Article

Functional dizziness: From phobic postural vertigo and chronic subjective dizziness to persistent postural-perceptual dizziness

Authors:
  • Ludwig-Maximilians-University München Germany
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Abstract

Purpose of review: Functional dizziness is the new term for somatoform or psychogenic dizziness. The aim of this study is to review arguments for the new nomenclature, clinical features, possible pathomechanisms, and comorbidities of functional dizziness. Recent findings: The prevalence of functional dizziness as a primary cause of vestibular symptoms amounts to 10% in neuro-otology centers. Rates of psychiatric comorbidity in patients with structural vestibular syndromes are much higher with nearly 50% and with highest rates in patients with vestibular migraine, vestibular paroxysmia, and Ménière's disease. Pathophysiologic processes seem to include precipitating events that trigger anxiety-related changes in postural strategies with an increased attention to head and body motion and a cocontraction of leg muscles. Personality traits with high levels of neuroticism and low levels of extraversion appear as risk factors for anxiety and depressive disorders and increased morbidity in functional disorders. Summary: Correct and early diagnosis of functional dizziness, as primary cause or secondary disorder after a structural vestibular syndrome, is very important to prevent further chronification and enable adequate treatment. Treatment plans that include patient education, vestibular rehabilitation, cognitive and behavioral therapies, and medications substantially reduce morbidity and offer the potential for sustained remission when applied systematically.

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... PPPD is estimated at 8-10% of all cases in neurotology centers, and vestibulopathy bilateral is 4-7% in various reports. 16,17 Other common diseases in CVS are neoplasms in the posterior fossa tumors, chronic bilateral vestibulopathy, and chronic psychological or behavioral manifestations of vestibular disorders. 7 The new international classification differs from psychiatric dizziness and functional dizziness. ...
... Symptoms wax and wane and significantly cause distress or functional impairment. 16 Vestibulopathy bilateral is a condition with bilateral impairment of the peripheral vestibular. This disease is characterized by a chronic vestibular syndrome that worsens in darkness or uneven ground, with no symptoms while sitting. ...
... The use of serotonergic antidepressants and vestibular habituation exercise has been investigated and shown to have a beneficial effect. 16 ...
Article
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Vestibular symptoms are symptoms that interfere with daily activities. Diagnosing these symptoms often relies on radiologic examinations that lead to a false negative. Proper clinical approach and study showed higher accuracy than radiologic examination on vestibular disease. These clinical approaches are based on time, triggers, and targeted analysis. The new vestibular symptoms will be classified into acute vestibular syndrome, episodic vestibular syndrome, and chronic vestibular syndrome. An acute vestibular syndrome is a vestibular symptom that lasts for days up to weeks. The episodic vestibular syndrome is vestibular symptoms that periodically appear. The chronic vestibular syndrome is a vestibular symptom that appears from months to years. Diagnosing vestibular symptoms must be precisely made. The proper termination is the best way to facilitate doctors in communicating with each other. Using this classification is a precise and easy way to detect vestibular etiology. This review is made for clinicians to determine and differentiate the etiology of the vestibular syndrome and gives information in uniforming nomenclature of vestibular symptoms.
... Categorized as a chronic functional vestibular disorder, PPPD is now the most common cause of chronic dizziness in the middle-aged with incidence peak between 30 and 50 years. [1,3,6] Numerous studies have since shown that PPPD interferes in daily life as well as the way individuals experience their personal, social, and work life in the presence of chronic conditions. [7] The pathophysiologic process has been hypothesized that it may be due to a persistent shift in multi-sensory processing of space-motion information. ...
... Those with anxiety-related personality traits of neuroticism and introversion poses as a risk factor and becomes a sustaining mechanism. [1,3,6,8] PPPD is a diagnosis made by clinical history that fulfills the diagnostic criteria and is not a diagnosis of exclusion. Physical examination, clinical laboratory testing, vestibular evaluation, and diagnostic neuroimaging may be normal but should be tailored to the patient's history and is performed to rule out more sinister conditions. ...
... Symptoms such as muscular pain, neck stiffness, eye strain, and fatigue especially at the end of the day which are due to visual dependence and postural control mechanism can sometimes create confusion in making the etiological diagnosis. [1,3,6,8] History of falls is also important as it is seen in patients with disequilibrium rather than in those with chronic dizziness. [22] While some diagnosis is heavily reliant on history such as in Meniere's Disease, vestibular migraine, and PPPD, [2,23,24] clinical examination can help confirm the diagnosis such as in BPPV. ...
... Although various organic disorders may be underlying, a substantial number of patients presented without any detectable structural dysfunction and therefore suffer from functional vertigo and dizziness. The term "functional vertigo and dizziness" has been defined and supported by Dieterich and Staab (2017) [5] as the new nomenclature to refer to one and the same construct that had previously been given very different terms such as somatoform dizziness, phobic postural vertigo, or persistent postural-perceptual dizziness. ...
... Although various organic disorders may be underlying, a substantial number of patients presented without any detectable structural dysfunction and therefore suffer from functional vertigo and dizziness. The term "functional vertigo and dizziness" has been defined and supported by Dieterich and Staab (2017) [5] as the new nomenclature to refer to one and the same construct that had previously been given very different terms such as somatoform dizziness, phobic postural vertigo, or persistent postural-perceptual dizziness. ...
... Inclusion criteria were age of 18 years or older (with an average age at entry of M = 53.7 for the experimental and M = 53.5 for the control group) and a diagnosis of functional vertigo or dizziness. This diagnosis is made based on the criteria presented by Dieterich and Staab (2017) [5]. Those criteria include (a) one or more symptom of dizziness, unsteadiness, or nonspinning vertigo that are present on most days for 3 months or more and (b) symptoms being present without specific provocation but exacerbated by upright posture, active or passive motion without regard to direction or position, and/or exposure to moving visual stimuli or complex visual patterns. ...
Article
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We tested the efficacy of an integrative psychotherapeutic group treatment (IPGT) in reducing vertigo/dizziness-related impairment along with depression, anxiety, and somatization by conducting a randomized controlled superiority trial comparing IPGT to self-help groups moderated by a clinical psychologist (SHG). Adult patients with functional vertigo and dizziness symptoms were randomly allocated to either the IPGT or SHG as active control group. Outcomes were assessed at baseline (t0), after treatment lasting 16 weeks (t1), and 12 months after treatment (t2). A total of 81 patients were assigned to IPGT and 78 patients were assigned to SHG. Vertigo related impairment was reduced in both conditions (IPGT: t0-t1: d = 1.10, t0-t2: d = 1.06; SHG: t0-t1: d = 0.86, t0-t2: d = 1.29), showing the efficiency of both IPGT and SHG. Clinically relevant improvements were also obtained for depression in both groups. Linear mixed model analyses revealed no differences between groups for all outcomes (effect of group for the primary outcome: b = −1.15, SE = 2.13, t = −0.54, p = 0.59). Attrition rates were higher in SHG (52.6%) than in IPGT (28.4%). Both conditions improved primary and secondary outcomes while IPGT was better accepted by patients than SHG. Trial registration: ClinicalTrials.gov, Identifier: NCT02320851.
... Пациенты могут иметь анамнез острых или хронических вестибулярных нарушений, таких как ДППГ или болезнь Меньера, а затем после головокружения возникают тревожные расстройства. С другой стороны, пациенты могут сначала обратиться с первичными тревожными расстройствами, такими как паническое расстройство или генерализованное тревожное расстройство, с последующим возникновением головокружения [43][44][45][46][47][48]. Более того, тревожность -часто наблюдаемый симптом при множестве вестибулярных расстройств, таких как вестибулярная мигрень, ДППГ, болезнь Меньера и ПППГ. ...
... Это предполагает, что любая вестибулярная дисфункция может вызвать тревожное расстройство [49]. Вероятно, существует взаимная и само-воспроизводящаяся связь между ними, когда головокружение и постуральная нестабильность приводят к тревоге из-за страха падения и тошноты, а состояние повышенной тревожности вызывает больше симптомов головокружения [8,9,39,40,[48][49][50][51]. В нашем исследовании был выявлен достоверно больший уровень тревоги в группе пациентов с ПППГ и вестибулярной мигренью, чем в группах пациентов с ПППГ и мигренью без ауры и с аурой. ...
Article
Introduction . Dizziness and headache are among the most frequent complaints in neurological practice, which significantly reduce the quality of life of patients, so the development of effective methods of managing patients with persistent postural perceptual vertigo (PPPD) and migraine is an urgent task. Objective . To study and optimize typical management practices of patients with PPPD and migraine. Materials and methods . Twenty-two patients aged 39.3 ± 10.2 years with PPPD and migraine according to the diagnostic criteria of the Classification of Vestibular Disorders of the Barany Society were examined. During the study we used Hospital Anxiety and Depression scale, Beck Depression Inventory, State-Trait Anxiety Inventory, clinical otoneurological examination, otoneurological questionnaire, Dizziness Handicap Inventory, videonystagmography. After the diagnosis was made, the patients were prescribed a complex treatment. To relieve an acute attack of vertigo, dimenhydrinate was prescribed, as well as the combined drug cinnarizine 20 mg + dimenhydrinate 40 mg Arlevert, which in a number of studies showed high efficacy and good tolerability. One month later, the patients were examined in the dynamics. Results . Patients with PPPD had migraine without aura (54%), migraine with aura (14%), and vestibular migraine (32%). The level of anxiety was significantly higher in the group of patients with PPPD and vestibular migraine. There was moderate severity of dizziness in all groups of patients, after one month against the background of ongoing therapy severity of dizziness significantly decreased in all groups. Diagnoses “PPPD” and “vestibular migraine” were not set beforehand in any of the examined patients. Conclusions . The study showed a low level of diagnosis of PPPD and vestibular migraine. Management of patients with PPPD and migraine requires a complex approach.
... Later, space-motion discomfort (SMD) symptoms were identified as overlapping factors with PPV and CSD [3]. In 2010, scientists globally started conducting investigations in collecting the core features of the above disorders along with visual vertigo [4,5]. Moreover, the Barany Society reached a consensus that PPPD includes core features described in the above-mentioned syndromes, including postural sensitivity. ...
... Moreover, the Barany Society reached a consensus that PPPD includes core features described in the above-mentioned syndromes, including postural sensitivity. In 2017, the World Health Organization included PPPD in the list of diagnoses in the International Classification of Diseases (ICD-11) [5,6]. PPPD is a described as dizziness, nonspinning vertigo, and/or unsteadiness that persist for 3 months or more due to a mismatch in sensory stimuli triggered by active or passive motion, complex visual and active or passive motions [7][8][9]. ...
Article
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Persistent and inconsistent unsteadiness with nonvertiginous dizziness (persistent postural-perceptual dizziness (PPPD)) could negatively impact quality of life. This study highlights that the use of virtual reality (VR) systems offers bimodal benefits to PPPD, such as understanding symptoms and providing a basis for treatment. The aim is to develop an understanding of PPPD and its interventions, including current trends of VR involvement to extrapolate and re-evaluate VR design strategies. Therefore, recent virtual-reality-based research work that progressed in understanding PPPD is identified, collected, and analysed. This study proposes a novel approach to the understanding of PPPD, specifically for VR technologists, and examines the principles of effectively aligning VR development for PPPD interventions.
... This is not surprising because FD is characterized by the combination of typical symptoms and the absence of others (38). Thus, the sequence of longer attack duration, no hearing problems, younger age, no vegetative symptoms, and a presentation as dizziness rather than rotational vertigo indicated FD, which is in line with the approach presented by Dieterich et al. (54,55). On the other hand, FD was also frequently present in other nodes (between 13 and 29%). ...
... This finding may be explained by the relatively high prevalence of FD in this sample. Furthermore, patients with FD report a multitude of uncharacteristic symptoms fluctuating in time and intensity, triggered by various situations (55). Furthermore, FD often manifests as a comorbidity to or consequence of different organic vestibular disorders, most commonly VM, BPPV, and MD (56). ...
Article
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Precise history taking is the key to develop a first assumption on the diagnosis of vestibular disorders. Particularly in the primary care setting, algorithms are needed, which are based on a small number of questions and variables only to guide appropriate diagnostic decisions. The aim of this study is to identify a set of such key variables that can be used for preliminary classification of the most common vestibular disorders. A four-step approach was implemented to achieve this aim: (1) we conducted an online expert survey to collect variables that are meaningful for medical history taking, (2) we used qualitative content analysis to structure these variables, (3) we identified matching variables of the patient registry of the German Center for Vertigo and Balance Disorders, and (4) we used classification trees to build a classification model based on these identified variables and to analyze if and how these variables contribute to the classification of common vestibular disorders. We included a total of 1,066 patients with seven common vestibular disorders (mean age of 51.1 years, SD = 15.3, 56% female). Functional dizziness was the most frequent diagnosis (32.5%), followed by vestibular migraine (20.2%) and Menière's disease (13.3%). Using classification trees, we identified eight key variables which can differentiate the seven vestibular disorders with an accuracy of almost 50%. The key questions comprised attack duration, rotational vertigo, hearing problems, turning in bed as a trigger, doing sport or heavy household chores as a trigger, age, having problems with walking in the dark, and vomiting. The presented algorithm showed a high-face validity and can be helpful for taking initial medical history in patients with vertigo and dizziness. Further research is required to evaluate if the identified algorithm can be applied in the primary care setting and to evaluate its external validity.
... Overall, the application of CSMI methods identified physiological factors of the balance control system that can at least partially account for the Aphysiological pattern observed on the SOT in chronic mTBI subjects, suggesting that the aphysiological term may not be appropriate in some situations. Future applications of CSMI methods may similarly provide insight into unusual patterns of balance control seen in patients with disorders categorized as "functional dizziness" such as PPPD, CSD (63). ...
Article
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Imbalance is common following mild Traumatic Brain Injury (mTBI) and can persist months after the initial injury. To determine if mTBI subjects with chronic imbalance differed from healthy age- and sex-matched controls (HCs) we used both the Central SensoriMotor Integration (CSMI) test, which evaluates sensory integration, time delay, and motor activation properties and the standard Sensory Organization Test (SOT). Four CSMI conditions evoked center-of-mass sway in response to: surface tilts with eyes closed (SS/EC), surface tilts with eyes open viewing a fixed visual surround (SS/EO), visual surround tilts with eyes open standing on a fixed surface (VS/EO), and combined surface and visual tilts with eyes open (SS+VS/EO). The mTBI participants relied significantly more on visual cues during the VS/EO condition compared to HCs but had similar reliance on combinations of vestibular, visual, and proprioceptive cues for balance during SS/EC, SS/EO, and SS+VS/EO conditions. The mTBI participants had significantly longer time delays across all conditions and significantly decreased motor activation relative to HCs across conditions that included surface-tilt stimuli with a sizeable subgroup having a prominent increase in time delay coupled with reduced motor activation while demonstrating no vestibular sensory weighting deficits. Decreased motor activation compensates for increased time delay to maintain stability of the balance system but has the adverse consequence that sensitivity to both internal (e.g., sensory noise) and external disturbances is increased. Consistent with this increased sensitivity, SOT results for mTBI subjects showed increased sway across all SOT conditions relative to HCs with about 45% of mTBI subjects classified as having an “Aphysiologic” pattern based on published criteria. Thus, CSMI results provided a plausible physiological explanation for the aphysiologic SOT pattern. Overall results suggest that rehabilitation that focuses solely on sensory systems may be incomplete and may benefit from therapy aimed at enhancing rapid and vigorous responses to balance perturbations.
... Typical central vestibular disorders are, e.g., vestibular migraine (VM) or brainstem-cerebellar syndromes induced by infarction (e.g., Wallenberg´s syndrome) or degenerative disorders (e.g., downbeatnystagmus syndrome). Furthermore, somatoform vestibular disorders, which are currently covered by the umbrella terms "persistent posturalperceptual dizziness" (PPPD) and "functional dizziness", are frequent 5 Biomedicines acting as a medical regulatory body and research institution. In line with international statistics, the PEI reports an overall low rate of serious adverse reactions and life-threatening unsolicited events 6 . ...
Article
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Background: Dizziness and vertigo are common post-COVID-19-vaccination symptoms. We aimed to prospectively evaluate objective central or peripheral-vestibular function in patients with dizziness, vertigo, and postural symptoms that started or worsened after COVID-19-vaccination. Methods: Out of 4,137 patients who presented between 01/2021 and 04/2022 at the German Center for Vertigo and Balance Disorders, LMU Munich, we identified 72 patients (mean age 47yrs) with enduring vestibular symptoms following COVID-19-vaccination. All underwent medical history-taking, neurological and neuro-otological workup with bithermal calorics, video head-impulse-test, orthoptics, and audiometry. Diagnoses were based on international criteria. The distribution of diagnoses was compared to a cohort of 39,964 patients seen before the COVID-19-pandemic. Results: Symptom onset was within the first four weeks post-vaccination. The most prevalent diagnoses were somatoform vestibular disorders (34.7%), vestibular migraine (19.4%), or overlap syndromes of both (18.1%). These disorders were significantly overrepresented compared to the pre-pandemic control-cohort. 36% of patients with somatoform complaints reported a positive history of depressive or anxiety disorders. Nine patients presented with benign paroxysmal positional vertigo, three with acute unilateral vestibulopathy, and seven with different entities (vestibular paroxysmia, Menière's disease, polyneuropathy, ocular muscular paresis). Causally related central-vestibular deficits were lacking. Novel peripheral-vestibular deficits were found in four patients. Discussion: Newly induced persistent vestibular deficits following COVID-19-vaccination were rare. The predominant causes of prolonged vestibular complaints were somatoform vestibular disorders and vestibular migraine, possibly triggered or aggravated by stress-related circumstances due to the COVID-19-pandemic or vaccination. An increase of other central or peripheral vestibular syndromes after COVID-19-vaccination was not observed.
... This latter explanation has gained recognition and already resulted in the development of cognitive behavioral therapies (Langguth et al. 2013). Our results may point in the same direction when considering diseases like mal de débarquement syndrome (Mucci et al. 2018) or persistent postural-perceptual dizziness (Dieterich and Staab 2017), where patients report persistent motion sensations or dizziness in the absence of related sensory input. ...
Article
Full-text available
Various studies have demonstrated a role for cognition on self-motion perception. Those studies all concerned modulations of the perception of a physical or visual motion stimulus. In our study, however, we investigated whether cognitive cues could elicit a percept of oscillatory self-motion in the absence of sensory motion. If so, we could use this percept to investigate if the resulting mismatch between estimated self-motion and a lack of corresponding sensory signals is motion sickening. To that end, we seated blindfolded participants on a swing that remained motionless during two conditions, apart from a deliberate perturbation at the start of each condition. The conditions only differed regarding instructions, a secondary task and a demonstration, which suggested either a quick halt (“Distraction”) or continuing oscillations of the swing (“Focus”). Participants reported that the swing oscillated with larger peak-to-peak displacements and for a longer period of time in the Focus condition. That increase was not reflected in the reported motion sickness scores, which did not differ between the two conditions. As the reported motion was rather small, the lack of an effect on the motion sickness response can be explained by assuming a subthreshold neural conflict. Our results support the existence of internal models relevant to sensorimotor processing and the potential of cognitive (behavioral) therapies to alleviate undesirable perceptual issues to some extent. We conclude that oscillatory self-motion can be perceived in the absence of related sensory stimulation, which advocates for the acknowledgement of cognitive cues in studies on self-motion perception.
... The current study utilizing CSD not only added more insightful knowledge about the relationship between vestibular function and brain Ab plaque deposition as opposed to the prior study [6], but also highlighted the potential connection between CSD, neuropsychiatric symptoms (depression and anxiety), and Ab deposition. On the one hand, several studies point out that CSD is a clinical syndrome accompanied by anxiety or depression or both, which patients often describe as vague, non-specific light-headedness and subjective sensations of imbalance [1,2,17,18]. On the other hand, there is evidence that the Ab plaque deposition in the ageing brain can contribute to an increased frequency of neuropsychiatric symptoms in cognitively normal or cognitively impaired people [19][20][21][22][23]. ...
Article
Objectives. Alzheimer's disease (AD) pathogenesis is widely believed to be driven by the Amyloid-β (Aβ) deposition. A relationship between Aβ deposition and objective measures of vestibular function in cognitively intact older adults with peripheral vestibular disorders had gained previous attention; however, no significant relationship between the two was observed. The aim of this study was to examine the association between chronic subjective dizziness (CSD) and Aβ deposition among older adults who are at risk of AD. Methods. The study included 5707 participants without dementia, enrolled in the Mayo Clinic Study of Ageing with reported dizziness, neuropsychological and cognitive evaluations, and brain imaging at baseline and for every 15-months. Results. A total of 924 ageing adults reported dizziness at baseline. The estimated risk of developing CSD at 10 years was 49%. The CSD group is twice likely to have elevated Aβ deposition (HR = 2.23; p ≤ .001) compared to the control group. After controlling for demographic and other risk factors, CSD was significantly associated with Aβ deposition [HR = 1.8, p ≤ .001]. The status of neuropsychiatric symptoms plays a significant role in this association [HR = 1.0, p ≤ .001]. Conclusion. CSD was associated with Aβ deposition in older adults who are at risk of AD including those without dementia and cognitively unimpaired individuals, and modestly more significant cognitive decline during follow-up. The status of neuropsychiatric symptoms plays a significant role in this association. Screening for and appropriately managing CSD as a risk factor for AD may be warranted.
... Anxiety and anxiety-related personality traits, in particular neuroticism, has been defined as a possible predisposing risk factor in the development of constant dizziness following an episode of acute vestibular disease as it happens in PPPD [19,42,[44][45][46][47][48][49][50][51]. ...
Article
Objective To compare vestibular migraine (VM) and persistent postural-perceptual dizziness (PPPD) regarding dizziness associated handicap, emotional and somatic disorders, health-related quality of life (QoL) and personality traits. Methods Thirty patients for each group [VM, PPPD and healthy volunteers (HC)] were studied. Dizziness Handicap Inventory (DHI), Beck depression and anxiety scales, Somatic Symptom Scale-8 (SSS-8), Short Form (36) Health Survey (SF 36) and the Big Five Inventory (BFI) were used. Results DHI sub-scores were significantly high in both patient groups in comparison with the HC (p<0.001 for all). Emotional (p= 0.001) and functional (p=0.022) sub-scores of the PPPD patients were worse. Anxiety and somatic symptom scores of VM (p=0.026 and p<0.001 respectively) and PPPD (p<0.001 for both) and depression scores of the PPPD (p=0.003) were higher than the HC. Both anxiety (p=0.009) and somatization (p=0.005) scores of the PPPD patients were higher than the VM. SF-36subscales were affected in both groups (p<0.05). Vitality (p= 0.002), mental health (p= 0.045) and social role functioning (p= 0.006) of the PPPD group were worse than the VM. Higher scores for neuroticism (p<0.001) was present for both groups. Scores for extraversion was low in PPPD patients (p=0.010) in comparison with the HC. Conclusion Dizziness associated handicap, anxiety and somatic symptom burden is high in both groups, even higher in PPPD with additional depression. Severe impairment in QoL is present with more severe impairment in emotional aspects in patients with PPPD. Neuroticism is a common personality trait for both groups with additional introversion in PPPD.
... PPPD treatment mainly includes VR treatment in combination with CBT, supplemented with medications ( Figure 4) [103][104][105]. A retrospective study conducted by Thompson et al. in 2015 showed that VR based on acclimatization training was effective against PPPD, showing that the head/body movement-related symptoms improved more than environmentally/visually-induced dizziness symptoms did [106]. ...
Article
Full-text available
Introduction: Vestibular rehabilitation (VR) is now a subject of active studies and has been shown to be effective for multiple vestibular disorders, peripheral or central. VR is a physical therapy that helps train the central nervous system to compensate for vestibular dysfunction. There is moderate to strong evidence that VR is safe and effective for the management of peripheral vestibular dysfunction. Nonetheless, the studies on how VR works on central vestibular dysfunction remains scanty. Areas covered: This article addressed the rehabilitation strategies and possible mechanisms, including how central vestibular function might improve upon rehabilitation. In addition, it provides some examples concerning the effect of VR on central vestibular dysfunction. Expert opinion: VR works on the vestibular system through repetition of specific physical exercises that activate central neuroplastic mechanisms to achieve adaptive compensation of the impaired functions. VR has become a mainstay in the management of patients with dizziness and balance dysfunction. Individualized VR programs are a safe and effective treatment option for a large percentage of patients with central vestibular disease reporting imbalance and dizziness. Exploration of various treatment strategies and possible mechanisms will help develop the best and personalized VR treatment for patients with central vestibular dysfunction.
... Several factors, such as active/passive motion, upright posture, and exposure to a complex environment, can aggravate the symptoms of PPPD . A previous study demonstrated that PPPD was one of the most common causes of chronic vestibular symptoms (Dieterich and Staab, 2017). However, the potential pathogenesis of PPPD remains unclear and has received much attention from clinical researchers. ...
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Objective The aim of our study was to investigate abnormal changes in brain activity in patients with persistent postural-perceptual dizziness (PPPD) using magnetoencephalography (MEG). Methods Magnetoencephalography recordings from 18 PPPD patients and 18 healthy controls were analyzed to determine the source of brain activity in seven frequency ranges using accumulated source imaging (ASI). Results Our study showed that significant changes in the patterns of localization in the temporal-parietal junction (TPJ) were observed at 1–4, 4–8, and 12–30 Hz in PPPD patients compared with healthy controls, and changes in the frontal cortex were found at 1–4, 80–250, and 250–500 Hz in PPPD patients compared with controls. The neuromagnetic activity in TPJ was observed increased significantly in 1–4 and 4–8 Hz, while the neuromagnetic activity in frontal cortex was found increased significantly in 1–4 Hz. In addition, the localized source strength in TPJ in 1–4 Hz was positively correlated with DHI score ( r = 0.7085, p < 0.05), while the localized source strength in frontal cortex in 1–4 Hz was positively correlated with HAMA score ( r = 0.5542, p < 0.05). Conclusion Our results demonstrated that alterations in the TPJ and frontal cortex may play a critical role in the pathophysiological mechanism of PPPD. The neuromagnetic activity in TPJ may be related to dizziness symptom of PPPD patients, while the neuromagnetic activity in frontal lobe may be related to emotional symptoms of PPPD patients. In addition, frequency-dependent changes in neuromagnetic activity, especially neuromagnetic activity in low frequency bands, were involved in the pathophysiology of PPPD.
... In the presence of hypertension, depression is associated with lower volumes of the anterior and middle cingulate cortex which could also be PPPD-related areas [37]. In a diagnostic validation study on CSD (a precursor of PPPD), 45% of patients with CSD had clinically significant depressive symptoms [38,39]. Therefore, hypertension might be a confounding signal of PPPD. ...
Article
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Background Persistent postural-perceptual dizziness (PPPD) unifies the main characteristics of chronic subjective dizziness, visual vertigo and related diseases, which is a common chronic disease in neurology. At present, the pathology of PPPD is not fully understood.Objective In this single-center retrospective case series review, we aim to investigate the potential risk factors of PPPD.Methods Eighty inpatients diagnosed with PPPD were recruited with 81 apparently healthy controls. Patient-specific clinico-radiological data were collected from both groups. Conditions of hypertension, diabetes, smoking, and drinking were derived from medical history. Blood test results were recorded including total cholesterol, triglyceride, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, fibrinogen, vitamin B12, folic acid, total cholesterol, triglyceride, and folate level. The subjects were examined by carotid artery CTA and cranial MRI, and the imaging findings of carotid atherosclerosis (CAS), white matter hyperintensities (WMHs) and lacunar infarction (LI) were recorded. Binary logistic regression analysis was used to investigate the difference between the case and control groups. Significance was defined as p value less than 0.05.ResultsThe prevalence rate of hypertension in the case group was significantly higher than that in the control group, and the detection rates of CAS, WMHs, and LI in the case group were significantly higher than those in the control group (p < 0.05 for all).Conclusion Hypertension, CAS, WMHs, and LI are associated with PPPD, which may be potential risk factors for its development.
... The patient's orientation adapts to visual cues and somatosensory inputs known as ''visual-somatosensory dependence'' rather than vestibular stimulation [1]. The underlying anxiety or depressive tendency or apprehension of falling which perpetuates these physiological effects are underreported [2,3]. ...
Article
Notwithstanding current understanding of vertigo, there are various clinical scenarios which are intriguing for clinicians, where patients have been too symptomatic but the presentation does not fit into any diagnosis. We stumbled upon a new entity during literature search known as Persistent Postural Perceptual Dizziness (PPPD). It fills the lacuna where we are often left wanting for diagnosis in the existing pool of knowledge. This case series has been prepared keeping in view the lack of data regarding PPPD in Indian population. For better understanding we present the illustration of our patients in this case series. We presented the details of three patients who were diagnosed as PPPD and managed effectively and followed up for one year. The nomenclature portrays the core concept of dizziness. The diagnostic criteria clearly define PPPD. It should not be used as escape or exclusion diagnosis. Our case series highlights various presentation of, not so uncommon, PPPD in Indian population. The case series has been brought out to address the deficiency of knowledge in dealing with intriguing vertigo. Careful thorough history is important to reach a diagnosis and avoids unwarranted vestibular sedatives. It highlights that proper counselling and vestibular rehabilitation can help the patients overcome their chronic disability.
... One the one hand, there is evidence that patients with vestibular migraine have a different vestibular threshold and sensitivity to motion than healthy controls (210,211). On the other hand, there is evidence that patients with persistent postural-perceptual dizziness (PPPD), a functional vestibular disorder (212) showed altered activity and connectivity in the vestibular cortical network, including areas processing visuo-vestibular integration and emotions (213)(214)(215). In an fMRI study, SVS evoked reduced activation and connectivity of key vestibular areas such as the posterior and anterior insula, hippocampus and anterior cingulate cortex in chronic subjective dizziness compared to healthy controls (213). ...
Article
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The human vestibular cortex has mostly been approached using functional magnetic resonance imaging and positron emission tomography combined with artificial stimulation of the vestibular receptors or nerve. Few studies have used electroencephalography and benefited from its high temporal resolution to describe the spatiotemporal dynamics of vestibular information processing from the first milliseconds following vestibular stimulation. Evoked potentials (EPs) are largely used to describe neural processing of other sensory signals, but they remain poorly developed and standardized in vestibular neuroscience and neuro-otology. Yet, vestibular EPs of brainstem, cerebellar, and cortical origin have been reported as early as the 1960s. This review article summarizes and compares results from studies that have used a large range of vestibular stimulation, including natural vestibular stimulation on rotating chairs and motion platforms, as well as artificial vestibular stimulation (e.g., sounds, impulsive acceleration stimulation, galvanic stimulation). These studies identified vestibular EPs with short latency (<20 ms), middle latency (from 20 to 50 ms), and late latency (>50 ms). Analysis of the generators (source analysis) of these responses offers new insights into the neuroimaging of the vestibular system. Generators were consistently found in the parieto-insular and temporo-parietal junction-the core of the vestibular cortex-as well as in the prefrontal and frontal areas, superior parietal, and temporal areas. We discuss the relevance of vestibular EPs for basic research and clinical neuroscience and highlight their limitations.
... The clinical hallmark of PPPD is the presence of chronic dizziness, unsteadiness, and swaying or rocking (non-spinning) vertigo that wax and wane throughout the day and last a minimum of 3 months. These core vestibular symptoms are exacerbated by upright posture, active or passive self-motion, and exposure to environments with complex or moving visual stimuli [8,9]. PPPD may be triggered by various conditions that share an ability to produce acute or recurrent bouts of vertigo, unsteadiness or dizziness or disrupt balance function, including peripheral and central vestibular disorders, migraine, anxiety disorders, autonomic disorders, mild traumatic brain injury, metabolic disorders, cardiac dysrhythmias, and adverse reactions to medications [1,10,11]. ...
Article
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Persistent postural-perceptual dizziness (PPPD), defined in 2017, is a vestibular disorder characterized by chronic dizziness that is exacerbated by upright posture and exposure to complex visual stimuli. This review focused on recent neuroimaging studies that explored the pathophysiological mechanisms underlying PPPD and three conditions that predated it. The emerging picture is that local activity and functional connectivity in multimodal vestibular cortical areas are decreased in PPPD, which is potentially related to structural abnormalities (e.g., reductions in cortical folding and grey-matter volume). Additionally, connectivity between the prefrontal cortex, which regulates attentional and emotional responses, and primary visual and motor regions appears to be increased in PPPD. These results complement physiological and psychological data identifying hypervigilant postural control and visual dependence in patients with PPPD, supporting the hypothesis that PPPD arises from shifts in interactions among visuo-vestibular, sensorimotor, and emotional networks that overweigh visual over vestibular inputs and increase the effects of anxiety-related mechanisms on locomotor control and spatial orientation.
... The disease is associated with a considerable personal and healthcare burden, such as reduced quality of life, increased sick leave, social withdrawal and high use of healthcare resources (Mueller et al., 2014;Neuhauser et al., 2008;Ruthberg et al., 2020). Anxiety and symptoms of depression are common comorbidities (Dieterich & Staab, 2017;Staab, 2019). In a review study by Kundakci et al., exercise-based vestibular rehabilitation (VR) shows benefits for adult patients with chronic dizziness with regard to symptom score, fall risk, balance and emotional status (Kundakci et al., 2018). ...
Article
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Objectives The aims of the study were to investigate the feasibility and preliminary outcome of a Norwegian web‐based self‐help application for vestibular rehabilitation (VR) among patients with high symptom burden of chronic dizziness fulfilling the criteria for persistent postural‐perceptual dizziness (PPPD). Materials and methods The web application consists of six weekly online sessions, with written information and video presentations. It is self‐instructive and freely available on NHI.no (https://nhi.no/for‐helsepersonell/vestibular‐rehabilitering/). Ten consecutive patients referred to a neurologic outpatient clinic for chronic dizziness were included. They signed informed consent forms and were examined at inclusion and after three months. State of health and symptom burden were recorded using Vertigo symptom score (VSS), Niigata symptom score (NPQ), Patient Health Questionnaire (PHQ‐9) and health‐related quality of life score (EQ5D‐5L). Experiences with the program were measured using a semi‐structured interview at the end of the study. Results Nine out of ten patients completed the program. The findings suggest that the web application was easy to use, instructive and educatable. Challenges were the load of exercises, motivation to continue training during relapses and performing the body rolling on the floor. Participants had high symptom burden (VSS mean 32.9) and long duration of symptoms in years (mean 11.5). The participants improved on average 6.9 points on the VSS score. Conclusions This web application for chronic dizziness appears to be feasible and may reduce symptoms in patients who have struggled with serious and long‐lasting dizziness.
... 2 Vertigo or dizziness is related to a number of biological causes associated with vestibulocochlear disorders. 3 The most reported sources of vertigo are ischaemia involving too little blood supply to the nerve, labyrinthitis involving inflamed vestibular nerves, and accidental head injuries compromising the vestibular anterior artery to produce symptoms of vertigo. 4 Current literature highlights the underlying concept regarding patients experiencing tinnitus and vertigo and their tendency to exhibit numerous psychiatric features in the form of anxiety, depression and stress, therefore influencing various disease-related activities among patients experiencing these symptoms. ...
Article
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Objective: To identify the mental health problems among patients having symptoms of tinnitus and vertigo due to vestibulocochlear disturbances. Methods: The cross-sectional study was conducted from May to September 2019 at the Hearts International Hospital and the Hearing and Balance Clinic, Rawalpindi, in collaboration with the Foundation University, Islamabad, and comprised vestibulocochlear disorder patients of either gender aged >18 years having chief symptoms of vertigo and tinnitus for at least the preceding 3 months. Psychiatric evaluation was conducted using the Tinnitus Handicap Inventory, the Dizziness Handicap Inventory and the Depression, Anxiety, Stress Scale. Audiological evaluations were carried out to gauge the severity of symptoms. Data was analysed using SPSS 20. Results: Of the 202 subjects, 60(30%) were females and 142(70%) were males. Patients experiencing vertigo and tinnitus symptoms had a strong tendency to develop psychiatric problems (p<0.05). Significant differences were noted among male and female patients regarding the representation of psychiatric symptoms (p<0.05). Conclusion: Patients experiencing tinnitus and vertigo symptoms tended to have a deviant psychological profile analogous with other chronic diseases.
... The first classification task represented two groups of patients suffering from chronic dizziness of almost diametrical etiology. In bilateral vestibular failure, imbalance can be directly assigned to an organic damage of vestibular afferents, which is accompanied by a low degree of balance-related anxiety (60,61), while in functional dizziness the vestibular system is physiologically intact, but the subjective perception of balance is severely disturbed due to fearful introspection (62). It can be expected that ML-based algorithms will predominantly select features as most important for the segregation of both disorders, which represent either measurements of vestibular function or scales for anxiety and perceived disability. ...
Article
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Background: Multivariable analyses (MVA) and machine learning (ML) applied on large datasets may have a high potential to provide clinical decision support in neuro-otology and reveal further avenues for vestibular research. To this end, we build base-ml, a comprehensive MVA/ML software tool, and applied it to three increasingly difficult clinical objectives in differentiation of common vestibular disorders, using data from a large prospective clinical patient registry (DizzyReg). Methods: Base-ml features a full MVA/ML pipeline for classification of multimodal patient data, comprising tools for data loading and pre-processing; a stringent scheme for nested and stratified cross-validation including hyper-parameter optimization; a set of 11 classifiers, ranging from commonly used algorithms like logistic regression and random forests, to artificial neural network models, including a graph-based deep learning model which we recently proposed; a multi-faceted evaluation of classification metrics; tools from the domain of “Explainable AI” that illustrate the input distribution and a statistical analysis of the most important features identified by multiple classifiers. Results: In the first clinical task, classification of the bilateral vestibular failure ( N = 66) vs. functional dizziness ( N = 346) was possible with a classification accuracy ranging up to 92.5% (Random Forest). In the second task, primary functional dizziness ( N = 151) vs. secondary functional dizziness (following an organic vestibular syndrome) ( N = 204), was classifiable with an accuracy ranging from 56.5 to 64.2% (k-nearest neighbors/logistic regression). The third task compared four episodic disorders, benign paroxysmal positional vertigo ( N = 134), vestibular paroxysmia ( N = 49), Menière disease ( N = 142) and vestibular migraine ( N = 215). Classification accuracy ranged between 25.9 and 50.4% (Naïve Bayes/Support Vector Machine). Recent (graph-) deep learning models classified well in all three tasks, but not significantly better than more traditional ML methods. Classifiers reliably identified clinically relevant features as most important toward classification. Conclusion: The three clinical tasks yielded classification results that correlate with the clinical intuition regarding the difficulty of diagnosis. It is favorable to apply an array of MVA/ML algorithms rather than a single one, to avoid under-estimation of classification accuracy. Base-ml provides a systematic benchmarking of classifiers, with a standardized output of MVA/ML performance on clinical tasks. To alleviate re-implementation efforts, we provide base-ml as an open-source tool for the community.
... 34 Expanded telemedicine services may also mitigate access to care issues, particularly given that patient education substantially reduces morbidity. [46][47][48] Surprisingly, veterans who received diagnoses of or treatment for substance use had reduced odds for dizziness or vestibular dysfunction diagnoses. This finding may reveal a generalization of clinical practice in more common conditions, such as PTSD, which recommend a 3-to 9-month period of abstinence or substantially reduced substance use as a precondition for treatment. ...
Article
Objective: To identify disruption due to dizziness symptoms following deployment-related traumatic brain injury (TBI) and factors associated with receiving diagnoses for these symptoms. Setting: Administrative medical record data from the Department of Veterans Affairs (VA). Participants: Post-9/11 veterans with at least 3 years of VA care who reported at least occasional disruption due to dizziness symptoms on the comprehensive TBI evaluation. Design: A cross-sectional, retrospective, observational study. Main measures: International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes of dizziness, vestibular dysfunction, and other postconcussive conditions; neurobehavioral Symptom Inventory. Results: Increased access to or utilization of specialty care at the VA was significant predictors of dizziness and/or vestibular dysfunction diagnoses in the fully adjusted model. Veterans who identified as Black non-Hispanic and those with substance use disorder diagnoses or care were substantially less likely to receive dizziness and vestibular dysfunction diagnoses. Conclusions: Access to specialty care was the single best predictor of dizziness and vestibular dysfunction diagnoses, underscoring the importance of facilitating referrals to and utilization of specialized, comprehensive clinical facilities or experts for veterans who report disruptive dizziness following deployment-related TBI. There is a clear need for an evidence-based pathway to address disruptive symptoms of dizziness, given the substantial variation in audiovestibular tests utilized by US providers by region and clinical specialty. Further, the dearth of diagnoses among Black veterans and those in more rural areas underscores the potential for enhanced cultural competency among providers, telemedicine, and patient education to bridge existing gaps in the care of dizziness.
... Although PPPD is a relatively new disorder, syndromes presenting as dizziness provoked by motion or visually stimulating environments have been described in the medical literature as early as the 1870s (3,4). Contemporary predecessors to PPPD include phobic postural vertigo (5,6), chronic subjective dizziness (7,8), visual vertigo (9), and space-motion discomfort (10,11). PPPD is a unifying term, based upon key features of these previously-described syndromes. ...
Article
Objective: Persistent postural-perceptual dizziness (PPPD) is a recently defined diagnostic syndrome characterized by chronic symptoms of dizziness, unsteadiness, and/or non-spinning vertigo. Although PPPD has been studied in adults, reports in the pediatric population are few. The goal of this study was to describe the presentation and treatment of PPPD in a group of pediatric patients. Study design: Retrospective chart review. Setting: Tertiary referral center. Patients: ≤21 years old, who met Bárány Society consensus criteria for a diagnosis of PPPD and were followed for ≥6 months or until symptom resolution. Main outcome measuress: Patient demographics, comorbidities, symptom chronicity, and response to treatment(s). Results: Of the 53 patients identified, 44 (83.0%) were women. Mean age at the time of initial evaluation was 14.6 years old. Common diagnoses in addition to PPPD included benign paroxysmal positional vertigo (64.2%), vestibular migraine (56.6%), and anxiety (28.3%). A high proportion of patients (43.4%) reported initially missing school or work due to their symptoms. Eighteen patients (34.0%) reported symptom resolution ranging from 2 to 48 months after diagnosis (median 9 mo). Of these patients, 15 of 18 attended physical therapy (PT), 11 of 18 attended cognitive behavioral therapy (CBT) and/or biofeedback therapy, and 10 of 18 took selective serotonin reuptake inhibitor (SSRI) medications, and 7 of 18 (40%) did a combination of all three therapies. Conclusion: PPPD can impact patients at a young age, and prolonged symptoms present a significant burden to children and adolescents, many of whom are unable to attend school. Treatments such as PT, CBT, and SSRI medication may be effective.
... Persistent postural perceptual dizziness (PPPD) is a condition characterised by postural instability and dizziness when exposed to self-movement and challenging visual environments [15,63]. Common triggers include supermarket aisles, action movies, and crowded streets. ...
Article
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Background: Images that deviate from natural scene statistics in terms of spatial frequency and orientation content can produce visual stress (also known as visual discomfort), especially for migraine sufferers. These images appear to over-activate the visual cortex. Objective: To connect the literature on visual discomfort with a common chronic condition presenting in neuro-otology clinics known as persistent postural perceptual dizziness (PPPD). Sufferers experience dizziness when walking through highly cluttered environments or when watching moving stimuli. This is thought to arise from maladaptive interaction between vestibular and visual signals for balance. Methods: We measured visual discomfort to stationary images in patients with PPPD (N = 30) and symptoms of PPPD in a large general population cohort (N = 1858) using the Visual Vertigo Analogue Scale (VVAS) and the Situational Characteristics Questionnaire (SCQ). Results: We found that patients with PPPD, and individuals in the general population with more PPPD symptoms, report heightened visual discomfort to stationary images that deviate from natural spectra (patient comparison, F (1, 1865) = 29, p < 0.001; general population correlations, VVAS, rs (1387) = 0.46, p < 0.001; SCQ, rs (1387) = 0.39, p < 0.001). These findings were not explained by co-morbid migraine. Indeed, PPPD symptoms showed a significantly stronger relationship with visual discomfort than did migraine (VVAS, zH = 8.81, p < 0.001; SCQ, zH = 6.29, p < 0.001). Conclusions: We speculate that atypical visual processing -perhaps due to a visual cortex more prone to over-activation -may predispose individuals to PPPD, possibly helping to explain why some patients with vestibular conditions develop PPPD and some do not.
... However, despite the high success rate of CRMs (70%-80%), BPPV often recurs in a 15% to 30% of all patients [1,2]. And in cases of recurrent BPPV, they may lead to disability due to frequent falling or other complicating dizzy syndrome such as persistent posturalperceptual dizziness [1][2][3][4]. ...
... Vertigo (mostly spinning) triggered by head movements is typical for benign paroxysmal vertigo [27]. Swaying vertigo is often described as a somatoform and/or phobic vertigo [28]. In recent decades, cervical vertigo has emerged as a special category of dizziness, generating considerable controversy. ...
Article
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(1) Background: Cervical vertigo (CV) represents a controversial entity, with a prevalence ranging from reported high frequency to negation of CV existence. (2) Objectives: To assess the prevalence and cause of vertigo in patients with a manifest form of severe cervical spondylosis–degenerative cervical myelopathy (DCM) with special focus on CV. (3) Methods: The study included 38 DCM patients. The presence and character of vertigo were explored with a dedicated questionnaire. The cervical torsion test was used to verify the role of neck proprioceptors, and ultrasound examinations of vertebral arteries to assess the role of arteriosclerotic stenotic changes as hypothetical mechanisms of CV. All patients with vertigo underwent a detailed diagnostic work-up to investigate the cause of vertigo. (4) Results: Symptoms of vertigo were described by 18 patients (47%). Causes of vertigo included: orthostatic dizziness in eight (22%), hypertension in five (14%), benign paroxysmal positional vertigo in four (11%) and psychogenic dizziness in one patient (3%). No patient responded positively to the cervical torsion test or showed significant stenosis of vertebral arteries. (5) Conclusions: Despite the high prevalence of vertigo in patients with DCM, the aetiology in all cases could be attributed to causes outside cervical spine and related nerve structures, thus confirming the assumption that CV is over-diagnosed.
... Bu durum daha öncesinde yaşanmış bir akut vestibuler sendromdan (BPPV, vestibülernörinit, labirintit, vb) sonra semptomların vestibuler adaptasyonun tam kurulamaması nedenli sebat etmesi nedenli görüldüğü düşünülmektedir. 1,26 Fonskiyonel yürüyüş ve postür bozukluklarında, nörolojik muayenede anlamlı bir bradikinezi olmadan aşırı yürüyüş yavaşlığı, serebellar defisitle uyumlu olmayan denge sorunları ve ani diz çökmeler, ambulasyon için abartılı efor harcanması (huffing and puffing sign), düşmelere neden olabilecek ani sıçrayıcı ekstremite hareketleri, yürüme esnasında bloklar, düşerken kendisini koruyucu manevralar, kalça rotasyon hareketleriyle birlikte ayak sürüyerek yürüyüş örnekleri görülebilir. 1,[27][28][29] Fonksiyonel konuşma bozukluklarında kekemelik benzeri akıcı olmayan konuşma, artikülasyon defektleri izlenebildiği gibi, konuşmak için abartılı efor harcama durumu, disfonik ya da afonik konuşma şekilleri, prozodik bozuklukların olduğu, yabancı aksan sendromu benzeri tablolar izlenebilir. ...
Chapter
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Functional neurological symptom disorder occurs involuntarily. There is no underlying neurological or medical disease. It is a set of symptoms that are thought to occur as a result of the central nervous system malfunction without a structural pathology. It is a picture of the subconscious transformation of emotional negative experiences into a somatic symptom in an effort to suppress them. Non-epileptic psychogenic seizures, paralysis, functional movement disorders, visual disturbances and non-dermatomal sensory deficits are frequently seen. Special examination methods have important roles for diagnosing this disorder. In addition to psychodynamic and cognitive-behavioral models, functional neuroimaging studies suggesting a change in the basal nuclei-thalamocortical circuits with the activation of the frontal and subcortical regions by emotional stress have provided a different perspective on etiopathogenesis. It is important to tell the patients that their symptoms are real symptoms and that they occur out of their control. Psychotherapy, physiotherapy, pharmacotherapy treatments are used.
... Though only recently officially defined in 2015 in the International Classification of Diseases (ICD-11), the condition has been previously investigated for decades, and prior labels include phobic postural vertigo, space-motion discomfort, chronic subjective dizziness, and visual vertigo. 1 The condition is characterized by 3 or more months of non-spinning vertigo, dizziness, or unsteadiness that is often initially triggered by an event that involves vestibular symptoms, psychological distress, or heightened awareness of posture (Table 1). 2 The subsequent maladaptive response results in continued nonspinning vertigo or imbalance symptoms even after the inciting event has concluded. For example, a patient may develop vestibular neuritis and experience a continued sensation of motion even after the neuritis has resolved. ...
Article
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Objectives To evaluate the presence of migraine features in patients with persistent postural-perceptual dizziness (PPPD). Methods In a retrospective survey study, consecutive patients presenting to a tertiary care neurotology clinic during an 18-month period were given questionnaires about headache and dizziness symptoms. The survey responses plus history and examination of the patient were used to diagnose patients with PPPD. The prevalence of migraine headache, vestibular migraine (VM), and migraine characteristics was evaluated. Results In total, 36 subjects with PPPD were included in the study. The mean age of the subjects was 56 ± 16 years with a female (72%) predominance. A total of 19 (53%) patients met the International Classification of Headache Disorders criteria for migraine headache, and 6 of those (17%) met the criteria for definite VM. Of the patients who did not meet full migraine headache criteria, 6 (17%) patients met 4 of 5 criteria, and 5 (14%) patients met 3 of 5 criteria. There was no significant difference between PPPD patients who fulfilled full migraine headache criteria and those who did not in sensitivity to light, sound, smells, weather changes, feelings of mental fog/confusion, and sinus pain/facial pressure. Conclusions This study demonstrates that a majority of patients with PPPD fulfill the criteria for migraine headache. A large proportion of PPPD patients who do not meet the full criteria for migraine headache still meet a majority of the migraine headache criteria. This suggests an association between the 2 conditions. PPPD may be a part of the spectrum of otologic migraine, where migraine manifests as otologic symptoms.
... Según la evidencia, la TFV puede ser útil para el tratamiento de los pacientes con mareo perceptual postural persistente, incluyendo educación, reducción de gatillantes identificados, práctica de relajación, atención integrada, habituación gradual, reentrenamiento del balance y desensibilización visual del movimiento optocinético (33,34). Para que avance el manejo efectivo del mareo perceptual postural persistente no puede sólo entenderse como un diagnóstico de exclusión, sino que requiere el cumplimiento de sus características clínicas, un diagnóstico temprano para minimizar el desarrollo de síntomas crónicos y un enfoque interdisciplinario cuya rehabilitación vestibular es una de las modalidades clave para el éxito (35,36). Se necesitan estudios futuros para mejorar y definir la interdependencia de varias intervenciones de tratamiento y las estrategias de tratamiento específicas más efectivas para las personas que viven con mareo perceptual postural persistente. ...
Technical Report
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Este documento es de autoría del Colegio de Kinesiólogos de Chile. . El propósito de la segunda versión de esta guía es proporcionar un marco de apoyo a los profesionales de la salud que brindan (o brindarán) terapia kinesiológica o de rehabilitación a través de telerehabilitación (ya sea sincrónica y/o asincrónica) optimizando la seguridad y la calidad de su práctica en contexto de emergencia por COVID-19 o a futuro. La segunda versión ha incorporado sugerencias recibidas de profesionales y sociedades científicas para representar de manera más amplia el quehacer kinesiológico. Al inicio, se presenta un resumen global de los conceptos que son transversales a las diferentes disciplinas, junto con recomendaciones generales para su práctica e implementación. Posteriormente, se exhiben las recomendaciones derivadas del trabajo de cada una de las áreas de especialidad, las cuales fueron elaboradas por sociedades científicas y grupos de interés registrados en el COLKINE. Se adjuntan anexos para facilitar la puesta en marcha de las sesiones de telerehabilitación, así como links útiles para mayor información y formación en el área de especialidad o práctica.
... The processes thought to give rise to and then drive PPPD are a combination of those described for its precursors, namely phobic postural vertigo, space-motion discomfort, visual vertigo and chronic subjective dizziness (1). Anxiety and anxiety-related personality traits, in particular neuroticism, have been described as possible predisposing factors, making the affected individual prone to a hypervigilant state of increased introspective selfmonitoring that arises from fear of further attacks of vertigo or the consequences of being dizzy during or following the episode of acute vestibular disease (7,10,11,(18)(19)(20)(21)(22)(23)(24)(25). Yagi et al. (26) have recently developed a PPPD severity questionnaire (the Niigata PPPD Questionnaire) that reflects the diagnostic criteria of PPPD (26). ...
Article
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Objectives: (1) To assess whether neuroticism, state anxiety, and body vigilance are higher in patients with persistent postural-perceptual dizziness (PPPD) compared to a recovered vestibular patient group and a non-dizzy patient group; (2) To gather pilot data on illness perceptions of patients with PPPD. Materials and Methods: 15 cases with PPPD and two control groups: (1) recovered vestibular patients ( n = 12) and (2) non-dizzy patients (no previous vestibular insult, n = 12). Main outcome measures: Scores from the Big Five Inventory (BFI) of personality traits, Generalized Anxiety Disorder - 7 (GAD-7) scale, Body Vigilance Scale (BVS), Dizziness Handicap Inventory (DHI), modified Vertigo Symptom Scale (VSS) and Brief Illness Perception Questionnaire (BIPQ). Results: Compared to non-dizzy patients, PPPD cases had higher neuroticism ( p = 0.02), higher introversion ( p = 0.008), lower conscientiousness ( p = 0.03) and higher anxiety ( p = 0.02). There were no differences between PPPD cases and recovered vestibular patients in BFI and GAD-7. PPPD cases had higher body vigilance to dizziness than both control groups and their illness perceptions indicated higher levels of threat than recovered vestibular patients. Conclusion: PPPD patients showed statistically significant differences to non-dizzy patients, but not recovered vestibular controls in areas such as neuroticism and anxiety. Body vigilance was increased in PPPD patients when compared with both recovered vestibular and non-dizzy patient groups. PPPD patients also exhibited elements of negative illness perception suggesting that this may be the key element driving the development of PPPD. Large scale studies focusing on this area in the early stages following vestibular insult are needed.
Article
BACKGROUND: Persistent Postural-Perceptual Dizziness (PPPD) is a chronic neuro-vestibular condition characterised by subjective dizziness, non-spinning vertigo, and postural imbalance. Symptoms are typically induced by situations of visuo-vestibular conflict and intense visual-motion. OBJECTIVE: Little research has focused on the lived experiences of people with PPPD. Therefore, our objective was to present an in-depth exploration of patient experiences and sense-making, and the effect of PPPD on psycho-social functioning. METHODS: We conducted semi-structured interviews with 6 people with PPPD, who were recruited from an Audiovestibular department in Wales. We present a case-by-case Interpretive Phenomenological Analysis (IPA) for each participant and present common themes. RESULTS: Our analysis revealed a range of superordinate and subordinate themes, individualised to each participant, but broadly described under the following headings: dismissal and non-belief, identity loss, dissociative experiences, poor psychological well-being and processes of sense-making. CONCLUSION: The qualitative experiences documented in this study will help clinicians and researchers to better understand the lived experiences of PPPD, how PPPD patients make sense of their symptoms, and the psycho-social impacts of the condition.
Article
Objective We describe the first-year implementation experience of an Instrumented Sensory Integration Therapy Program in Audiological & Balance Center patients. Design This is a retrospective descriptive study. Participants included Seventy-three adults with diagnoses of acute, episodic, or chronic vestibular syndromes. They were classified into the following two groups: group 1 included 46 individuals treated with ISIT plus VRT, and group 2 included 27 individuals treated only with ISIT. Results The Sensory Organization Test (SOT) for both groups showed a statistical significance for all three sensory inputs; visual systems (G1: p = 0.0003; G2: p = 0.0337), vestibular system (G1: p < 0.0001; G2: p = 0.0003), and balance as demonstrated by compound balance score (G1: p < 0.0001; G2: p = 0.0035), and balance percentage deficit (G1: p < 0.0001; G2: p = 0.0078). Conclusions The severity and complexity of functional neurological disorders in the context of vestibular syndromes seem to require between 10-20 therapy sessions, and combined ISIT plus VRT appears to be more effective than ISIT as a monotherapy.
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Background Stroke accounts for 5–10% of all presentations with acute vertigo and dizziness. The objective of the current study was to examine determinants of long-term functioning and health-related quality of life (HRQoL) in a patient cohort with vestibular stroke. Methods Thirty-six patients (mean age: 66.1 years, 39% female) with an MRI-proven vestibular stroke were followed prospectively (mean time: 30.2 months) in the context of the EMVERT (EMergency VERTigo) cohort study at the Ludwig-Maximilians Universität, Munich. The following scores were obtained once in the acute stage (<24 h of symptom onset) and once during long-term follow-up (preferably >1 year after stroke): European Quality of Life Scale-five dimensions-five levels questionnaire (EQ-5D-5L) and Visual Analog Scale (EQ-VAS) for HRQoL, Dizziness Handicap Inventory (DHI) for symptom severity, and modified Rankin Scale (mRS) for general functioning and disability. Anxiety state and trait were evaluated by STAI-S/STAI-T, and depression was evaluated by the Patient Health Questionnaire-9 (PHQ-9). Voxel-based lesion mapping was applied in normalized MRIs to analyze stroke volume and localization. Multiple linear regression models were calculated to determine predictors of functional outcome (DHI, EQ-VAS at follow-up). Results Mean DHI scores improved significantly from 45.0 in the acute stage to 18.1 at follow-up ( p < 0.001), and mean mRS improved from 2.1 to 1.1 ( p < 0.001). Mean HRQoL (EQ-5D-5L index/EQ-VAS) changed from 0.69/58.8 to 0.83/65.2 ( p = 0.01/ p = 0.11). Multiple linear regression models identified higher scores of STAI-T and DHI at the time of acute vestibular stroke and larger stroke volume as significant predictors for higher DHI at follow-up assessment. The effect of STAI-T was additionally enhanced in women. There was a significant effect of patient age on EQ-VAS, but not DHI during follow-up. Conclusion The average functional outcome of strokes with the chief complaint of vertigo and dizziness is favorable. The most relevant predictors for individual outcomes are the personal anxiety trait (especially in combination with the female sex), the initial symptom intensity, and lesion volume. These factors should be considered for therapeutic decisions both in the acute stage of stroke and during subsequent rehabilitation.
Article
Pain and dizziness are common experiences throughout the lifespan. However, nearly a quarter of those with acute pain or dizziness experience persistence, which is associated with disability, social isolation, psychological distress, decreased independence, and poorer quality of life. Thus, persistent pain or dizziness impacts peoples' lives in similarly negative ways. Conceptual models of pain and dizziness also have many similarities. Many of these models are more expansive than explaining mere symptoms; rather they describe pain or dizziness as holistic experiences that are influenced by biopsychosocial and contextual factors. These experiences also appear to be associated with multi-modal bodily responses related to evaluation of safety, threat detection and anticipation, as influenced by expectations, and predictions anticipation, not simply a reflection of tissue injury or pathology. Conceptual models also characterize the body as adaptable and therefore capable of recovery. These concepts may provide useful therapeutic narratives to facilitate understanding, dethreaten the experience, and provide hope for patients. In addition, therapeutic alliance, promoting an active movement-based approach, building self-efficacy, and condition-specific approaches can help optimize outcomes. In conclusion, there are significant overlaps in the patient experience, theoretical models and potential therapeutic narratives that guide care for people suffering with persistent pain or dizziness.
Article
Abstract. Aim. To study the emotional and personal characteristics of patients with benign paroxysmal positional vertigo (BPPV) and their impact on the development of functional dizziness (FD). Materials and methods. 93 patients with BPPV were examined. Patients were twice examined (immediately after BPPV treatment and 1 month follow up) with scales: dizziness (DHI), depression (PHQ-9), anxiety (GAD-7), somatic symptoms scale (PHQ-15), Holmes-Rahe Stress Inventory, Leonhard-Schmishek personality accentuation test, Anxiety Sensitivity Index, and Agoraphobic Cognitions Scale. Results. Seventeen (18%) patients had FD 1 month after BPPV treatment (FD+ group), 76 patients had no dizziness (FD- group). Immediately after BPPV treatment patients FD+ group had more hight results of DHI (57 [49; 68] vs 49 [33; 61], p = 0.035), GAD-7 (13 [7; 15] vs 4 [2; 7]), p <0.001) and PHQ-9 (9 [6; 13] vs 5 [3; 11], p = 0.025). One month after BPPV treatment, the level of depression in the FD+ group was higher (4.5 [4; 11] vs 3 [1; 6], p = 0.049), but the level of anxiety decreased and became comparable with the FD- group (p = 0.2). In the FD+ group had found higher rates of anxious personal accentuation (15 [12; 18] vs 12 [9; 15]; p=0.02), anxious sensitivity (55.5 [43; 68.5] vs 36.5 [22.5; 53.5]; p=0.01), as well as agoraphobia (11 [9; 18] vs 6 [2; 9], p=0.003). The level of psychosocial stress did not differ between the groups. Conclusion. Anxiety-depressive reaction is common in patients with BPPV. Anxiety and depression decreases after successful treatment with repositioning maneuvers. High levels of anxiety and depression, personal anxiety and anxiety sensitivity may be predictors of the development of functional dizziness. Keywords: BPPV, functional dizziness, anxiety, depression, somatization
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Die meisten Schwindelformen und vestibulären Syndrome des Erwachsenen können sich ebenso in der Kindheit manifestieren, weshalb wir in diesem Kapitel die spezifischen Punkte der richtungsgebenden Anamnese, Befunde, Verläufe und der Therapie beim Kind hervorheben. Die Beschreibung der Beschwerden ist bei Kindern jedoch – je nach Alter – weniger präzise als bei Erwachsenen. Auch hängen die Untersuchungsbefunde der Gleichgewichtsfunktion und Okulomotorik bei Kindern (Devaraja 2018) stärker von der konzentrierten Mitarbeit ab.
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Globalization in the last decades has led to an increase of exchanges through the globe and an expansion of global markets as well as an increase of levels of urbanization through the continents. In particular, urbanization includes environmental, social, and economic changes and factors that may affect the mental health of the general population. In fact, emerging evidence reports higher rates of mental disorders in the urban settings than in rural areas, and social disparities and insecurity may impact on the mental health of the weaker groups of society. Also, the lack of contact with nature in the city and higher levels of pollution are associated with a remarkable rate of psychological distress. Pollution, in particular, is tightly related to the level of industrialization and employment of technology. It has been demonstrated that environmental pollutants (e.g., air pollutants, noise, ionizing radiations, etc.) may impact directly or indirectly on mental health: there may be a direct biological consequence of pollution on the human central nervous system as well as a range of psychological stress generated by the lasting exposure to pollutant agents. This chapter reports emerging evidence regarding the impact of urbanicity and pollution on public mental health and suggests further research and action in order to develop strategies of prevention of mental illness due to the burden of global urbanization.
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Functional neurological disorder (FND) is a medical condition defined by the presence of genuine neurological symptoms without any underlying organic neurological diseases. Functional symptoms are very common in neurological practice. It is not anymore considered that FND is of the purely psychogenic origin. However, scientific data still support the importance of psychological factors and of some personality traits in the development and persistence of these symptoms. There are some specific and sensible clinical signs pointing to the functional origin of a neurological disability. The early diagnosis of FND is very important for a good outcome. The treatment of FND should be multidisciplinary and include psychotherapy. However, the prognosis is usually poor with symptoms unchanged or worse in most patients. There are no wide-accepted efficient prevention strategies for FND yet.
Article
Objective: The purpose of this study was to provide empirical data describing the relationship between behavioral responses to dynamic visual motion in adults with chronic dizziness symptoms with and without clinically identifiable peripheral vestibular impairment. Design: Prospective, quasi-experimental study including individuals with chronic dizziness symptoms with identified unilateral peripheral vestibular impairment (n=27), and individuals with chronic dizziness symptoms without identified vestibular impairment (n=26). We measured (a) visual perception of verticality in a dynamic background, (b) postural displacement in a dynamic background, (c) eye movement behaviors in various visual contexts, and (d) self-rating degree of anxiety. Results: Status of peripheral vestibular function was not a significant predictor of behavioral responses to visual motion. The data show that the ability to fixate on a visual target was predictive of postural control in a dynamic visual background. Trial-to-trial variability in verticality responses and degree of self-rated anxiety were also associated with postural control. Conclusions: Apart from vestibular function, oculomotor control is important for maintaining control of whole-body motor responses during exposure to a dynamic visual stimulus. Vertical perception precision-not accuracy-may be more important for understanding real-world consequences of visual motion sensitivity. Traditional diagnostic evaluations focusing exclusively on characterizing the peripheral vestibular system may not provide insight into the behaviors associated with visual motion sensitivity.
Chapter
Balance disorders include a large number of syndromes and diseases that affect the central or peripheral vestibular pathways, the cerebellum, or the sensory pathways associated with proprioception. Such disorders usually present with one of two mayor symptoms: vertigo or ataxia. The aim of this chapter is to offer a general overview of the pharmacotherapy of balance disorders, that we have classified in three major categories: acute vestibular syndrome, episodic vestibular disorders and persistent balance disorders. Episodic vestibular disorders include motion sickness, benign paroxysmal positional vertigo (BPPV), vestibular migraine, Meniere disease and vestibular paroxysmia. Among persistent balance disorders we have considered persistent postural-perceptual dizziness (PPPD) and mal de debarquement syndrome (MdDS). Pharmacotherapy of balance disorders is still in its infancy and further randomized clinical trials are needed to control vertigo and ataxia in central and peripheral disorders.
Article
Objectives: Persistent postural-perceptual dizziness (PPPD) is a chronic functional vestibular disorder that may have normal physical examination, clinical laboratory testing and vestibular evaluation. However, advances in neuroimaging have provided new insights in brain functional connectivity and structure in patients with PPPD. This systematic review was aimed at identifying significant structural or alterations in functional connectivity in patients with PPPD. Databases reviewed: Science Direct, Pubmed, Embase via Ovid databases, and Cochrane library. Methods: This review following the guidelines of PRISMA, systematically and independently examined papers published up to March 2021 which fulfilled the predetermined criteria. PROSPERO Registration (CRD42020222334). Results: A total of 15 studies were included (MRI = 4, SPECT = 1, resting state fMRI = 4, task-based fMRI = 5, task-based fMRI + MRI = 1). Significant changes in the gray matter volume, cortical folding, blood flow, and connectivity were seen at different brain regions involved in vestibular, visual, emotion, and motor processing. Conclusion: There is a multisensory dimension to the impairment resulting in chronic compensatory changes in PPPD that is evident by the significant alterations in multiple networks involved in maintaining balance. These changes observed offer some explanation for the symptoms that a PPPD patient may experience.Systematic Review Registration: This study is registered with PROSPERO (CRD42020222334).
Article
Objectives/Hypothesis Chronic dizziness (CD) and imbalance have multiple etiologies. CD is strongly linked with psychiatric and psychological comorbidities, thus an interdisciplinary approach, including psychopharmacological interventions, is recommended. Despite the use of this comprehensive treatment approach, the recovery of individuals with CD that pursue long-term disability (LTD) insurance or legal claims (LC) appears hampered. As such, we aimed to compare symptom recovery from CD in an interdisciplinary setting between patients receiving LTD/LC versus those who were not, and to explore the factors that may contribute to changes in symptom severity. Study Design Retrospective cohort study. Methods Dizziness-related diagnoses were extracted from the charts of 195 adults in an outpatient interdisciplinary neurotology clinic in Toronto, Canada. Patients with baseline Dizziness Handicap Inventory (DHI) and Dizziness Catastrophizing Scale (DCS) assessments between August 2012 and July 2018 and a mean follow-up visit within approximately 10 months were included. The study participants were categorized as “LTD/LC+” (n = 92) or “LTD/LC−” (n = 103), referring to either receiving or pursuing LTD/LC or not, respectively. Results There were differences in the mean percentage changes in DHI (t[187] = 3.02, P = .003) and DCS (t[179] = 2.63, P = .009) scores between LTD/LC+ and LTD/LC− patients. LTD/LC+ patients showed 8.0% and 7.6% mean increases in DHI and DCS scores, respectively, whereas LTD/LC− patients showed 21.5% and 25.9% reductions in DHI and DCS scores, respectively, controlling for age, sex, and baseline illness severity. Conclusions Patients receiving or pursuing LTD insurance or a legal claim did not improve from CD and dizziness catastrophizing compared to those who were not. Future studies are required to test these findings prospectively and to determine the factors that may contribute to symptom recovery, including the anxiety-aggravating effects of the LTD/LC process and the deleterious consequences of developing a sick-role while afflicted with a chronic illness. Level of Evidence 3 Laryngoscope, 2021
Article
Vestibular physical therapy (VPT) is a specialized form of evidence-based therapy designed to alleviate primary (vertigo, dizziness, imbalance, gait instability, falls) and secondary (deconditioning, cervical muscle tension, anxiety, poor quality of life, fear of falling/fear avoidance behavior) symptoms related to vestibular disorders. This article provides an overview of VPT, highlighting various exercise modalities used to treat a variety of vestibular disorders. Patient safety and fall prevention are paramount; therefore, fall risk assessment and treatment are also addressed.
Article
Zusammenfassung Die 8 häufigsten Schwindelsyndrome liegen über 70% aller Schwindelpräsentationen zugrunde. Bei den akuten (meist einzeitigen) Schwindelsyndromen sind die akute unilaterale Vestibulopathie und der vestibuläre Schlaganfall von besonderer Bedeutung, bei den episodischen Schwindelerkrankungen der gutartige Lagerungsschwindel, der Morbus Menière und die vestibuläre Migräne und bei chronischem Schwindel die bilaterale Vestibulopathie/Presbyvestibulopathie, der funktionelle Schwindel und der zerebelläre Schwindel. In der letzten Dekade wurden für die häufigsten Schwindelsyndrome international konsentierte diagnostische Kriterien und Krankheitsbezeichnungen erarbeitet, die einfach im klinischen Alltag angewendet werden können. Die diagnostischen Leitlinien beruhen überwiegend auf einer gezielten Anamnese (Beginn, Dauer, Verlauf, Trigger, Begleitsymptome), klinischen Untersuchung und wenigen apparativen Verfahren zur Diagnosesicherung (vor allem mittels Videookulographie und Audiometrie). Die Therapie der häufigen Schwindelsyndrome basiert in der Regel auf einer Kombination aus physikalischen Verfahren (Lagerungsmanöver, multimodales Gleichgewichtstraining) und pharmakologischen Prinzipien (u.a. Kortikosteroide, Antiepileptika, Antidepressiva, Kaliumkanalblockern, plastizitätsfördernde Medikamente). Allerdings fehlt meist eine hochwertige Evidenz aus prospektiven und kontrollierten Studien. In der klinischen Praxis lassen sich die häufigen Schwindelsyndrome oft effektiv behandeln, sodass eine Chronifizierung oder sekundäre Komorbidität (durch Immobilität, Stürze oder psychiatrische Erkrankungen wie Angst oder Depression) vermieden werden kann.
Article
Patients with complaints of “dizziness” often make an odyssey of visits to physicians belonging to various specialties. The prevalence of vertigo in the population is 17–30%. In most cases, disorders of various areas of the vestibular analyzer form the pathogenetic basis of vertigo and unsteadiness, while the most common cause of these complaints is the pathology of the peripheral area of the vestibular system: benign paroxysmal positional vertigo, vestibular neuronitis, Meniere’s disease. The cerebral vessel disease caused by hypertensive cerebral microangiopathy and cerebral atherosclerosis can also manifest by vertigo and unsteadiness. They can be represented by acute cerebrovascular disorders in the vertebrobasilar arterial system, transient ischemic attacks, as well as manifestations of chronic cerebrovascular disease (chronic cerebral ischemia, discirculatory encephalopathy). Episodes of recurrent spontaneous vestibular vertigo can be caused by vestibular migraine, which is rarely diagnosed in our country. The variety of reasons for complaints of vertigo and unsteadiness defines many therapeutic approaches to the treatment of these diseases. In recent times, modern drug and non-drug approaches to the treatment have been developed for patients with various diseases manifested by vertigo and unsteadiness. The most effective treatment is a comprehensive therapeutic approach that combines non-drug therapy, including vestibular gymnastics, training on the stabilographic platform with biofeedback according to the support reaction, and drugs that help reduce the severity, duration, and frequency of vertigo attacks, as well as accelerate vestibular compensation. Many studies have shown the efficacy of drugs enhancing microcirculation used for the prophylactic treatment of various causes of vertigo and unsteadiness.
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This paper presents diagnostic criteria for persistent postural-perceptual dizziness (PPPD) to be included in the International Classification of Vestibular Disorders (ICVD). The term PPPD is new, but the disorder is not. Its diagnostic criteria were derived by expert consensus from an exhaustive review of 30 years of research on phobic postural vertigo, space-motion discomfort, visual vertigo, and chronic subjective dizziness. PPPD manifests with one or more symptoms of dizziness, unsteadiness, or non-spinning vertigo that are present on most days for three months or more and are exacerbated by upright posture, active or passive movement, and exposure to moving or complex visual stimuli. PPPD may be precipitated by conditions that disrupt balance or cause vertigo, unsteadiness, or dizziness, including peripheral or central vestibular disorders, other medical illnesses, or psychological distress. PPPD may be present alone or co-exist with other conditions. Possible subtypes await future identification and validation. The pathophysiologic processes underlying PPPD are not fully known. Emerging research suggests that it may arise from functional changes in postural control mechanisms, multi-sensory information processing, or cortical integration of spatial orientation and threat assessment. Thus, PPPD is classified as a chronic functional vestibular disorder. It is not a structural or psychiatric condition.
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Patients with somatoform vertigo and dizziness (SVD) disorders often report instability of stance or gait and fear of falling. Posturographic measurements indeed indicated a pathological postural strategy. Our goal was to evaluate the effectiveness of a psychotherapeutic and psychoeducational short-term intervention (PTI) using static posturography and psychometric examination. Seventeen SVD patients took part in the study. The effects of PTI on SVD were evaluated with quantitative static posturography. As primary endpoint a quotient characterizing the relation between horizontal and vertical sway was calculated ( Q H / V ), reflecting the individual postural strategy. Results of static posturography were compared to those of age- and gender-matched healthy volunteers ( n = 28 ); baseline measurements were compared to results after PTI. The secondary endpoint was the participation-limiting consequences of SVD as measured by the Vertigo Handicap Questionnaire (VHQ). Compared to the healthy volunteers, the patients with SVD showed a postural strategy characterized by stiffening-up that resulted in a significantly reduced body sway quotient before PTI (patients: Q H / V = 0.31 versus controls: Q H / V = 0.38 ; p = 0.022 ). After PTI the postural behavior normalized, and psychological distress was reduced. PTI therefore appears to modify pathological balance behaviour. The postural strategy of patients with SVD possibly results from anxious anticipatory cocontraction of the antigravity muscles.
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Background: Persistent postural-perceptual dizziness (PPPD) (formerly chronic subjective dizziness) may be treated using the habituation form of vestibular and balance rehabilitation therapy (VBRT), but therapeutic outcomes have not been formally investigated. Objective: This pilot study gathered the first data on the efficacy of VBRT for individuals with well-characterized PPPD alone or PPPD plus neurotologic comorbidities (vestibular migraine or compensated vestibular deficits). Methods: Twenty-six participants were surveyed by telephone an average of 27.5 months after receiving education about PPPD and instructions for home-based VBRT programs. Participants were queried about exercise compliance, perceived benefits of therapy, degree of visual or motion sensitivity remaining, disability level, and other interventions. Results: Twenty-two of 26 participants found physical therapy consultation helpful. Fourteen found VBRT exercises beneficial, including 8 of 12 who had PPPD alone and 6 of 14 who had PPPD with co-morbidities. Of the 14 participants who found VBRT helpful, 7 obtained relief of sensitivity to head/body motion, 5 relief of sensitivity to visual stimuli, and 4 complete remission. Comparable numbers for the 12 participants who found VBRT not helpful were 1 (head/body motion), 3 (visual stimuli), and 0 (remission). Conclusions: This pilot study offers the first data supporting the habituation form of VBRT for treatment of PPPD.
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Background Vertigo and dizziness are often not fully explained by an organic illness, but instead are related to psychiatric disorders. This study aimed to evaluate psychiatric comorbidity and assess psychosocial impairment in a large sample of patients with a wide range of unselected organic and non-organic (ie, medically unexplained) vertigo/dizziness syndromes. Methods This cross-sectional study involved a sample of 547 patients recruited from a specialised interdisciplinary treatment centre for vertigo/dizziness. Diagnostic evaluation included standardised neurological examinations, structured clinical interview for major mental disorders (SCID-I) and self-report questionnaires regarding dizziness, depression, anxiety, somatisation and quality of life. Results Neurological diagnostic workup revealed organic and non-organic vertigo/dizziness in 80.8% and 19.2% of patients, respectively. In 48.8% of patients, SCID-I led to the diagnosis of a current psychiatric disorder, most frequently anxiety/phobic, somatoform and affective disorders. In the organic vertigo/dizziness group, 42.5% of patients, particularly those with vestibular paroxysmia or vestibular migraine, had a current psychiatric comorbidity. Patients with psychiatric comorbidity reported more vertigo-related handicaps, more depressive, anxiety and somatisation symptoms, and lower psychological quality of life compared with patients without psychiatric comorbidity. Conclusions Almost half of patients with vertigo/dizziness suffer from a psychiatric comorbidity. These patients show more severe psychosocial impairment compared with patients without psychiatric disorders. The worst combination, in terms of vertigo-related handicaps, is having non-organic vertigo/dizziness and psychiatric comorbidity. This phenomenon should be considered when diagnosing and treating vertigo/dizziness in the early stages of the disease.
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The diagnosis of somatisation disorder in DSM-IV was based on 'medically unexplained' symptoms, which is unsatisfactory. To determine the value of a total somatic symptom score as a predictor of health status and healthcare use after adjustment for anxiety, depression and general medical illness. Data from nine population-based studies (total n = 28 377) were analysed. In all cross-sectional analyses total somatic symptom score was associated with health status and healthcare use after adjustment for confounders. In two prospective studies total somatic symptom score predicted subsequent health status. This association appeared stronger than that for medically unexplained symptoms. Total somatic symptom score provides a predictor of health status and healthcare use over and above the effects of anxiety, depression and general medical illnesses.
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Phobic postural vertigo (PPV) is characterized by a subjective dizziness and postural imbalance. Changes in postural control strategy may cause the disturbed postural performance in PPV. A better understanding of the mechanisms behind this change in strategy is required to improve the diagnostic tools and therapeutic options for this prevalent disorder. Here we apply stabilogram diffusion analysis (SDA) to examine the characteristics and modes of interaction of open- and closed-loop processes that make up the postural control scheme in PPV. Twenty patients with PPV and 20 age-matched healthy controls were recorded on a stabilometer platform with eyes open and with eyes closed. Spatio-temporal changes of the center of pressure (CoP) displacement were analyzed by means of SDA and complementary CoP amplitude measures. (1) Open-loop control mechanisms in PPV were disturbed because of a higher diffusion activity (p < 0.001). (2) The interaction of open- and closed-loop processes was altered in that the sensory feedback threshold of the system was lowered (p = 0.010). These two changes were comparable to those observed in healthy subjects during more demanding balance conditions such as standing with eyes closed. These data indicate that subjective imbalance in PPV is associated with characteristic changes in the coordination of open- and closed-loop mechanisms of postural control. Patients with PPV use sensory feedback inadequately during undisturbed stance, and this impairs postural performance. These changes are compatible with higher levels of anti-gravity muscle activity and co-contraction during the conscious concentration on control of postural stability.
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Phobic postural vertigo is characterized by subjective imbalance and dizziness while standing or walking, despite normal values for clinical balance tests. Patients with phobic postural vertigo exhibit an increased high-frequency sway in posturographic tests. Their postural sway, however, becomes similar to the sway of healthy subjects during difficult balance tasks. Posturographic recordings of 30s of quiet stance was compared to recordings of 30s of quiet stance during a postural threat, which consisted of the knowledge of forthcoming vibratory calf muscle stimulation, in 37 consecutive patients with phobic postural vertigo and 24 healthy subjects. During quiet stance without the threat of forthcoming vibratory stimulation, patients with phobic postural vertigo exhibited a postural sway containing significantly more high-frequency sway than the healthy subjects. During the quiet stance with forthcoming vibratory stimulation, i.e., anticipation of a postural threat, the significant differences between groups disappeared for all variables except sagittal high-frequency sway. During postural threat, healthy subjects seemed to adopt a postural strategy that was similar to that exhibited by phobic postural vertigo patients. The lack of additional effects facing a postural threat among phobic postural vertigo patients may be due to an already maximized postural adaptation. Deviant postural reactions among patients with phobic postural vertigo may be considered as an avoidant postural response due to a constant fear of losing postural control.
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High rates of coexisting vestibular deficits and psychiatric disorders have been reported in patients with vertigo. Hence, a causal linkage between the vestibular system and emotion processing systems has been postulated. The aim of this study was to evaluate the impact of vestibular function and vestibular deficits as well as preexisting psychiatric pathologies on the course of vestibular vertigo syndromes over 1 year. This interdisciplinary prospective longitudinal study included a total of 68 patients with vestibular vertigo syndromes. Four subgroups were compared: benign paroxysmal positioning vertigo (BPPV, n=19), vestibular neuritis (VN, n=14), vestibular migraine (VM, n=27), and Menière's disease (MD, n=8). All patients underwent neurological and detailed neurootological examinations as well as two standardized interviews and a psychometric examination battery at five different times (T0-T4) over 1 year. The prevalence of psychiatric disorders at baseline (T0) did not differ between the four subgroups. Only patients with VM showed significantly higher rates of psychiatric disorders (p=0.044) in the follow-up over 1 year. Patients with a positive history of psychiatric disorders before the onset of the vestibular disorder had significantly increased rates of psychiatric disorders compared to patients with a negative history of psychiatric disorders (T1: p=0.004, T3: p=0.015, T4: p=0.012). The extent of vestibular deficit or dysfunction did not have any influence on the further course of the vestibular disease with respect to the development of psychiatric disorders. A positive history of psychiatric disorders is a strong predictor for the development of reactive psychiatric disorders following a vestibular vertigo syndrome. Especially patients with vestibular migraine are at risk of developing somatoform dizziness. The degree of vestibular dysfunction does not correlate with the development of psychiatric disorders.
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Little is known about the general population prevalence or severity of DSM-IV mental disorders. To estimate 12-month prevalence, severity, and comorbidity of DSM-IV anxiety, mood, impulse control, and substance disorders in the recently completed US National Comorbidity Survey Replication. Nationally representative face-to-face household survey conducted between February 2001 and April 2003 using a fully structured diagnostic interview, the World Health Organization World Mental Health Survey Initiative version of the Composite International Diagnostic Interview. Nine thousand two hundred eighty-two English-speaking respondents 18 years and older. Twelve-month DSM-IV disorders. Twelve-month prevalence estimates were anxiety, 18.1%; mood, 9.5%; impulse control, 8.9%; substance, 3.8%; and any disorder, 26.2%. Of 12-month cases, 22.3% were classified as serious; 37.3%, moderate; and 40.4%, mild. Fifty-five percent carried only a single diagnosis; 22%, 2 diagnoses; and 23%, 3 or more diagnoses. Latent class analysis detected 7 multivariate disorder classes, including 3 highly comorbid classes representing 7% of the population. Although mental disorders are widespread, serious cases are concentrated among a relatively small proportion of cases with high comorbidity.
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To improve treatment outcomes for patients with chronic dizziness by identifying clinical conditions associated with persistent symptoms and delineating key diagnostic features that differentiate its causes and direct attention to specific treatments. Prospective cohort study from 1998 to 2004. Tertiary care balance center. A total of 345 men and women, aged 15 to 89 years, referred for evaluation of chronic dizziness (duration of > or =3 months) of uncertain cause. Patients were systematically directed through multiple specialty examinations until definitive diagnoses were made. Final diagnoses associated with dizziness. Nearly all patients with chronic subjective dizziness were diagnosed with psychiatric or neurologic illnesses. These included primary and secondary anxiety disorders (n = 206 [59.7%]) and central nervous system conditions (n = 133 [38.6%]), specifically migraine headaches, mild traumatic brain injuries, and neurally mediated dysautonomias. A small number of patients (6 [1.7%]) had dysrhythmias. Four of 5 patients with migraine or dysrhythmias had comorbid anxiety. Chronic dizziness has several common causes, including anxiety disorders, migraine, traumatic brain injuries, and dysautonomia, that require different treatments. Key features of the clinical history distinguish these illnesses from one another and from active neurotologic conditions. The high prevalence of secondary anxiety may give a false impression of psychogenicity.
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A high degree of psychiatric disorders has repeatedly been described among patients with organic vertigo syndromes and attributed to vestibular dysfunction. Yet almost no investigations exist which differentiate between various organic vertigo syndromes with regard to psychiatric comorbidity. The following prospective, interdisciplinary study was carried out to explore whether patients with different organic vertigo syndromes exhibit different psychological comorbidities. 68 patients with organic vertigo syndromes (benign paroxysmal positioning vertigo (BPPV) n = 20, vestibular neuritis (VN) n = 18, Menière's disease (MD) n = 7, vestibular migraine (VM) n = 23) were compared with 30 healthy volunteers. All patients and control persons underwent structured neurological and neuro-otological testing. A structured diagnostic interview (-I) (SCID-I) and a battery of psychometric tests were used to evaluate comorbid psychiatric disorders. Patients with VM and MD showed significantly higher prevalence of psychiatric comorbidity (MD = 57%, VM = 65%) especially with anxiety and depressive disorders, than patients with VN (22%) and BPPV (15 %) compared to normal subjects (20 %). These elevated rates of comorbidities resulted in significantly elevated odds-ratios (OR) for the development of comorbid psychiatric disorders in general (for VM OR = 7.5, for MD OR = 5.3) and especially for anxiety disorders (for VM OR = 26.6, for MD OR = 38.7). As a consequence, a structured psychological and psychometric testing and an interdisciplinary therapy should be proceeded in cases with complex and prolonged vertigo courses, especially in patients with VM and MD. Possible reasons of these unexpected results in VM and MD are discussed.
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Chronic subjective dizziness (CSD) is frequent and affects twice as many women as men. Anxiety is a strong predisposing factor. The pathophysiologic concept of this disorder assumes that balance function and emotion share common neurologic pathways, which might explain that the balance disorder can provoke fear and vice versa, giving rise to a problem in perception of space and motion. In anxious patients this can turn into a space and motion phobia, with avoidance behaviour. CSD is a diagnosis based on the hypothesis of an interaction between the vestibular system and the psychiatric sphere. Patients complain of chronic imbalance, worsened by visual motion stimulation, and frequently suffer from anxiety. Vestibular examination reveals no anomalies. We evaluated the incidence and characteristics of CSD in patients referred to our neuro-otology centre (tertiary hospital outpatient clinic). This was a retrospective study of 1552 consecutive patients presenting with vertigo. CSD was diagnosed in 164 patients (female:male=111:53). CSD represents 10.6% of the dizzy patients in our clinic. Psychiatric disorder, mainly anxiety, was found in 79.3% of the cases. Other frequently associated factors were fear of heights and former vestibular lesion (healed). In all, 79.0% of the patients with CSD had poor balance performance on dynamic posturography testing.
Article
Objective: To examine the triggering causes of inadequate neuromuscular regulation of posture and subjective imbalance in patients with phobic postural vertigo (PPV), a subtype of functional dizziness. Methods: Postural performance was assessed by center-of-pressure displacements and surface EMG of lower-limb muscles (the tibialis anterior and soleus) in 10 patients with PPV and 10 healthy controls under 4 stance conditions: standing with eyes open or closed and with or without an additional cognitive dual task. The level of muscle cocontraction and the characteristics of open- and closed-loop postural control were analyzed. Results: At baseline (i.e., standing with eyes open without dual task), patients exhibited increased muscle cocontractions (p = 0.003), which were further associated with increased open-loop diffusion activity (p = 0.022) and a lowering of the primary feedback threshold for closed-loop control (p = 0.003). However, postural performance of patients improved considerably and normalized to that of healthy controls when performing an additional dual task. Conclusions: PPV is characterized by a dissociation of subjective postural instability and objectively maintained balance capabilities. The dual-task effects on balance in patients with PPV indicate that this dissociation might result from an increased attention to postural adjustments at baseline, which is normally required only during demanding balance situations. This internal focus on balance control promotes an inappropriate neuromuscular regulation of posture, with increased muscle cocontractions, higher short-term body sway, and an oversensitivity to external stimuli. However, if patients are distracted, muscle cocontractions and balance control normalize. Such distraction may therefore be an effective coping strategy for preventing PPV attacks in susceptible patients.
Article
Background: Vertigo and dizziness are among the most prevalent symptoms in neurologic disorders. Although many of these patients suffer from postural instability and gait disturbances, there is only limited data on their risk of falling. Methods: We conducted a controlled cross-sectional study at the tertiary care outpatient clinic of the German Center for Vertigo and Balance Disorders using a self-administered questionnaire to assess falls, fall-related injuries, and fear of falling. The recruitment period was 6 months. Results: A total of 569 patients (mean age 59.6 ± 17.1 years, 55% females) and 100 healthy participants were included (response rate > 90%). Dizzy patients with central balance disorders (Parkinsonian, cerebellar, and brainstem oculomotor syndromes) had the highest fall rates (> 50% recurrent fallers, odds ratio > 10). The rate of recurrent fallers was 30% in bilateral vestibular failure and peripheral neuropathy (odds ratio > 5). Patients with functional dizziness (somatoform or phobic vertigo) were concerned about falling but did not fall more often than healthy controls (odds ratio 0.87). Conclusion: Falls are common in patients presenting to a dizziness unit. Those with central syndromes are at risk of recurrent and injurious falling. Fall rates and fear of falling should be assessed in balance disorders and used to guide the regimen of rehabilitation therapy. The identification of risk factors would help provide protective measures to these groups of patients.
Article
Errors in Byline, Author Affiliations, and Acknowledgment. In the Original Article titled “Prevalence, Severity, and Comorbidity of 12-Month DSM-IV Disorders in the National Comorbidity Survey Replication,” published in the June issue of the ARCHIVES (2005;62:617-627), an author’s name was inadvertently omitted from the byline on page 617. The byline should have appeared as follows: “Ronald C. Kessler, PhD; Wai Tat Chiu, AM; Olga Demler, MA, MS; Kathleen R. Merikangas, PhD; Ellen E. Walters, MS.” Also on that page, the affiliations paragraph should have appeared as follows: Department of Health Care Policy, Harvard Medical School, Boston, Mass (Drs Kessler, Chiu, Demler, and Walters); Section on Developmental Genetic Epidemiology, National Institute of Mental Health, Bethesda, Md (Dr Merikangas). On page 626, the acknowledgment paragraph should have appeared as follows: We thank Jerry Garcia, BA, Sara Belopavlovich, BA, Eric Bourke, BA, and Todd Strauss, MAT, for assistance with manuscript preparation and the staff of the WMH Data Collection and Data Analysis Coordination Centres for assistance with instrumentation, fieldwork, and consultation on the data analysis. We appreciate the helpful comments of William Eaton, PhD, Michael Von Korff, ScD, and Hans-Ulrich Wittchen, PhD, on earlier manuscripts. Online versions of this article on the Archives of General Psychiatry Web site were corrected on June 10, 2005.
Article
Classifications and definitions are essential to facilitate communication; promote accurate diagnostic criteria; develop, test, and use effective therapies; and specify knowledge gaps. This article describes the development of the International Classification of Vestibular Disorders (ICVD) initiative. It describes its history, scope, and goals. The Bárány Society has played a central role in organizing the ICVD by establishing internal development processes and outreach to other scientific societies. The ICVD is organized in four layers. The current focus is on disorders with a high epidemiologic importance, such as Menière disease, benign paroxysmal positional vertigo, vestibular migraine, and behavioral aspects of vestibular disorders. Copyright © 2015 Elsevier Inc. All rights reserved.
Article
This review shows that persons with visual height intolerance or acrophobia exhibit typical restrictions of visual exploration and imbalance during stance and locomotion when exposed to heights. Eye and head movements are reduced, and gaze freezes to the horizon. Eye movements tend to be horizontal saccades during stance and vertical saccades during locomotion. Body posture is characterized by a stiffening of the musculoskeletal system with increased open-loop diffusion activity of body sway, a lowered sensory feedback threshold for closed-loop balance control, and increased co-contraction of antigravity leg and neck muscles. Walking is slow and cautious, broad-based, consisting of small, flat-footed steps with less dynamic vertical oscillation of the body and head. Anxiety appears to be the critical symptom that causes the typical but not specific eye and body motor behavior, which can be described as tonic immobility. Guidelines for preventing acrophobia, which could be an add-on to behavioral therapy, are provided. © 2015 New York Academy of Sciences.
Article
Fear of heights is elicited by a glance into an abyss. However, the visual exploration behavior of fearful subjects at height has not been analyzed yet. We investigated eye- and head movements, i.e. visual exploration behavior, of subjects susceptible to fear of heights during exposure to a visual cliff. The movements of eyes and head were recorded in 19 subjects susceptible to fear of heights and 18 controls while standing still on an emergency balcony 20 meters above ground level for periods of 30 seconds. Participants wore mobile, infrared eye-tracking goggles with inertial sensors for recording head movements. Susceptibles exhibited fewer and smaller-amplitude eye-in-head saccades with fixations of longer duration. Spontaneous head movements were reduced by 49% in susceptibles with a significantly lower mean absolute angular velocity (5.3°/s vs. 10.4°/s), and all three dimensions (yaw, pitch and roll) were equally affected. Gaze-in-space - which indicates exploration by coordinated eye-head movements - covered a smaller total area of the visual scene (explored horizontal angle: 19° vs. 32°, vertical: 9° vs. 17°). We hypothesize that the susceptibles suppress eye and head movements to alleviate fear of heights. However, this behavior has the potential disadvantage of impairing the visual stabilization of postural balance.
Article
Patients who experience chronic dizziness are considered to be difficult to treat. Persisting symptoms of vertigo can be caused by recurrent organic as well as a variety of psychogenic factors, the latter usually being part of anxiety and depression disorders. Psychotherapeutic interventions can achieve improvements, the effects, however, in general do not persist over a longer time. The purpose of this study is to investigate the long-term effects of a symptom-related indoor treatment including neurotological and psychotherapeutic approaches as well as vestibular and balance rehabilitation. 23 indoor patients 16 male patients and 7 female., mean age 56.6 years (SD 12) with chronic vestibular symptoms (longer than six months), who were treated with neurotological counseling, psychotherapy, vestibular and balance rehabilitation and-if necessary-antidepressant drugs during a lengthy hospital stay [average 40 days (SD 14)], were re-examined. After a time period of at least one year (average 32 months; SD 15) they were asked to answer a questionnaire concerning post-therapeutic status of dizziness, symptoms and coping strategies as well as the Hospital Anxiety and Depression Score (HADS D). 18 of 23 patients (78%) reported a sustained reduction in their vertiginous symptoms. Four patients did not report a persistent improvement and one even got worse. Patients with a chronic form of dizziness can improve through a coordinated neurotologic and psychotherapeutic approach including vestibular and balance rehabilitation.
Article
Chronic subjective dizziness (CSD) is a neurotologic disorder of persistent non-vertiginous dizziness, unsteadiness, and hypersensitivity to one's own motion or exposure to complex visual stimuli. CSD usually follows acute attacks of vertigo or dizziness and is thought to arise from patients' failure to re-establish normal locomotor control strategies after resolution of acute vestibular symptoms. Pre-existing anxiety or anxiety diathesis may be risk factors for CSD. This study tested the hypothesis that patients with CSD are more likely than individuals with other chronic neurotologic illnesses to possess anxious, introverted personality traits. Data were abstracted retrospectively from medical records of 40 patients who underwent multidisciplinary neurotology evaluations for chronic dizziness. Twenty-four subjects had CSD. Sixteen had chronic medical conditions other than CSD plus co-existing anxiety disorders. Group differences in demographics, Dizziness Handicap Inventory (DHI) scores, Hospital Anxiety and Depression Scale (HADS) scores, DSM-IV diagnoses, personality traits measured with the NEO Personality Inventory - Revised (NEO-PI-R), and temperaments composed of NEO-PI-R facets were examined. There were no differences between groups in demographics, mean DHI or HADS-anxiety scores, or DSM-IV diagnoses. The CSD group had higher mean HADS-depression and NEO-PI-R trait anxiety, but lower NEO-PI-R extraversion, warmth, positive emotions, openness to feelings, and trust (all p<0.05). CSD subjects were significantly more likely than comparison subjects to have a composite temperament of high trait anxiety plus low warmth or excitement seeking. An anxious, introverted temperament is strongly associated with CSD and may be a risk factor for developing this syndrome.
Article
The influence of anxiety on ocular motor control and gaze has received less research attention than its effects on postural control and locomotion. This review summarizes research on trait anxiety, state anxiety, anxiety disorders, ocular motor reflexes, and gaze. It applies these findings to clinical problems of visually induced unsteadiness and dizziness (VUD, also known as visual vertigo), fear of falling (FoF), and chronic subjective dizziness (CSD). Humans are inherently more sensitive to vertical heights than horizontal distances. Vertical height intolerance is reported by one-quarter to one-third of the general population. Humans also possess a gaze bias toward potentially threatening stimuli in the visual field, more prominent in individuals with higher versus lower trait anxiety and increased by state anxiety. This bias may drive hypervigilance-avoidance gaze patterns in patients with social anxiety disorder and specific phobias. Trait and state anxiety also appear to adversely affect gaze control, reducing gaze stability on visual targets. This may be one mechanism underlying persistent VUD and visual symptoms of CSD. Anxiety-related gaze diversion may increase gait instability in patients with FoF. Anxiety affects ocular motor reflexes and gaze control in ways that may contribute to clinically significant visual and visual-vestibular syndromes.
Article
The objectives were to compare the personality of fibromyalgia (FM) patients with other chronic painful and nonpainful disorders considering the confusion due to psychopathology and to assess the clustering of FM patients according to their personality profile. Differences in the NEO Five-Factor Inventory between FM, non-FM chronic pain and drug-resistant epileptic patients were assessed including the confounding effect of demographics and psychopathological status by multivariate regression analysis. Clustering of FM patients was assessed by two-step cluster analysis. Differences in clinical severity and psychosocial problems between subgroups and their outcome 6 months after multidisciplinary treatment were assessed. The final sample comprised 874 patients. Once the effect of confounding variables was considered, clinically nonsignificant differences in personality were observed between groups. FM patients could, however, be grouped into two clusters. Cluster 1 was characterized by higher neuroticism and lower extraversion and showed a worse pretreatment clinical state including more psychosocial problems. In spite of having reached a wider general improvement at 6-month follow-up, Cluster 1 patients remained more anxious and depressed. Identifying personality-based subgroups of FM might allow implementing specific preventive strategies. FM treatment might be optimized by increasing medication compliance, improving therapeutic alliance and testing different therapeutic options and treatment sequencing for each personality subgroup.
Article
It is well established that personality traits are associated with anxiety and depressive disorders in Western populations, but it is not known whether this is true also for people from non-Western cultures. In this study, we examined whether ethnicity moderates the association between personality dimensions and anxiety or depressive disorders or symptoms. In a random urban population sample, stratified by ethnicity, in Amsterdam, the Netherlands, we interviewed 309 native Dutch subjects, 203 Turkish-Dutch subjects, and 170 Moroccan-Dutch subjects. Dimensions of personality were measured using the NEO Five-Factor Inventory. Anxiety and depressive disorders and symptom levels were assessed with the Composite International Diagnostic Interview and the Symptom Checklist-90-Revised. The association between personality factors and disorders or symptoms of anxiety and depression was very similar in the three ethnic groups: all show the typical profile of high neuroticism and low extraversion, agreeableness, and conscientiousness.
Article
Purpose: The study sought to evaluate the longer-term effects of a brief cognitive behavior therapy (CBT) intervention for patients with chronic subjective dizziness (CSD). In addition, it sought to identify predictors of longer-term disability in this group. Materials and methods: Forty-four patients with CSD referred by a neuro-otological clinic were followed-up six months after completing a brief treatment program based on the CBT model of panic disorder. Patients completed the following measures: Dizziness Handicap Inventory, Depression, Anxiety and Stress Scales, Dizziness Symptoms Inventory, and the Safety Behaviours Inventory. Measures were completed at pre and post-treatment, as well as at one and six months post-treatment. Results: Treatment gains observed immediately after treatment were maintained at one and six months post-treatment. High levels of pre-treatment anxiety predicted higher levels of disability at six months post-treatment. Duration and severity of dizziness, and medical or psychiatric comorbidity did not predict disability at six month follow-up. Conclusions: A brief CBT intervention for patients with CSD produced improvements in physical symptoms, disability, and functional impairment which were sustained at one month and six months post intervention. Patients with high levels of anxiety prior to treatment had higher levels of disability at six months post-treatment. It is possible that more focused interventions that specifically target anxiety might produce further benefits for this cohort.
Article
Purpose of review: In 1986, the German neurologists Thomas Brandt and Marianne Dieterich described a syndrome of phobic postural vertigo (PPV) based on clinical observations of patients with nonvertiginous dizziness that could not be explained by then-known neuro-otologic disorders. Subsequent research by an American team led by Jeffrey Staab and Michael Ruckenstein confirmed the core physical symptoms of PPV, clarified its relationship to behavioral factors, and streamlined its definition, calling the syndrome chronic subjective dizziness (CSD). This article reviews the 26-year history of PPV and CSD and places it within the context of current neurologic practice. Recent findings: Recent investigations in Europe, the United States, Israel, and Japan have validated the primary symptoms of CSD; identified its provoking factors and precipitants; elucidated its long-term clinical course, differential diagnosis, and common comorbidities; developed successful treatment strategies with serotonergic antidepressants, vestibular habituation, and possibly cognitive-behavioral therapy; and raised new hypotheses about pathophysiologic processes that initiate and maintain the disorder. In tertiary neuro-otology centers where it is recognized, CSD is the second most common diagnosis among patients presenting with vestibular symptoms. Summary: A quarter century of research has established CSD as a common clinical entity in neurologic and otorhinolaryngologic practice. Its identification and treatment offer relief to many patients previously thought to have enigmatic and unmanageable cases of persistent dizziness. Internationally sanctioned diagnostic criteria for CSD are under development for the first edition of the International Classification of Vestibular Disorders, scheduled for publication in early 2013.
Article
To compare presentations of Ménière's disease (MD), vestibular migraine (VM), and Ménière's disease plus vestibular migraine (MDVM), with and without comorbid chronic subjective dizziness (CSD). Retrospective review with diagnosis confirmed by consensus conference of investigators using published criteria for MD, VM, and CSD. Ambulatory, tertiary dizziness clinic. Approximately 147 consecutive patients with diagnoses of MD, VM, or MDVM, with/without comorbid CSD. Diagnostic consultation. Similarities and differences between diagnostic groups in demographics; symptoms; and results of neurotologic, audiometric, and vestibular laboratory assessments. Seventy-six patients had MD, 55 MD alone. Ninety-two patients had VM, 71 VM alone. Twenty-one patients had MDVM, representing about one-quarter of those diagnosed with MD or VM. Clinical features thought to differentiate VM from MD were found in all groups. Twenty-seven patients with VM (38%) had ear complaints (subjective hearing loss, aural pressure, and tinnitus) during episodes of vestibular symptoms and headache, including 10 (37%) with unilateral symptoms. Conversely, 27 patients with MD alone (49%) had headaches with migraine features that did not meet full IHS diagnostic criteria, migrainous symptoms (photophobia, headache with vomiting), or first-degree relative with migraine. Including MDVM patients, 59% (45/76) of all patients with MD had migrainous features. Thirty-two patients had CSD; most (29; 91%) were in the VM group. Comorbidity was common between MD and VM, and their symptoms overlapped. More specific diagnostic criteria are needed to differentiate these diseases and address their coexistence. CSD co-occurred with VM but was rarely seen with MD.