Prediction of handicap and emotional distress in patients with recurrent vertigo: Symptoms, coping strategies, control beliefs and reciprocal causation

Sm. Sci. Med. Vol. 39. No. 4. LTD.573-581. 1994

Pergamon

Copyright 0 1994 Elkier Science Ltd Printed in Great Britain. All rights reserved 0277-9536/94 $7.00 + 0.00

0277-9536(93)30053-H

PREDICTION OF HANDICAP AND EMOTIONAL DISTRESS IN PATIENTS WITH RECURRENT VERTIGO: SYMPTOMS, COPING STRATEGIES, CONTROL BELIEFS AND RECIPROCAL CAUSATION LUCY YARDLEY Department

of Psychology,

University

College

London,

Gower

St, London

WCIE

6BT, England

Abstract-Factors predicting handicap and distress were examined in a longitudinal study of 101 patients suffering from recurrent vertigo (dizziness). Analysis of a questionnaire assessing coping strategies yielded four distinct individualised coping styles: problem-focused information-seeking; distraction; denial; and relinquishing responsibility. After controlling for the severity of physical and psychological symptoms and distress, handicap was negatively related to internal locus of control and positively correlated with relinquishing responsibility. Symptoms of somatic anxiety predicted an increase in handicap over a 7 month period, while handicap and somatic anxiety symptoms predicted an increase in distress. These results are interpreted in terms of a reciprocal causal relationship between handicap and distress, mediated partly by somatic symptoms. Parallels benefit from psychological therapies. Key words-vestibular

disorder,

with pain, panic and phobia

somatisation,

symptom

INTRODUCIION

Recurrent episodes of vertigo (medically defined as a disturbance of orientation perception) can have serious adverse effects on the lifestyle of sufferers and are often associated with significant emotional distress [l-3]. The symptoms of vertigo resulting from balance system (usually vestibular) dysfunction range from a vague but persistent disorientation, disequilibrium and malaise, to sudden attacks of acute dizziness together with loss of postural control and vomiting. While the annual incidence of people seeking medical help in Britain on account of classic vertigo attacks is

around 0.5% [4], a recent community survey found that a quarter of people aged fifty to sixty-five reported giddiness [5]. Symptoms can occur spontaneously and without warning, or may be provoked by head movements or by complex motion environments (for example, riding in lifts or buses). Consequently, many people with balance system disorders deliberately restrict their physical activity, travel and social commitments in order to reduce the risk of provoking these unpleasant and frightening symptoms, and to avoid the social embarrassment and stigma they might cause [6]. Unfortunately, this self-imposed anticipatory disability has the potential to create an escalating cycle of handicap and distress. The resulting loss of valued roles, supportive social contacts and rewarding pastimes may fuel the feelings of anxiety and helplessness initially caused by physical illness. In addition, avoidance of vigorous movement and demanding perceptual environments

suggest that patients

monitoring,

with vertigo might

anxiety

may actually prolong the duration of the vertigo by retarding neuro-physiological and sensorimotor adaptation, which requires active experience of varied motions and perceptual conditions [7,8]. Previous studies have shown that the degree of handicap and emotional distress associated with recurrent vertigo is not closely related to measures of illness severity [9-l 11. Psychological and behavioral factors which may influence the impact of vertigo include predisposing personality characteristics, such as trait

anxiety [12-141, beliefs about the significance and likely consequences of vertigo [ 1.51,and use of coping strategies. Although numerous studies have documented the existence of an intimate connection between vertigo and elevated scores on scales measuring anxiety and psychological disturbance (e.g. [16-18]), none has yet explored the way in which cognitive and behavioral coping responses may mediate or moderate this association. While many investigators have been interested in identifying the social factors and processes which influence coping, a large body of research has focused upon individualised coping efforts [ 191.Individual&d coping responses can be usefully categorised as ‘approach strategies’, which are concerned with actively managing the stress, or ‘avoidance strategies’, which comprise cognitive and behavioral attempts to escape or ignore the stressor [20]. Investigations into the utility of approach or avoidance strategies for coping with physical illness have produced conflicting evidence. For example, Felton and Revenson [21,22] found that seeking information about illness was 573

574

LUCYYARDLEY

positively associated with emotional well-being, but in other studies (e.g.[23,24]), ignoring or distracting oneself from the health problem has proved to be most beneficial. Interactions between coping style and the nature and duration of the stressor may partly account for these inconsistent findings [19,25]; for instance, avoidant coping might be optimal for dealing with inescapable or temporary stressors, but approach strategies may eventually be required to achieve long-term solutions to prolonged stress [26,27]. In addition, both approach and avoidance responses to stress can be either constructive or maladaptive. Information-seeking may be for the purpose of active problem-solving [28], or may simply reflect an anxious preoccupation with threat cues [29]. Similarly, avoidance includes active attempts to minimise or bypass the problem [30], but also encompasses the denial and disengagement which are known to accompany unhealthy pessimism [31, 321. Small variations in the content and wording of coping questionnaires, and the context in which they are administered, may therefore determine whether an item describing avoidant coping loads on an adaptive ‘threat minimisation’ scale, or forms part of a less helpful ‘denial’ factor. Equally, an item assessing symptom monitoring could measure either obsessive anxiety or an acceptance of personal responsibility for self-care. The aim of the present study was, firstly, to examine the influence on handicap of approach and avoidance strategies for coping with vertigo. In order to permit discrimination of positive and negative aspects of both approach and avoidance, a questionnaire was constructed which assessed coping strategies associated with psychological well-being in some previous studies, such as seeking information and advice [22], diverting attention [33] and staying busy [30], as well as coping responses previously linked with poor adjustment to health problems, such as a preoccupation with symptoms and illness [23,34] or escapist fantasy [35, 361. According to this conceptualisation, responses to the questionnaire might be expected to be ranged along two independent dimensions, the first defined by the approach/avoidance distinction, and the second characterised by the extent to which items represented constructive coping efforts, whether orientated towards approach or avoidance. For comparison with this vertigo-specific coping questionnaire, a well-validated scale was administered [37] which assesses preference for approach and avoidant modes of coping with a variety of stressors. The correlation between coping style and physical and psychosocial well-being is not only affected by interactions between the nature of the stress and of the coping strategy, but may also be influenced by third variables, such as emotional status or beliefs concerning personal control over health. To permit examination of these potentially confounding fac-

tors, measures of illness characteristics and severity, psychological well-being, and control beliefs were included as independent variables in our study. Furthermore, selection of coping strategies may simply reflect the constraints of illness and handicap, and the correlations between coping style and handicap may change over time. A longitudinal design was therefore employed so as to assess both the immediate and the long-term relationship of approach and avoidance strategies to handicap, and hence determine whether choice of coping strategy had any causal influence upon future handicap. Finally, this design allowed us to test the validity of the model of handicap developed by Yardley, Todd et al. [6], which predicts that handicap (restriction of activities) and emotional distress form a vicious cycle by exerting reciprocal causal effects over time. METHOD

Subjects and procedure At Time 1 all patients consecutively referred to two outpatient neuro-otology clinics on account of a major complaint of vertigo (defined for the purpose of this study as dizziness, perceptual disorientation or disequilibrium) were requested to complete questionnaire booklets at home, which assessed handicap, emotional distress, somatic symptoms, control beliefs and coping style. Of the 185 people approached, complete data was obtained from 127 (68.6%); the demographic characteristics of non-respondents did not differ from respondents. Seven months after they had returned the original questionnaire booklet, subjects were again sent the questionnaires assessing handicap and emotional distress. At Time 2, 107 people replied and complete data was obtained from 59 females and 42 males (79.5% of the Time 1 respondents). The age range was from 18 to 80 years; the mean age of females (45.2 years) was a little lower than that of the males (51.6 years; t = 2.35, P < 0.05). The majority of subjects (54.6%) complained of spontaneous episodes of rotatory vertigo, while the remainder suffered from position-induced vertigo (20.2%) or non-specific disorientation or disequilibrium (25.3%). The duration of the vertigo varied from less than a year at Time 1 (25% of the sample) to over 3 years (41%). Neuro-otological function was assessed at Time 1 by audiometry, electro-oculographic recording, and caloric, positional and rotational testing. Evidence of labyrinthine disorder (canal paresis or benign positional nystagmus) was found in 51 of the 87 subjects for whom complete test data was available, and signs of vestibular imbalance (spontaneous nystagmus or directional preponderance) were observed in a further 13 cases. Presence or absence of positive test findings was unrelated to any variable measured in this study, including diagnosis and illness duration or severity.

Handicap and emotional distress in patients with vertigo Measures

575

behavior (blunting, distraction, minimisation); and maladaptive avoidance behavior (passivity, denial). Subjects rated the frequency with which they used each strategy on a scale ranging from 0 (not used) to 4 (used a great deal).

Vertigo symptom scale (US). The VSS assesses sensations of dizziness and unsteadiness, common associated symptoms (e.g. nausea, sweating), and signs of anxiety arousal and somatisation. The frequency of each symptom during the past year is rated RESULTS on a scale ranging from 0 (never) to 5 (very often; The Time 1 analyses focus upon coping style and more than once a week). Two robust sub-scales can locus of control, since details of the relationship be derived from the questionnaire [14], measuring (a) between physical status, anxiety and handicap at symptoms of mild and acute vertigo attacks (dizziTime 1 are given elsewhere [lo]. In order to achieve ness, postural instability, nausea, vomiting), and (b) an adequate subject to item ratio, the factor analysis anxiety symptoms, which include both autonomic of coping items and calculation of factor scores on symptoms (e.g. heart pounding, excessive sweating, the coping scales was carried out on the data from all feeling faint or short of breath) and indications of Time 1 respondents. All subsequent analyses were somatisation, manifested as a tendency to complain based only on data from the 101 subjects who of a large number of diverse symptoms. provided data at both Time 1 and Time 2. Factor Vertigo Handicap Questionnaire (VHQ). This quesanalysis of the coping items from this sub-sample tionnaire was developed from accounts of the most common psychosocial consequences of vertigo [l 11. revealed an identical factor structure to that obtained using the complete Time 1 sample. The majority of its 25 items concern restriction and disruption of a wide range of physical and social Analysis of predictor variables activities (daily chores, travel, family affairs, leisure Firstly, items in the Vertigo Coping Questionnaire pursuits), but some also assess perceived social supwere submitted to principal components analysis with port or stigmatisation, and emotional distress caused Varimax rotation. Examination of the Eigenvalues by vertigo. Ratings of frequency of disability or and scree plot suggested an optimal solution based on handicap (e.g. I am unable to walk very far), or four factors, which accounted for 48.1% of the agreement with attitudinal items (e.g. I find the variance (see Appendix). All of the items assessing attacks frightening) are scored on a scale of G4, approach and monitoring strategies loaded on the yielding a cumulative index of handicap ranging from first factor, which was therefore labelled ‘Problem0 to 100. focused Information-seeking’. Over 90% of the Hospital Anxiety and Depression Scale (HADS). sample reported using these strategies to some extent The HADS [38] was selected to measure current and around three-quarters of the subjects used them anxiety and depression because it avoids extreme and extensively-indeed, 53 people had actually looked somatic items, and is therefore suitable for medical up medical information. The second factor, ‘Distracoutpatient populations. tion’, included both mental and behavioral strategies The Multidimensional Health Locus of Control for diverting attention from the vertigo, while four (MHLC) Scales. The MHLC questionnaire [39] items assessing minimisation or refusal to think about consists of three scales assessing perceived Internal the problem loaded on a third factor, ‘Denial’. control over health, and belief in external control of Although the use of some form of distraction was health by Chance or by significant Others (family, quite common, only about 10% of subjects were able doctors). Since beliefs may differ depending upon the to consistently employ denial as a coping tactic. The nature of the health problem, the scale was particuremaining items described a variety of coping stratlarised in this study by substituting the words ‘veregies (e.g. asking for advice from others, watching tigo’ or ‘attack’ for more general references to illness. TV, eating, drinking or taking tranquillisers) which Miller Behavioral Style Scale (MBSS). The two seemed to evade the necessity for personal mental or scales of the MBSS provide indices of the tendency to physical effort; the factor upon which they loaded ‘monitor’ potential sources of information in threatwas therefore labelled “Relinquishing Responsibilening situations, or to ‘blunt’ threat cues by diverting ity”. Few subjects (less than 10% of the sample) attention from them [37]. reported using such strategies often. Vertigo Coping Questionnaire. The 28 items inInternal consistency of the questionnaires and subcluded in this questionnaire were principally derived scales (including sub-scales created from items or modified from existing questionnaires assessing making up each factor of the Vertigo Coping Quesways of coping [21,40,41], supplemented by items tionnaire) was assessed by Cronbach’s alpha coconstructed from clinical experience of coping stratefficient; all of the scales had good or excellent egies of patients with vertigo. The items were selected reliability (CI> 0.7) apart from Chance locus of conto represent four hypothesised dimensions of coping: trol (MHLC) and Relinquishing Responsibility constructive approach behavior (information seek(VCQ), which had adequate reliabilities of 0.62 and ing, problem-solving); maladaptive approach behav0.64 respectively. The inter-relationships between the ior (anxious monitoring); constructive avoidance variables used as predictors in this study (i.e. age, sex,

576

LUCY YARDLEY

handicap nor distress were related to age or illness duration, but the female subjects had higher handicap scores at Time 1, t (99) = 2.72, P < 0.01, and Time 2, t (99) = 2.70, P < 0.01. At both Time 1 and Time 2, handicap was correlated with the following questionnaire measures: vertigo severity (VSS), anxiety symptoms (VSS), distress (HADS), Distraction, Relinquishing Responsibility, and Internal locus of control (MHLC). Emotional distress was consistently related to: anxiety symptoms (VSS), handicap (VHQ), Distraction and Relinquishing Responsibility. Since many of the predictors were moderately intercorrelated, multiple regression analyses were conducted in order to examine the relative contributions of each variable. Firstly, all Time 1 variables significantly related to handicap were entered into a hierarchical regression with handicap at Time I as the dependent variable (see Table 2). Gender, vertigo severity, and anxiety symptoms and distress were forcibly entered on the first three steps of the equation, in order to control for any effects of demographic, physical and psychological status on beliefs and coping. Since control beliefs might be expected to influence coping strategy, the next variable entered was Internal locus of control, while Relinquishing Responsibility and Distraction were entered together on the last step. Every step of the equation added significantly to the total variance explained by the regression equation. The partial correlations, controlling for all other variables in the equation, indicated that vertigo severity, distress, and Relinquishing Responsibility made the most significant independent contributions to variance in handicap. A second hierarchical multiple regression analysis examined the relative importance of all variables significantly correlated with emotional distress. Variables relating to illness severity and negative affect (in

symptoms and illness duration, coping and locus of control) were then examined. None of the coping or locus of control scales were related to vertigo symptoms or duration, but both Distraction and Relinquishing Responsibility were correlated with anxiety symptoms (r = 0.25, P < 0.001; r = 0.30, P < 0.01). Use of Distraction as a coping strategy was more common among females (t = 3.94, P < 0.001). Problem-focused Information-seeking was correlated with the Monitoring scale of the MBSS (r = 0.23, P < 0.01) and Distraction was correlated with Blunting (r = 0.24, P < 0.01). An Internal locus of control was negatively related to a Chance locus of control (r = 0.33, P < 0.01) and to Relinquishing Responsibility (I = 0.24, P < 0.01). Conversely, the belief that the vertigo was controlled by Others (family and friends) was positively associated with Relinquishing Responsibility (r = 0.27, P c 0.01) as well as with age (v = 0.35, P < 0.001) and male gender (t = 2.76, P < 0.01) and was negatively correlated with Distraction (r = 0.26, P < 0.01). No other relationships between the predictor variables reached significance. Relationship

of predictor

variables

to handicap

and

distress

Table 1 shows the correlation of the predictor variables with handicap (VHQ scores), and emotional distress, assessed by the combined scores on the anxiety and depression scales of the HADS, which were correlated r = 0.59 at Time 1 and r = 0.62 at Time 2 (P < 0.001). There was only a small change between Time 1 and Time 2 in the mean level of handicap (Time 1: M =44.1, SD = 17.1; Time 2: M = 41 .O,SD = 18.9) and emotional distress (Time I : A4 = 13.3, SD=7.0; Time 2: M = 12.4, SD=7.6). Nevertheless, there was a quite substantial variance in Time 2 minus Time 1 difference scores for both handicap (SD = 12.13, range = -27 to + 29) and distress (SD = 5.18, range = - 12 to + 15). Neither

Table I. Correlation of predictor variables with handicap and distress at Time Predictor variables (Time 1) Emotional distress (HADS) Handicap (VHQ) Vertigo Symptom Scale (VSS): Vertigo symptoms Anxiety symptoms Locus of Control (MHLC): Internal Chance Others Miller Behavioral Style Scale (MBSS): Monitoring Blunting Vertigo Coping Questionnaire: Information-seeking Distraction Denial Relinquishing responsibility lf < 0.05, **p < 0.01, l**P < 0.001

I and Time 2

Time I Handicap

Time 2 Distress

0.448.1 0.38’;’ 0.40***

Handicap

Distress

0.44***

0.43*** 0.78”.

0.75**. 0.49”’

0.04 0.47***

0.24” 0.47***

0.13 0.53”’

-0.25** 0.08 0.03

0.04 -0.13 -0.02

-0.18’ 0.01 0.04

0.09 -0.218 -0.07

0.09 0.12

0.22’ -0.06

0.05 0.00

0.16 -0.03

0.01 0.23** -0.05 0.251’

0.09 0.24.’ 0.03 0.34”’

-0.02 0.19’ 0.00 0.2w

0.16 0.17’ -0.05 0.42***

Handicap and emotional distress in patients with vertigo Table

2.

Hierarchical

multiple

Dependent

2.

3. 4. 5.

*P

variable

variable

**p

<

regressions

step

I. 2. 3.

6. I5* 4.00’

0.27 0.09 0.04

30.32”’ 11.34** 1.57

R * = 0.36***

0.32 0.26 0.18 0.17 0.12

strategies (relying on others or upon medication, wish-fulfilling fantasy, sleeping) which have also proven maladaptive in the context of coping with chronic pain [30] and stress [35]. Although this coping style could be the consequence of severe illness or depression, in the present study relinquishing responsibility predicted handicap even after controlling for the severity of symptoms and emotional distress. As might be expected, relinquishing responsibility was correlated with the belief that the vertigo was controlled by others and negatively related to an internal locus of control, and a low perception of internal control over the vertigo was also associated with increased handicap. Nevertheless, the association between relinquishing responsibility and handicap remained significant after controlling for locus of control, and so did not appear to be mediated entirely by control beliefs. Several ways in which this coping style could actively contribute to psychosocial difficulties were suggested during interviews with vertigo sufferers [6]. Dependence upon relatives can promote feelings of inadequacy and family conflict, while resorting to inactive pastimes may result in a sense of isolation and the loss of valued roles. In addition, both physical immobility and the use of psychoactive medi-

of predictor variables significantly and distress scores at T&e 2

Variable = Handicap

(Time

= Distress

(Time

<

0.001.

Change in R2

(change in R 2,

0.64 0.02 (variable

147.1”’ 4.9* not in the equation)

F

handicao

Partial correlation

R’

= 0.65’”

0.73 0.24 0.11

2)

Total equation: R = 0.80, Adjusted Distress (Time I) Handicap (VHQ) Anxiety symptoms (VSS)

lP < 0.05, l*P < 0.01, l**p

related to residualised

2)

Total equation: R = 6.81, Adjusted Handicap (Time I) Anxiety symptoms (VSS) Emotional distress (HADS) variable

0.04 0.05

0.01, +*p < 0.001

Table 3. Stepwise multiple

Dependent

0.10 0.32 0.08 0.40 -0.17 0.31 0.03

8.09** 15.90***

= Distress

The ‘relinquishing responsibility’ style of coping identified in these analyses as most closely related to handicap and distress consisted of a combination of

I. 2.

Partial correlation

5.97*

0.07

0.09 0.24

DISCUSSION

variable

F

(change in R’)

and

R ’ = 0.45***

this case, handicap and anxiety symptoms) were again entered into the equation before coping style. After controlling for these variables, coping style did not explain a significant proportion of the variance in HADS scores. A final series of multiple regressions were performed in order to determine which of the Time 1 variables was associated with an increase in handicap and distress. Preliminary analyses revealed that only anxiety symptoms and HADS scores at Time 1 were significantly correlated (P < 0.05) with residualised Time 2 handicap scores, and only handicap and anxiety symptoms at Time 1 were significantly related to residualised distress. Table 3 shows the results of stepwise regressions of these variables on residualised handicap and distress. After controlling for handicap at Time 1, anxiety symptoms at Time 1 predicted Time 2 handicap. Both anxiety symptoms and handicap at Time 1 predicted emotional distress at Time 2.

Dependent

related to handicap

= Handicap

Total equation: R = 0.63, Adjusted Handicap (VHQ) Anxiety symptoms (VSS) Distraction Monitoring Relinquishing responsibility < 0.05,

significantly

Change in R2

Total equation: R = 0.71, Adjusted (Female) sex Vertigo symptoms (VSS) Anxiety symptoms (VSS) Emotional distress (HADS) Internal locus of control Relinquishing responsibility Distraction

Dependent

I. 2. 3.

of predictor variables distress at Time I

Variable

step

I.

regressions

571

R * = 0.63***

0.56 0.05 0.03

107.2*** 10.06** 6.45.

0.61 0.27 0.27

578

LUCY YARDLEY

cation (particularly tranquilhsers) can retard the process of neurophysiological adaptation. A number of studies of chronic pain patients have also found that, although family support is negatively related to handicap and depression [42], a coping style which involves excessive dependence upon other people, emotional expression, fantasy, or medication is associated with increased distress [30,44,45]. However, relinquishing responsibility did not have a significant longitudinal influence on residuahsed handicap scores. One interpretation of this finding is that the coping strategies concerned are simply the natural counterpart to handicap; people are more likely to turn to passive pastimes such as watching television when they are unable to engage in active pursuits. Yet important elements of this coping factor (turning to others for advice, fantasising about sudden recovery) cannot be characterised as the inevitable consequences of handicap. An alternative explanation for the failure to demonstrate a longitudinal effect of relinquishing responsibility is that coping styles may change over time, while relinquishing responsibility may have only an immediate or short-term impact upon handicap. The remaining items on the coping questionnaire loaded on three factors, which described strategies of information-seeking, distraction and denial. Although information-seeking was moderately correlated with the monitoring scale of the Miller Behavioral Style Scale, and distraction with blunting, the vertigo-specific coping scales were most closely associated with handicap and distress. This might be because the MBSS scores are calculated from anticipated responses to imaginary brief but acute environmental stressors; the coping style preferred in these situations may therefore be only distantly related to the strategies actually employed to cope with chronic vertigo. Attempts to actively divert attention from the vertigo, using pleasant thoughts or activities as distractors, were positively correlated with handicap and distress, albeit to a lesser extent than relinquishing responsibility. Although this finding might suggest that active avoidance strategies are maladaptive, some previous studies have found that tactics such as keeping busy and ignoring symptoms can be a beneficial mode of coping with chronic illness [30, 331. Naturally, such inconsistencies may be attributable to differences in the nature of the health problems and populations studied, and the precise content of the questionnaires employed. Alternatively, Frese [43] has explained a negative longitudinal association between avoidance coping and health by arguing that people may be more aware of their use of distraction as a coping technique when it is unsuccessful. From this perspective, reports of attempted distraction could be considered as indicative of failed efforts to divert attention from the vertigo, and hence

actually represent a high level of symptom monitoring, poorly suppressed. Some evidence in support of this interpretation of these results is provided by the positive correlation between distraction and reported symptoms of somatic anxiety. However, reports of overt monitoring behavior formed part of a problem-solving/informationseeking mode of coping which was very widely employed, and which was unrelated to psychosocial well-being. The most robust, and probably the most important, set of relationships identified in this study demonstrate a reciprocal predictive association between handicap, emotional distress, and somatic symptoms of anxiety (depicted in Fig. 1). These findings validate the ‘vicious circle’ model of handicap proposed by Yardley, Todd et al. (61, which describes how the anxiety and depression which can result from actual and anticipatory disability may, in turn, increase the fears and feelings of incompetence which motivate restriction of activity. These results also confirm the causal mediating role of anxiety symptoms suggested by Yardley, Masson et al. [14]. There are several ways in which psychosocial status might be related to the presence of symptoms measured by the anxiety scale, which (despite a high level of internal consistency) comprised sensations which are variously considered as signs of somatic anxiety, arousal, hyperventilation and/or somatisation. High anxiety symptom scores may indicate the development of a secondary panic response to vertigo. In addition, over-arousal or hyperventilation might add to the symptomatology and malaise associated with vertigo, or even directly exacerbate the dizziness itself [46,47]. Finally, a high level of symptom reporting may reflect a heightened perception and negative interpretation of internal sensations, which could contribute to maladaptive reactions to vertigo. It is clear that the combination of a low internal locus of control and dependence upon others and upon medication (or other sources of gratification or comfort) is closely associated with handicap and distress in patients with vertigo. A comparable syndrome is seen in chronic pain patients, for whom cognitive-behavioral therapy has been shown to be effective [44]. Moreover, although control beliefs and coping style did not directly predict long-term changes in handicap in this study, both were correlated with somatic anxiety symptoms, which were associated longitudinally with increases in handicap and emotional distress. The links between anxiety, negative perceptions of somatic symptoms, and voluntary restriction of activity which were apparent in this sample of vertiginous patients have also been noted in panic and phobia [48,49]. Hence, many of the techniques validated in the treatment of pain, panic and phobia may well prove beneficial to people suffering from chronic vertigo.

Handicap and emotional distress in patients with vertigo

Time 1

579

Time 2

HANDICAP (VHQ)

EMOTIONAL DISTRESS

EMOTIONAL b

HANDICAP

DISTRESS

WHQ)

(HADS)

ANXIETY SYMPTOMS WSS)

Fig. 1. Association between handicap, emotional distress and anxiety symptoms at Time 1 and Time 2: correlations represented by open lines, predictive longitudinal relationships represented by solid arrowed lines. Acknowledgements-I would like to thank Carl Verschuur and Elaine Masson for their assistance with data collection and coding at Time 1, Linda Luxon and Norman Haacke for granting me access to patients and medical details, and Stanton Newman for his helpful comments on the analysis and presentation of results. The data presented in this paper was obtained while I was supported by the Medical Research Council as a member of the Human Movement and Balance Unit at the National Hospital for Neurology and Neurosurgery, Queen Square, London, U.K. REFERENCES

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Handicap and emotional distress in patients with vertigo

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APPENDIX Item content of the four coping factors, including all items with a loading greater than 0.3 on that factor (items loading more heavily on a different factor are shown in italics). Factor Problem-focused information-seeking (24.3% total variance; Eigenvalue = 6.3) Thought hard about whether there was anything you could do about it. Asked a doctor what the problem was and what was going to happen. Kept a check on the symptoms to see if they were getting better or worse. Made a mental note of all the symptoms and changes so you could report these accurately to the doctor at the next appointment. Tried to find out from health professional about all the different causes and treatments for it. Tried to work out just what the problems were and what made things or worse. Kept a look out for books, newspaper or magazine articles or TV nroarammes about it Went over in your mind everything-you knew or had heard about it. _ Tried to analyse the problem in order to understand it better. Kept a careful watch for signs of it coming on. Looked up medical information.

Loading 0.79 0.75 0.71

Tried to talk to other people who had had similar experiences.

0.70 0.71 0.68 0.67 0.65 0.64 0.58 0.52 0.43 0.42

Distraction (10.0% total variance; Eigenvalue = 3.5) Daydreamed about other situations which make you feel better. Thought about pleasant memories. Found yourself some cheerful company. __ Kept as busy as you could at home or work to keep from thinking about it. Took your mind off it by chatting to relatives, friends, neighbours or colleagues about other things. Occupied yourself with interests or activities (e.g. hobbies, shopping). Fantasised about the vertigo suddenly getting better.

0.75 0.68 0.65 0.59 0.50 0.50 0.41

Denial (7.2% total variance; Eigenvalue = 2.1) Tried to forget the whole thing. Did your best to pretend it was not happening. Refused to think about it at all, pushed it out of your mind. Carried on as much as possible as if nothing had happened.

0.82 0.78 0.59 0.56

Talked about the problem with a relative or friend.

Relinquishing responsibility (5.7% total variance; Eigenvalue = 1.7) Talked about the problem with a relative or friend Asked a friend or relative you respect for practical advice. Tried to make yourself feel better by any of these things: eating, taking pills to relax (not including anti-dizziness pills), drinking, smoking. Spent more time watching TV or reading. Fantasised about the vertigo suddenly getting better.

Slept more than usual.

0.64 0.63 0.59 0.58 0.39 0.34