control. This means that an individual who answered a question within the high range of points before treatment remained within the same range after treatment and vice versa. The inconsistency in answering the items dealing with predictability and personal control might be due to the explanation about the unpredictable nature of disease recurrence that the patients received during their first visit. The belief in personal control of their disease also showed the tendency to improve after successful treatment. In a previous study, we have demonstrated that patients with an acute vertigo attack (among them, one third were patients with BPPV) experience a stronger emotional reaction (anxiety and depression) than patients with more severe neurologic conditions such as hemiparesis, paraparesis, dysphagia, or loss of a part of the visual field [34]. Indeed, the present study has also shown a strong correlation of anxiety levels, the functional and emotional impact, as well as the belief in consequences of the disease. The surprising rigidity of most feelings, beliefs, and attitudes of
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Table 3 Pearson correlations between distinct questionnaires Questionnaire
DHI-f
DHI-e
IPQ-R-3
STAI-S
STAI-T
IUS
IPQ-R-4
IPQ-R-5
IPQ-R-6
IPQ-R-7
DHI-f
1
0.7 P b .001 1
0.3 P = .03 0.3 P = .02 1
0.4 P = .01 0.4 P = .007 0.4 P = .08 1
–
–
–
–
–
–
0.3 P = .004 0.3 P = .04 0.7 P = .001 1
0.3 P = .03 0.3 P = .04 0.4 P = .01 0.4 P = .005 1
–
–
–
–
–
–
–
–
–
0.4 P = .005 0.4 P = .003 –
–
–
–
–
–
–
–
1
0.4 P = .008 1
0.3 P = .03 0.6 P b .001 1
0.5 P = .001 –
DHI-e IPQ-R-3 STAI-S STAI-T IUS IPQ-R-4 IPQ-R-5 IPQ-R-6
patients with BPPV toward their disease despite successful treatment is probably the result of a high anxiety that the disease evokes. Anxiety accompanying BPPV and leading to negative attitudes despite effective treatment may also explain the persistence of symptoms in patients with BPPV [35,36]. However, not every patient who continues to complain about dizziness after treatment, despite the lack of nystagmus on positioning testing, should be labeled anxious. Further laboratory vestibular testing such as electronystagmography, rotational chair testing, or neuroimaging might reveal another organic cause of their complaints [35]. Anxiolytic treatment should be reserved for individuals in whom comorbid vestibular conditions were excluded. References [1] Bourgeois PM, Dehaene I. Benign paroxysmal positional vertigo (BPPV). Clinical features in 34 cases and review of literature. Acta Neurol Belg 1988;88:65-74. [2] Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ 2003;169:681-93. [3] Semont A, Freyss G, Vitte E. Curing the BPPV with a liberatory maneuver. Adv Otorhinolaryngol 1988;42:290-3. [4] Richard W, Bruintjes TD, Oostenbrink P, et al. Efficacy of the Epley maneuver for posterior canal BPPV: a long-term, controlled study of 81 patients. Ear Nose Throat J 2005;84:22-5. [5] Korres S, Balatsouras DG, Ferekidis E. Prognosis of patients with benign paroxysmal positional vertigo treated with repositioning manoeuvres. J Laryngol Otol 2006;120:528-33. [6] Yardley L, Luxon LM, Haacke NP. A longitudinal study of symptoms, anxiety and subjective well-being in patients with vertigo. Clin Otolaryngol Allied Sci 1994;19:109-16. [7] Balaban CD, Jacob RG. Background and history of the interface between anxiety and vertigo. J Anxiety Disord 2001;15:27-51. [8] Eckhardt-Henn A, Best C, Bense S, et al. Psychiatric comorbidity in different organic vertigo syndromes. J Neurol 2008;255:420-8. [9] Best C, Eckhardt-Henn A, Tschan R, et al. Psychiatric morbidity and comorbidity in different vestibular vertigo syndromes. Results of a prospective longitudinal study over one year. J Neurol 2009;256: 58-65.
– –
[10] Nishiike S, Takeda N, Kubo T, et al. Noradrenergic pathways involved in the development of vertigo and dizziness—a review. Acta Otolaryngol Suppl 2001;545:61-4. [11] Staab JP, Ruckenstein MJ, Solomon D, et al. Exertional dizziness and autonomic dysregulation. Laryngoscope 2002;112:1346-50. [12] Jacob RG. Panic disorder and the vestibular system. Psychiatr Clin North Am 1988;11:361-74. [13] Teggi R, Caldirola D, Colombo B, et al. Dizziness, migrainous vertigo and psychiatric disorders. J Laryngol Otol 2010;124:285-90. [14] Celestino D, Rosini E, Carucci ML, et al. Ménière's disease and anxiety disorders. Acta Otorhinolaryngol Ital 2003;23:421-7. [15] Yardley L, Kirby S. Evaluation of booklet-based self-management of symptoms in Ménière disease: a randomized controlled trial. Psychosom Med 2006;68:762-9. [16] Savastano M, Marioni G, Aita M. Psychological characteristics of patients with Ménière's disease compared with patients with vertigo, tinnitus, or hearing loss. Ear Nose Throat J 2007;86:148-56. [17] Kirby SE, Yardley L. Cognitions associated with anxiety in Ménière's disease. J Psychosom Res 2009;66:111-8. [18] Godemann F, Linden M, Neu P, et al. A prospective study on the course of anxiety after vestibular neuronitis. J Psychosom Res 2004;56:351-4. [19] Mandala M, Nuti D. Long-term follow-up of vestibular neuritis. Ann N Y Acad Sci 2009;1164:427-9. [20] Nagarkar AN, Gupta AK, Mann SB. Psychological findings in benign paroxysmal positional vertigo and psychogenic vertigo. J Otolaryngol 2000;29:154-8. [21] Monzani D, Genovese E, Rovatti V, et al. Life events and benign paroxysmal positional vertigo: a case-controlled study. Acta Otolaryngol 2006;126:987-92. [22] Jacobson GP, Calder JH. A screening version of the Dizziness Handicap Inventory (DHI-S). Am J Otol 1998;19:804-8. [23] Treleaven J. Dizziness Handicap Inventory (DHI). Aust J Physiother 2006;52:67. [24] Trovato GM, Catalano D, Martines GF, et al. Illness perception questionnaire (IPQ-r): an useful paradigm in chronic disease. Recenti Prog Med 2006;97:129-33. [25] Sterba KR, DeVellis RF. Developing a spouse version of the Illness Perception Questionnaire-Revised (IPQ-R) for husbands of women with rheumatoid arthritis. Psychol Health 2009;24:473-7. [26] Buhr K, Dugas MJ. The Intolerance of Uncertainty Scale: psychometric properties of the English version. Behav Res Ther 2002;40:931-45. [27] Norton PJ. A psychometric analysis of the Intolerance of Uncertainty Scale among four racial groups. J Anxiety Disord 2005;19:699-707.
L. Pollak et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 33 (2012) 221–225 [28] Carleton RN, Norton MA, Asmundson GJ. Fearing the unknown: a short version of the Intolerance of Uncertainty Scale. J Anxiety Disord 2007;21:105-17. [29] Sexton KA, Dugas MJ. Defining distinct negative beliefs about uncertainty: validating the factor structure of the Intolerance of Uncertainty Scale. Psychol Assess 2009;21:176-86. [30] Layton C. Test-retest characteristics of State-Trait Anxiety Inventory, a-state scale. Percept Mot Skills 1986;62:586. [31] Kendall PC, Finch Jr AJ, Auerbach SM, et al. The State-Trait Anxiety Inventory: a systematic evaluation. J Consult Clin Psychol 1976;44: 406-12. [32] Nixon GF, Steffeck JC. Reliability of the State-Trait Anxiety Inventory. Psychol Rep 1977;40:357-8.
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[33] Whitney SL, Marchetti GF, Morris LO. Usefulness of the dizziness handicap inventory in the screening for benign paroxysmal positional vertigo. Otol Neurotol 2005;26:1027-33. [34] Pollak L, Klein C, Stryjer R, et al. Anxiety in the first attack of vertigo. Otolaryngol Head Neck Surg 2003;128:829-34. [35] Pollak L, Davies RA, Luxon LL. Effectiveness of the particle repositioning maneuver in benign paroxysmal positional vertigo with and without additional vestibular pathology. Otol Neurotol 2002;23:79-83. [36] Lopez-Escamez JA, Gamiz MJ, Fernandez-Perez A, et al. Longterm outcome and health-related quality of life in benign paroxysmal positional vertigo. Eur Arch Otorhinolaryngol 2005; 262:507-11.
American Journal of Otolaryngology–Head and Neck Medicine and Surgery 33 (2012) 221 – 225 www.elsevier.com/locate/amjoto
Beliefs and emotional reactions in patients with benign paroxysmal positional vertigo: a longitudinal study☆ Lea Pollak, MD a,⁎, Perri Segal, MS a , Rafael Stryjer, MD b , Hadassah Goldberg Stern, MD c a
Department of Neurology, Assaf Harofeh Medical Center affiliated to Sackler Faculty of Medicine, Tel Aviv University, Israel b Mental Health Hospital, Beer Yaacov, Israel c Department of Neurology, Schneider Children's Medical center of Israel, Petach Tikva, Israel Received 19 March 2011
Abstract
Objective: Psychologic studies in patients with benign paroxysmal positional vertigo (BPPV) are scarce, considering the high frequency of the disorder. We performed a repeated-measures design questionnaire study in a cohort of patients with BPPV before and after treatment to investigate the dynamics of the psychologic findings and possible treatment consequences. Methods: Thirty-seven consecutive patients with idiopathic BPPV participated in the study. During the first visit and 2 to 3 months after therapy, the patients completed 4 questionnaires: the Dizziness Handicap Inventory, the Illness Perception Questionnaire-Revised, the Intolerance of Uncertainty Scale, and the State-Trait Anxiety Inventory. Results: The scores for all questioned items did not change before and after treatment except for the physical handicap scores. Correlation was found between the grade of functional and emotional impact of the disease and belief in consequences as well as anxiety levels of the patients. Moreover, uncertainty scores were in correlation with emotional impact, anxiety levels, and perceived consequences of the disease. The belief in personal control of the condition was correlated with the belief in treatment control and understanding of the disease. Conclusion: The main finding in this study is the lack of a significant change in beliefs and emotional reactions in patients with BPPV after treatment of their condition. Physicians dealing with BPPV should be aware that the disease is not solely a somatic condition but has a serious impact on the patient's mental state. Selected patients might benefit from anxiolytic medication. © 2012 Elsevier Inc. All rights reserved.
1. Introduction One of the most common and treatable causes of vertigo in the adult population is benign paroxysmal positional vertigo (BPPV) [1,2]. It is characterized by rotational vertigo induced by head position changes in the plane of one of the semicircular canals of the vestibular labyrinth. The diagnosis is confirmed by positioning testing that reveals a characteristic nystagmus. Benign paroxysmal positional vertigo is considered to be caused by canalithiasis
☆
The authors report no conflict of interest or financial support for this work. ⁎ Corresponding author. Department of Neurology, Assaf Harofeh Medical Center, Zerifin, Israel. Tel.: +972 8 9404747; fax: +972 8 9401995. E-mail address: [email protected] (L. Pollak). 0196-0709/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.amjoto.2011.07.002
and cupulolithiasis. Otoconial debris, derived from the utricular macula, loosens and becomes trapped in one of the semicircular canals or its cupula. This causes inappropriate stimulation of the sensory hair cells of the affected canal and results in vertigo and nystagmus. Particle repositioning maneuvers, aimed to remove the otoconial debris from the particular semicircular canal, are a simple and highly effective treatment of the condition [3,4]. Complete resolution of the symptoms can be achieved in 75% to 100% of patients after a single or couple of treatments. However, the condition recurs in up to 50% of patients within 5 years of follow-up [5]. The close relationship of dizziness or vertigo and psychiatric disturbances has been readily recognized [6-9]. Dizziness or vertigo can be a complaint in depression, generalized anxiety disorder, somatization disease, and panic
222
L. Pollak et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 33 (2012) 221–225
disorder. The link between psychic changes and dizziness is supported by neurophysiologic studies that showed the influence of increased arousal and hyperventilation, associated with anxiety, on various vestibular laboratory parameters [10,11]. On the other hand, vestibular lesions of distinct etiologies can trigger the onset of a psychiatric illness especially in predisposed individuals. They typically provoke an exaggerated emotional reaction sometimes persisting for a long period after the vestibular symptoms have resolved [7,8]. Anatomical and functional connections between the vestibular system and structures involved in the pathogenesis of panic disorder or conditioning of fear responses, such as locus coeruleus and raphe nucleus of the brainstem, further support this concept [9-12]. Although psychologic findings in some vestibular disorders, such as Ménière disease, vestibular migraine, and vestibular neuronitis, have been extensively reported, psychologic studies in patients with BPPV are surprisingly scarce, considering the high frequency of the disorder [1319]. In one study where the Hospital Anxiety-Depression scoring was applied, anxiety was found in 73.5% and depression in 41% of patients with BPPV [20,21]. We performed a repeated-measures design study in a cohort of patients with BPPV before and after treatment to investigate the dynamics of the psychologic findings and possible treatment consequences.
2. Methods 2.1. Patients Thirty-seven consecutive patients with idiopathic BPPV, diagnosed and treated at an outpatient clinic during the years 2008 and 2009, participated in the study. Their mean age was 59.2 ± 14.5 years; 14 were men, and 23 were women. Thirtytwo patients had a posterior canal BPPV, and 5 had a horizontal canal involvement. Patients with a physical disorder such as orthopedic disorders, surgical disorders, grave internal diseases, aphasia, agraphia, alexia, dementia and severe depression or psychosis, or previous otological disease were excluded. Patients with a history of mental illness, regardless to present medication intake, were also excluded. After the diagnostic test (Dix-Hallpike maneuver for the posterior and roll test for the horizontal canal type of BPPV), the patients received a detailed explanation of their condition and were treated by an appropriate particle repositioning maneuver during the same session. Patients were seen again within 1 week after the treatment. If necessary, the treatment was repeated in 3- to 7-day intervals until the nystagmus disappeared. The study was performed in accordance with the Helsinki declaration and approved by the local ethics committee of the Assaf Harofeh Medical Center.
2.2. Methods Four questionnaires were administered: 1. The Dizziness Handicap Inventory (DHI) was developed to measure self-perceived levels of handicap associated with the symptoms of dizziness. It has 25 items, with 3 response levels subgrouped into 3 domains: functional (DHI-f), emotional (DHI-e), and physical (DHI-p). The possible score ranges from 0 to 100, a higher score indicating worse handicap. The maximum possible scores are 28 for DHI-p, 36 for DHI-f, and 36 for DHI-e subscores. Test-retest reliability (r = 0.92–0.97) and internal consistency (α = .72–.89) have been demonstrated to be high [22,23]. 2. The Illness Perception Questionnaire-Revised (IPQ-R) (second part) measures patients' cognitive and emotional representations of their illness. It consists of 38 statements using 5-point Likert scales (“strongly agree” to “strongly disagree”). It gives separate scores for the timeline (short- vs long-term IPQ-R-1), unpredictability (IPQ-R-2), consequences (IPQ-R-3), personal and treatment control (IPQ-R-4 and IPQ-R-5), illness coherence (IPQ-R-6), and emotional representation (IPQ-R-7). High scores indicate strong beliefs in serious consequences of the disease, chronicity and/or recurrence of the disease, the patients' own ability to control symptoms, and effectiveness of treatment in controlling the disease. High scores on the illness coherence scale indicate a high degree of patients' belief in a good understanding of their medical condition, and high scores on the emotional representation scale indicate a strong emotional response to the illness. The internal reliability of the test has been shown to range from 0.71 to 0.90 for the distinct subscales [24,25]. 3. The Intolerance of Uncertainty Scale (IUS) is a 27-item measure that assesses emotional, cognitive, and behavioral responses to ambiguous situations, implications of being uncertain, and attempts to control the future. Items are scored on a 5-point scale. The responses are summed as a total scale score, ranging from 27 to 135. The test has demonstrated a good internal consistency (α = .94) and a good test-retest reliability (r = 0.74) [26-29]. 4. The State-Trait Anxiety Inventory (STAI) consists of 40 items: 20 designed to assess state anxiety, that is, anxiety level at the time of examination (S scale), and further 20 items to assess trait anxiety, that is, general anxiety of the individual (T scale). High scores mean more trait or state anxiety. The reliability of the tests has been reported to range from 0.65 to 0.86 for the trait anxiety subscale and from 0.16 to 0.62 for the state anxiety subscale [30-32]. Patients completed the questionnaires twice: the first time during their first visit and the second time 2 to 3 months later while free of vertigo symptoms.
L. Pollak et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 33 (2012) 221–225
2.3. Statistical methods Paired samples test (paired t test) was applied to investigate the differences of questionnaires' results before and after treatment. Pearson correlation coefficient investigated for internal consistency as well as interrelations between scores and subscores of the distinct questionnaires. The statistical power (P) was considered significant if less than .05.
3. Results The scores for all questioned items did not change before and after treatment except for the physical handicap subscores (Table 1). For example, the mean DHI total score was 29.6 before and 24.3 after treatment (P = .1). The DHI-f subscores changed from 11.2 to 9.4 (P = .1), and the DHI-e subscores, from 6.5 to 6.2 (P = .7). Significant change could be demonstrated only for the DHI-p subscores that decreased from 11.7 to 8.7 (P = .01). Good intrapersonal consistency was found for all items except for disease predictability (IPQ-R-2) and belief in personal control (IPQ-R-4) (Table 2). Correlation was found between the grade of functional and emotional impact (DHI) and belief in consequences (IPQ-R-3) of the disease as well as anxiety levels of the patients (STAI). A significant interrelation was also found between state and trait anxiety subscores (STAI-S, STAI-T). Moreover, uncertainty scores (IUS) were in correlation with emotional impact as well as anxiety levels and perceived consequences of BPPV. A belief in personal control of the condition (IPQ-R-4) was correlated with the belief in treatment control (IPQ-R-5) and understanding of the disease (IPQ-R-6) (Table 3).
Table 1 Questionnaires' results in patients with BPPV before and after treatment Questionnaire Mean score before SD2 Mean score after SD treatment treatment
P
DHI, total DHI-f DHI-p DHI-e IPQ-R, total IPQ-R-1 IPQ-R-2 IPQ-R-3 IPQ-R-4 IPQ-R-5 IPQ-R-6 IPQ-R-7 IUS STAI-S STAI-T
.105 .151 .019 .752 .942 .807 .818 .218 .9 .301 .583 .524 .191 .524 .347
29.6 11.2 11.7 6.5 109.3 17.9 12.5 13.4 15.6 17.8 15.1 16.8 73.8 39.4 39.7
17.1 24.3 7.7 9.4 5.6 8.7 6 6.2 16.7 109.2 2.4 18 3.2 12.3 4.3 12.7 4.4 15.7 4 18.6 3.4 15.5 6.9 16.1 20.6 70 14.2 38 11.1 38.5
19.7 8.9 6.3 6.8 12.1 2 3.4 3.5 4.9 2.3 2.3 5.8 20.2 13.4 10.5
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Table 2 Pearson correlation coefficients for questionnaires' scores before and after treatment Questionnaire
Correlation coefficient
P
DHI, total DHI-f DHI-p DHI-e IPQ-R, total IPQ-R-1 IPQ-R-2 IPQ-R-3 IPQ-R-4 IPQ-R-5 IPQ-R-6 IPQ-R-7 IUS STAI-S STAI-T
0.4 0.5 0.1 0.3 0.5 0.6 0.1 0.7 0.3 0.4 0.4 0.5 0.6 0.5 0.7
.06 .001 .239 .19 .001 .001 .323 .001 .023 .792 .13 .001 .001 .001 .001
4. Discussion The main finding in this study is the lack of a significant change in personal beliefs and emotional reactions in patients with BPPV before and after successful treatment. The scores of dizziness handicap (DHI) were comparable with previous reports [33] but did not improve after treatment except for perceived physical handicap. The physical handicap score reflects the direct impact of the disease on physical activity such as constraints in bending, getting up, or turning in bed, and the change in this parameter was therefore expectable after the disease has been cured and positional vertigo has cleared. Illness perception (IPQ-R), intolerance uncertainty (IUS), as well as anxiety (STAI) also remained unchanged after treatment. The individuals were consistent in their responses for all items before and after treatment except for feeling of predictability of their condition and belief in personal control. This means that an individual who answered a question within the high range of points before treatment remained within the same range after treatment and vice versa. The inconsistency in answering the items dealing with predictability and personal control might be due to the explanation about the unpredictable nature of disease recurrence that the patients received during their first visit. The belief in personal control of their disease also showed the tendency to improve after successful treatment. In a previous study, we have demonstrated that patients with an acute vertigo attack (among them, one third were patients with BPPV) experience a stronger emotional reaction (anxiety and depression) than patients with more severe neurologic conditions such as hemiparesis, paraparesis, dysphagia, or loss of a part of the visual field [34]. Indeed, the present study has also shown a strong correlation of anxiety levels, the functional and emotional impact, as well as the belief in consequences of the disease. The surprising rigidity of most feelings, beliefs, and attitudes of
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Table 3 Pearson correlations between distinct questionnaires Questionnaire
DHI-f
DHI-e
IPQ-R-3
STAI-S
STAI-T
IUS
IPQ-R-4
IPQ-R-5
IPQ-R-6
IPQ-R-7
DHI-f
1
0.7 P b .001 1
0.3 P = .03 0.3 P = .02 1
0.4 P = .01 0.4 P = .007 0.4 P = .08 1
–
–
–
–
–
–
0.3 P = .004 0.3 P = .04 0.7 P = .001 1
0.3 P = .03 0.3 P = .04 0.4 P = .01 0.4 P = .005 1
–
–
–
–
–
–
–
–
–
0.4 P = .005 0.4 P = .003 –
–
–
–
–
–
–
–
1
0.4 P = .008 1
0.3 P = .03 0.6 P b .001 1
0.5 P = .001 –
DHI-e IPQ-R-3 STAI-S STAI-T IUS IPQ-R-4 IPQ-R-5 IPQ-R-6
patients with BPPV toward their disease despite successful treatment is probably the result of a high anxiety that the disease evokes. Anxiety accompanying BPPV and leading to negative attitudes despite effective treatment may also explain the persistence of symptoms in patients with BPPV [35,36]. However, not every patient who continues to complain about dizziness after treatment, despite the lack of nystagmus on positioning testing, should be labeled anxious. Further laboratory vestibular testing such as electronystagmography, rotational chair testing, or neuroimaging might reveal another organic cause of their complaints [35]. Anxiolytic treatment should be reserved for individuals in whom comorbid vestibular conditions were excluded. References [1] Bourgeois PM, Dehaene I. Benign paroxysmal positional vertigo (BPPV). Clinical features in 34 cases and review of literature. Acta Neurol Belg 1988;88:65-74. [2] Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ 2003;169:681-93. [3] Semont A, Freyss G, Vitte E. Curing the BPPV with a liberatory maneuver. Adv Otorhinolaryngol 1988;42:290-3. [4] Richard W, Bruintjes TD, Oostenbrink P, et al. Efficacy of the Epley maneuver for posterior canal BPPV: a long-term, controlled study of 81 patients. Ear Nose Throat J 2005;84:22-5. [5] Korres S, Balatsouras DG, Ferekidis E. Prognosis of patients with benign paroxysmal positional vertigo treated with repositioning manoeuvres. J Laryngol Otol 2006;120:528-33. [6] Yardley L, Luxon LM, Haacke NP. A longitudinal study of symptoms, anxiety and subjective well-being in patients with vertigo. Clin Otolaryngol Allied Sci 1994;19:109-16. [7] Balaban CD, Jacob RG. Background and history of the interface between anxiety and vertigo. J Anxiety Disord 2001;15:27-51. [8] Eckhardt-Henn A, Best C, Bense S, et al. Psychiatric comorbidity in different organic vertigo syndromes. J Neurol 2008;255:420-8. [9] Best C, Eckhardt-Henn A, Tschan R, et al. Psychiatric morbidity and comorbidity in different vestibular vertigo syndromes. Results of a prospective longitudinal study over one year. J Neurol 2009;256: 58-65.
– –
[10] Nishiike S, Takeda N, Kubo T, et al. Noradrenergic pathways involved in the development of vertigo and dizziness—a review. Acta Otolaryngol Suppl 2001;545:61-4. [11] Staab JP, Ruckenstein MJ, Solomon D, et al. Exertional dizziness and autonomic dysregulation. Laryngoscope 2002;112:1346-50. [12] Jacob RG. Panic disorder and the vestibular system. Psychiatr Clin North Am 1988;11:361-74. [13] Teggi R, Caldirola D, Colombo B, et al. Dizziness, migrainous vertigo and psychiatric disorders. J Laryngol Otol 2010;124:285-90. [14] Celestino D, Rosini E, Carucci ML, et al. Ménière's disease and anxiety disorders. Acta Otorhinolaryngol Ital 2003;23:421-7. [15] Yardley L, Kirby S. Evaluation of booklet-based self-management of symptoms in Ménière disease: a randomized controlled trial. Psychosom Med 2006;68:762-9. [16] Savastano M, Marioni G, Aita M. Psychological characteristics of patients with Ménière's disease compared with patients with vertigo, tinnitus, or hearing loss. Ear Nose Throat J 2007;86:148-56. [17] Kirby SE, Yardley L. Cognitions associated with anxiety in Ménière's disease. J Psychosom Res 2009;66:111-8. [18] Godemann F, Linden M, Neu P, et al. A prospective study on the course of anxiety after vestibular neuronitis. J Psychosom Res 2004;56:351-4. [19] Mandala M, Nuti D. Long-term follow-up of vestibular neuritis. Ann N Y Acad Sci 2009;1164:427-9. [20] Nagarkar AN, Gupta AK, Mann SB. Psychological findings in benign paroxysmal positional vertigo and psychogenic vertigo. J Otolaryngol 2000;29:154-8. [21] Monzani D, Genovese E, Rovatti V, et al. Life events and benign paroxysmal positional vertigo: a case-controlled study. Acta Otolaryngol 2006;126:987-92. [22] Jacobson GP, Calder JH. A screening version of the Dizziness Handicap Inventory (DHI-S). Am J Otol 1998;19:804-8. [23] Treleaven J. Dizziness Handicap Inventory (DHI). Aust J Physiother 2006;52:67. [24] Trovato GM, Catalano D, Martines GF, et al. Illness perception questionnaire (IPQ-r): an useful paradigm in chronic disease. Recenti Prog Med 2006;97:129-33. [25] Sterba KR, DeVellis RF. Developing a spouse version of the Illness Perception Questionnaire-Revised (IPQ-R) for husbands of women with rheumatoid arthritis. Psychol Health 2009;24:473-7. [26] Buhr K, Dugas MJ. The Intolerance of Uncertainty Scale: psychometric properties of the English version. Behav Res Ther 2002;40:931-45. [27] Norton PJ. A psychometric analysis of the Intolerance of Uncertainty Scale among four racial groups. J Anxiety Disord 2005;19:699-707.
L. Pollak et al. / American Journal of Otolaryngology–Head and Neck Medicine and Surgery 33 (2012) 221–225 [28] Carleton RN, Norton MA, Asmundson GJ. Fearing the unknown: a short version of the Intolerance of Uncertainty Scale. J Anxiety Disord 2007;21:105-17. [29] Sexton KA, Dugas MJ. Defining distinct negative beliefs about uncertainty: validating the factor structure of the Intolerance of Uncertainty Scale. Psychol Assess 2009;21:176-86. [30] Layton C. Test-retest characteristics of State-Trait Anxiety Inventory, a-state scale. Percept Mot Skills 1986;62:586. [31] Kendall PC, Finch Jr AJ, Auerbach SM, et al. The State-Trait Anxiety Inventory: a systematic evaluation. J Consult Clin Psychol 1976;44: 406-12. [32] Nixon GF, Steffeck JC. Reliability of the State-Trait Anxiety Inventory. Psychol Rep 1977;40:357-8.
225
[33] Whitney SL, Marchetti GF, Morris LO. Usefulness of the dizziness handicap inventory in the screening for benign paroxysmal positional vertigo. Otol Neurotol 2005;26:1027-33. [34] Pollak L, Klein C, Stryjer R, et al. Anxiety in the first attack of vertigo. Otolaryngol Head Neck Surg 2003;128:829-34. [35] Pollak L, Davies RA, Luxon LL. Effectiveness of the particle repositioning maneuver in benign paroxysmal positional vertigo with and without additional vestibular pathology. Otol Neurotol 2002;23:79-83. [36] Lopez-Escamez JA, Gamiz MJ, Fernandez-Perez A, et al. Longterm outcome and health-related quality of life in benign paroxysmal positional vertigo. Eur Arch Otorhinolaryngol 2005; 262:507-11.