- Email: [email protected]
Psychiatric dysfunction and dizziness
CORRESPONDENCE
5
Bull World Health Organ 1980; 58: 665–69. Feachem RG. Environmental aspects of cholera epidemiology: I. A review of selected reports of endemic and epidemic situations during 1961–1980. Trop Dis Bull 1981; 78: 675–98.
Psychiatric dysfunction and dizziness Sir—Rona Moss-Morris and Keith Petrie’s Feb 13 commentary1 on our study2 of physical and psychiatric comorbidity in a community sample of dizzy patients suggests several alternative explanations for this association: the physiological and psychological symptoms might arise from a common cause; dizziness might cause psychological symptoms; psychological distress may cause dizziness, or might lead patients to attend to, negatively interpret, or report minor neuro-otological symptoms. By analyses of unpublished data from this large study, we provide evidence about the relative importance of each of these mechanisms. Moss-Morris and Petrie suggest that if a correlation were found between symptom reports and laboratory findings, this would provide support for a common neurophysiological basis for dizziness and distress. In our study,2 abnormal postural instability was over five times more prevalent in patients than controls (odds ratio 5·22 [95% CI 1·65–16·58]), and within the patient group there was a significant correlation (r=0·56, p=0·001) between instability and severity of self-reported physical symptoms (assessed by the vertigo symptom scale) during the past month. However symptoms of psychological distress (measured by the hospital anxiety and depression scale) were also correlated with postural instability in patients (r=0·49, p=0·003). The direction of the association between psychiatric and balance system dysfunction remains difficult to ascertain. There has been growing interest in the possibility that the well documented comorbidity between vestibular and panic disorder is mediated by various neurophysiological mechanisms, including central connections between the vestibular and autonomic nervous systems, and the effects of anxiety on perceptual-motor
Panic only or mainly when dizzy Panic also occurs when not dizzy
functioning.2,3 However, it is likely that the nature and prominence of neurootological and psychological factors differs widely among dizzy patients.3,4 The patients tested in our clinical study were drawn from a larger representative community sample reporting disabling dizziness (262; sampling details reported previously),5 of whom 126 completed validated questionnaires assessing symptoms of dizziness, panic, and agoraphobia (this subsample did not differ significantly in age, sex, or presenting symptoms from the other dizzy patients surveyed). Over a third (46) reported no panic symptoms. In 22 patients (17%) panic symptoms clearly predominated, preceding the onset of dizziness and occurring in the absence of dizziness. The remaining 58 patients reported diverse combinations of panic and dizziness (table); some panicked only when dizzy, whereas in others dizziness seems to be one trigger (or symptom) of panic among many. There was no significant difference in the nature or severity of physical symptoms reported by patients with previous dizziness, or by those who panicked only when dizzy, and those with previous or more extensive panic symptoms. Since the links between anxiety and balance disorders are evidently widespread, complex, and varied, we concur fully with your commentators’ conclusion, 1 that treatment should focus on both the physical and psychological aspects of dizziness. Fortunately, a programme of balance retraining or vestibular rehabilitation can simultaneously promote psychological habituation and neurophysiological adaption after attacks of dizziness.5 *Lucy Yardley, Irwin Nazareth, Linda Luxon *Department of Psychology, University of Southampton, Highfield, Southampton SO17 1BJ, UK; Department of Primary Care and Population Sciences, Royal Free Hospital School of Medicine and University College London Medical School, London; and Institute of Laryngology and Otology, University College London, London (e-mail: [email protected]) 1
Moss-Morris M, Petrie KJ. Link between psychiatric dysfunction and dizziness. Lancet 1999; 353: 515–16. 2 Yardley L, Burgneay J, Nazareth I, Luxon L. Neuro-otological and psychiatric abnormalities in a community sample of
Dizziness preceded panic
Dizziness and panic onset simultaneous
Panic symptoms preceded dizziness
5 (6%) 16 (20%)
11 (14%) 17 (21%)
9 (11%) 22 (28%)
Percentages of those reporting both dizziness and panic are shown in paretheses.
Number of patients reporting different patterns of covariance between onset and occurrence of dizziness and panic symptoms
THE LANCET • Vol 353 • June 12, 1999
people with dizziness: a blind, controlled investigation. J Neurol Neurosurg Psychiatr 1998; 65: 679–84. 3 Furman JM, Jacob RG. Psychiatric dizziness. Neurology 1997; 48: 1161–66. 4 Sullivan M, Clark MR, Katon WJ, et al. Psychiatric and otologic diagnoses in patients complaining of dizziness. Arch Intern Med 1993; 153: 1479–84. 5 Yardley L, Burgneay J, Anderson G, Owen N, Nazareth I, Luxon L. Feasibility and effectiveness of providing vestibular rehabilitation for dizzy patients in the community. Clin Otolaryngol 1998; 23: 442–48.
Sir—Rona Moss-Morris and Keith Petrie1 have entitled their commentary on an original paper by Lucy Yardley and co-workers,2 “Link between psychiatric dysfunction and dizziness”. This title is misleading. Whereas the original paper deals with the link between psychiatric dysfunction (as a whole) and dizziness without distinction, the commentary disappoints us since it discusses only the link between dizziness and psychogenic or psychological dysfunction. They do not comment on the whole spectrum of psychiatric dysfunction. Although the terms psychological and psychiatric are closely related, the former is included in the latter: psychiatric dysfunction consists of endogenous dysfunction, which covers, for example, schizophrenia, manic depressive disorders and other related disorders3 and psychogenic or psychologically based dysfunction.4 At the same time, the terms endogenous and psychogenic have different aetiological bases.5 We therefore suggest that it is necessary to discriminate strictly between the terms psychiatric and psychogenic. *Kazumasa Sudo, Kunio Tashiro Department of Neurology, Hokkaido University School of Medicine, Kita-Ku, Sapporo, 060-8648 Japan 1
Moss-Morris R, Petrie KJ. Link between psychiatric dysfunction and dizziness. Lancet 1999; 353: 515–16. 2 Yardley L, Burgneay J, Nazareth I, Luxon L. Neuro-otological and psychiatric abnormalities in a community sample of people with dizziness: a blind, controlled investigation. J Neurosurg Psychiatry 1998; 65: 679–84. 3 Ban TA. Clinical pharmacology and Leonhard’s classification of endogenous psychoses. Psychopathology 1990; 23: 331–38. 4 Berner P, Gabriel E, Kieffer W, Schanda H. Paranoid pyschoses. New aspects of classification and prognosis coming from the Vienna Research Group. Psychopathology 1986; 19: 16–29. 5 Strzyzewski W, Rybakowski J, Kapelski Z. Investigations on electrolyte and water contents in plasma and red blood cells in the course of thymoleptic treatment of depressive syndromes. Neuropsychobiology 1980; 6: 121–27.
2069
5
Bull World Health Organ 1980; 58: 665–69. Feachem RG. Environmental aspects of cholera epidemiology: I. A review of selected reports of endemic and epidemic situations during 1961–1980. Trop Dis Bull 1981; 78: 675–98.
Psychiatric dysfunction and dizziness Sir—Rona Moss-Morris and Keith Petrie’s Feb 13 commentary1 on our study2 of physical and psychiatric comorbidity in a community sample of dizzy patients suggests several alternative explanations for this association: the physiological and psychological symptoms might arise from a common cause; dizziness might cause psychological symptoms; psychological distress may cause dizziness, or might lead patients to attend to, negatively interpret, or report minor neuro-otological symptoms. By analyses of unpublished data from this large study, we provide evidence about the relative importance of each of these mechanisms. Moss-Morris and Petrie suggest that if a correlation were found between symptom reports and laboratory findings, this would provide support for a common neurophysiological basis for dizziness and distress. In our study,2 abnormal postural instability was over five times more prevalent in patients than controls (odds ratio 5·22 [95% CI 1·65–16·58]), and within the patient group there was a significant correlation (r=0·56, p=0·001) between instability and severity of self-reported physical symptoms (assessed by the vertigo symptom scale) during the past month. However symptoms of psychological distress (measured by the hospital anxiety and depression scale) were also correlated with postural instability in patients (r=0·49, p=0·003). The direction of the association between psychiatric and balance system dysfunction remains difficult to ascertain. There has been growing interest in the possibility that the well documented comorbidity between vestibular and panic disorder is mediated by various neurophysiological mechanisms, including central connections between the vestibular and autonomic nervous systems, and the effects of anxiety on perceptual-motor
Panic only or mainly when dizzy Panic also occurs when not dizzy
functioning.2,3 However, it is likely that the nature and prominence of neurootological and psychological factors differs widely among dizzy patients.3,4 The patients tested in our clinical study were drawn from a larger representative community sample reporting disabling dizziness (262; sampling details reported previously),5 of whom 126 completed validated questionnaires assessing symptoms of dizziness, panic, and agoraphobia (this subsample did not differ significantly in age, sex, or presenting symptoms from the other dizzy patients surveyed). Over a third (46) reported no panic symptoms. In 22 patients (17%) panic symptoms clearly predominated, preceding the onset of dizziness and occurring in the absence of dizziness. The remaining 58 patients reported diverse combinations of panic and dizziness (table); some panicked only when dizzy, whereas in others dizziness seems to be one trigger (or symptom) of panic among many. There was no significant difference in the nature or severity of physical symptoms reported by patients with previous dizziness, or by those who panicked only when dizzy, and those with previous or more extensive panic symptoms. Since the links between anxiety and balance disorders are evidently widespread, complex, and varied, we concur fully with your commentators’ conclusion, 1 that treatment should focus on both the physical and psychological aspects of dizziness. Fortunately, a programme of balance retraining or vestibular rehabilitation can simultaneously promote psychological habituation and neurophysiological adaption after attacks of dizziness.5 *Lucy Yardley, Irwin Nazareth, Linda Luxon *Department of Psychology, University of Southampton, Highfield, Southampton SO17 1BJ, UK; Department of Primary Care and Population Sciences, Royal Free Hospital School of Medicine and University College London Medical School, London; and Institute of Laryngology and Otology, University College London, London (e-mail: [email protected]) 1
Moss-Morris M, Petrie KJ. Link between psychiatric dysfunction and dizziness. Lancet 1999; 353: 515–16. 2 Yardley L, Burgneay J, Nazareth I, Luxon L. Neuro-otological and psychiatric abnormalities in a community sample of
Dizziness preceded panic
Dizziness and panic onset simultaneous
Panic symptoms preceded dizziness
5 (6%) 16 (20%)
11 (14%) 17 (21%)
9 (11%) 22 (28%)
Percentages of those reporting both dizziness and panic are shown in paretheses.
Number of patients reporting different patterns of covariance between onset and occurrence of dizziness and panic symptoms
THE LANCET • Vol 353 • June 12, 1999
people with dizziness: a blind, controlled investigation. J Neurol Neurosurg Psychiatr 1998; 65: 679–84. 3 Furman JM, Jacob RG. Psychiatric dizziness. Neurology 1997; 48: 1161–66. 4 Sullivan M, Clark MR, Katon WJ, et al. Psychiatric and otologic diagnoses in patients complaining of dizziness. Arch Intern Med 1993; 153: 1479–84. 5 Yardley L, Burgneay J, Anderson G, Owen N, Nazareth I, Luxon L. Feasibility and effectiveness of providing vestibular rehabilitation for dizzy patients in the community. Clin Otolaryngol 1998; 23: 442–48.
Sir—Rona Moss-Morris and Keith Petrie1 have entitled their commentary on an original paper by Lucy Yardley and co-workers,2 “Link between psychiatric dysfunction and dizziness”. This title is misleading. Whereas the original paper deals with the link between psychiatric dysfunction (as a whole) and dizziness without distinction, the commentary disappoints us since it discusses only the link between dizziness and psychogenic or psychological dysfunction. They do not comment on the whole spectrum of psychiatric dysfunction. Although the terms psychological and psychiatric are closely related, the former is included in the latter: psychiatric dysfunction consists of endogenous dysfunction, which covers, for example, schizophrenia, manic depressive disorders and other related disorders3 and psychogenic or psychologically based dysfunction.4 At the same time, the terms endogenous and psychogenic have different aetiological bases.5 We therefore suggest that it is necessary to discriminate strictly between the terms psychiatric and psychogenic. *Kazumasa Sudo, Kunio Tashiro Department of Neurology, Hokkaido University School of Medicine, Kita-Ku, Sapporo, 060-8648 Japan 1
Moss-Morris R, Petrie KJ. Link between psychiatric dysfunction and dizziness. Lancet 1999; 353: 515–16. 2 Yardley L, Burgneay J, Nazareth I, Luxon L. Neuro-otological and psychiatric abnormalities in a community sample of people with dizziness: a blind, controlled investigation. J Neurosurg Psychiatry 1998; 65: 679–84. 3 Ban TA. Clinical pharmacology and Leonhard’s classification of endogenous psychoses. Psychopathology 1990; 23: 331–38. 4 Berner P, Gabriel E, Kieffer W, Schanda H. Paranoid pyschoses. New aspects of classification and prognosis coming from the Vienna Research Group. Psychopathology 1986; 19: 16–29. 5 Strzyzewski W, Rybakowski J, Kapelski Z. Investigations on electrolyte and water contents in plasma and red blood cells in the course of thymoleptic treatment of depressive syndromes. Neuropsychobiology 1980; 6: 121–27.
2069