CASE STUDYCASE STUDY

PSYCHOGENIC PSYCHOGENIC VESTIBULAR VESTIBULAR DISORDERDISORDER

Date = 06/05/08Date = 06/05/08

Summary of Referral Summary of Referral InformationInformation

Summary of Letter from GP;

‘This young man has had unsteadiness and vertigo over the last six months. He has failed to respond to betahistine and prochloroperazine and has become very fed-up and down with this. He has also had panic attacks. Interestingly, he had a similar problem when his parents were separating as a child. He is a fairly self-critical and tense individual who has low self esteem. I would be most grateful if you could advise further on his dizziness.

Plan for SessionPlan for Session

Check MedicationsCheck Medications History History QuestionnairesQuestionnaires AudiogramAudiogram TympanometryTympanometry Balance Testing Balance Testing DebriefDebrief

General HistoryGeneral History

Attended with girlfriendAttended with girlfriend 24 years old24 years old Applying to police forceApplying to police force Personal adviserPersonal adviser Not working due to dizzinessNot working due to dizziness ClaustrophobicClaustrophobic

HistoryHistory Vague HistorianVague Historian Symptoms started as a teenager, 14 years oldSymptoms started as a teenager, 14 years old General sense of disorientationGeneral sense of disorientation no distinct episodic dizziness or rotatory no distinct episodic dizziness or rotatory

vertigovertigo Feels better when sat stillFeels better when sat still Motion sensitive Motion sensitive Symptoms are constantSymptoms are constant Loss of appetite and nausea since dizziness Loss of appetite and nausea since dizziness

beganbegan Anxiety and depressionAnxiety and depression Suffers from panic attacksSuffers from panic attacks

History cont…..History cont…..

Constant light-headed and faint Constant light-headed and faint feelingfeeling

Increase in anxiety and depression Increase in anxiety and depression symptoms since events startedsymptoms since events started

Hyperventilating during attacksHyperventilating during attacks

Clinical AppearanceClinical Appearance

Gait and balance looked normalGait and balance looked normal Tired and emotionalTired and emotional AnxiousAnxious Comments like ‘life wouldn’t be Comments like ‘life wouldn’t be

worth living’ if continuedworth living’ if continued

Medical HistoryMedical History

Colds and Sinus ProblemsColds and Sinus Problems No other significant historyNo other significant history

MedicationsMedications

Beta-Blockers for AnxietyBeta-Blockers for Anxiety

General TestsGeneral Tests

Otoscopy Otoscopy AudiometryAudiometry TympanometryTympanometry GHQ questionnaireGHQ questionnaire

Balance AssessmentBalance Assessment

Spontaneous and Gaze AssessmentSpontaneous and Gaze Assessment SaccadesSaccades Smooth PursuitSmooth Pursuit Dix Hallpike Dix Hallpike Head Roll testingHead Roll testing Caloric testingCaloric testing

Summary of ResultsSummary of Results OtoscopyOtoscopy - - No abnormalities observed bilaterallyNo abnormalities observed bilaterally Audiometry -Audiometry -Thresholds within normal limits Thresholds within normal limits

bilaterallybilaterally TympanometryTympanometry - - Raised middle ear compliance Raised middle ear compliance

on right and pressure within normal limits on right and pressure within normal limits bilaterallybilaterally

Gait and balanceGait and balance – – Informal observation Informal observation revealed normal gait and no obvious unsteadiness revealed normal gait and no obvious unsteadiness on walking into clinicon walking into clinic

Spontaneous and GazeSpontaneous and Gaze – – did not reveal any did not reveal any nystagmus or symptomsnystagmus or symptoms

Saccades and PursuitSaccades and Pursuit – – did not reveal any did not reveal any nystagmus or symptomsnystagmus or symptoms

Results Continued..Results Continued..

Dix-Hallpike and Head RollsDix-Hallpike and Head Rolls = = did not did not reveal any nystagmus or symptoms, reveal any nystagmus or symptoms, negative in all positionsnegative in all positions

Warm Calorics (44Warm Calorics (44º) - symmetricalº) - symmetrical – – No significant Canal Paresis or DP No significant Canal Paresis or DP observedobserved

GHQ = GHQ = scorescore = 9 ( = 9 (low for depressionlow for depression))

the 28-items "scaled" version (has four the 28-items "scaled" version (has four subscales: somatisation, social subscales: somatisation, social dysfunction, anxiety, and depression) dysfunction, anxiety, and depression)

ConclusionsConclusions

No evidence of peripheral or central No evidence of peripheral or central cause of dizziness cause of dizziness

Complete set of normal vestibular Complete set of normal vestibular testing resultstesting results

Suggests panic and anxiety may be Suggests panic and anxiety may be contributing significantly to the contributing significantly to the patient’s symptoms patient’s symptoms

May be Psychogenic in natureMay be Psychogenic in nature

Psychogenic DizzinessPsychogenic Dizziness

No organic disease is present No organic disease is present Large amount of psychological Large amount of psychological

disability in persons with vertigodisability in persons with vertigo Difficult diagnoses to reachDifficult diagnoses to reach

Clinical ManifestationsClinical Manifestations dizzy sensation is typically persistent and dizzy sensation is typically persistent and

continuous continuous punctuated by episodes of punctuated by episodes of hyperventilation provocative factors may be identified, such as provocative factors may be identified, such as

the presence of crowds, driving, or being in the presence of crowds, driving, or being in confined places confined places

““manifestations of anxiety, including manifestations of anxiety, including apprehension, dread, nervousness, tension, apprehension, dread, nervousness, tension, restlessness, and autonomic manifestations”restlessness, and autonomic manifestations”

Episodes are often poorly describedEpisodes are often poorly described Panic attacksPanic attacks

(all fits in with current patient)(all fits in with current patient)

ManagementManagement Psychotherapeutic approaches such as Psychotherapeutic approaches such as

cognitive behavioural therapy cognitive behavioural therapy Medications – to treat depression and anxiety Medications – to treat depression and anxiety

(beta-blockers) (beta-blockers) Perform tests - reassure the patient that no Perform tests - reassure the patient that no

organic disease is presentorganic disease is present Referrals to Psychiatry / NeurologyReferrals to Psychiatry / Neurology Vestibular Rehabilitation – possible breathing Vestibular Rehabilitation – possible breathing

control exercisescontrol exercises Multi-disciplinary team which includes ENT, Multi-disciplinary team which includes ENT,

audiologists, hearing therapist, clinical audiologists, hearing therapist, clinical psychologists, and physiotherapistspsychologists, and physiotherapists

Other Useful tests…Other Useful tests… Hyperventilation TestHyperventilation Test - The early literature - The early literature

suggested that this was a sign of suggested that this was a sign of psychogenic (psychiatric) disturbance (Drachman (Drachman and Hart, 1972), but later workers using better and Hart, 1972), but later workers using better technology to monitor eye movements suggest that technology to monitor eye movements suggest that nystagmus induced by hyperventilation is a good nystagmus induced by hyperventilation is a good sign of vestibular diseasesign of vestibular disease

Must be emphasised positive hyperventilation does Must be emphasised positive hyperventilation does not rule out vestibular disorder not rule out vestibular disorder

use of the Nijmegen Questionnaireuse of the Nijmegen Questionnaire

Evidence BaseEvidence Base

“ “A close association between anxiety A close association between anxiety and dizziness was emphasized by and dizziness was emphasized by Sigmund Freud in an early paper on Sigmund Freud in an early paper on anxiety neurosis” (Freud 1895)anxiety neurosis” (Freud 1895)

Studies: Simon Studies: Simon et alet al (1998)(1998)

Psychosomatic model -- a primary psychiatric Psychosomatic model -- a primary psychiatric disturbance causes dizzinessdisturbance causes dizziness hyperventilation and hyper arousal increased hyperventilation and hyper arousal increased

vestibular sensitivityvestibular sensitivity

Somato-psychic model -- a primary inner ear Somato-psychic model -- a primary inner ear disturbance causes anxiety, signals from the disturbance causes anxiety, signals from the inner ear are misinterpreted as signifying inner ear are misinterpreted as signifying immediate danger, which increases anxiety. immediate danger, which increases anxiety. Increased anxiety increases misinterpretation. Increased anxiety increases misinterpretation. Conditioning makes it persistent Conditioning makes it persistent

The chicken or the egg, difficult to know whichThe chicken or the egg, difficult to know which

Studies cont…… Studies cont……

Staab and colleagues (2003) Staab and colleagues (2003) Laryngoscope. 2003; 113:1714-8Laryngoscope. 2003; 113:1714-8

345 men and women age 15 to 89 (average age 43.5) 345 men and women age 15 to 89 (average age 43.5) dizziness for three months or longer due to unknown dizziness for three months or longer due to unknown causes. “All but six patients were diagnosed as causes. “All but six patients were diagnosed as having psychiatric or neurologic conditions, having psychiatric or neurologic conditions, including anxiety disorders, migraine, traumatic including anxiety disorders, migraine, traumatic brain injury and neurally mediated dysautonomias” brain injury and neurally mediated dysautonomias”

Anxiety disorders were associated with 60 percent of Anxiety disorders were associated with 60 percent of the chronic dizziness cases the chronic dizziness cases

33 percent of the subjects with psychogenic 33 percent of the subjects with psychogenic dizziness had a primary psychiatric diagnosis dizziness had a primary psychiatric diagnosis

Staab Staab et al.et al. 2003 2003

3 patterns emerged;3 patterns emerged; Anxiety disorders can be sole cause of dizzinessAnxiety disorders can be sole cause of dizziness Neurotologic condition can trigger the development of

anxiety and phobic behaviours A neurotologic condition was responsible for the onset

of dizziness but also exacerbated pre-existing or anxiety symptoms

N.B; Depression was considerably less common than anxiety and was never a primary cause of dizziness

Evidence BaseEvidence Base1.1. Lanska, D.J; Psychophysiological vertigo. Lanska, D.J; Psychophysiological vertigo.

(psychogenic vertigo) Neurology 2006 (psychogenic vertigo) Neurology 2006 (www.medlink.com)(www.medlink.com)

2.2. Staab JPStaab JP, Ruckenstein MJ. A psychiatric approach , Ruckenstein MJ. A psychiatric approach to chronic dizziness. Psychiatric Annals 2005 to chronic dizziness. Psychiatric Annals 2005 35(4): 330-8.35(4): 330-8.

3.3. Staab JP,Staab JP, Ruckenstein MJ. Which comes first? Ruckenstein MJ. Which comes first? Psychogenic dizziness versus otogenic anxiety. Psychogenic dizziness versus otogenic anxiety. Laryngoscope 2003 113:1714-8, 2003. Laryngoscope 2003 113:1714-8, 2003.

4.4. Hain, T.C. Vertigo and Psychological Disturbances Hain, T.C. Vertigo and Psychological Disturbances December 26, 2007 December 26, 2007

5.5. Simon NM, Pollack MH, Tuby KS, Stern TA. Simon NM, Pollack MH, Tuby KS, Stern TA. Dizziness and Panic disorder: A review of the Dizziness and Panic disorder: A review of the association between vestibular dysfunction and association between vestibular dysfunction and anxiety. Annals Clin Psych 10, 1998, 2, 75-80anxiety. Annals Clin Psych 10, 1998, 2, 75-80

6.6. Drachman D, Hart CW. Neurology 1972, 22, 323-Drachman D, Hart CW. Neurology 1972, 22, 323-334334

7.7. Hain, T.C website: Hain, T.C website: www.dizzinessandbalance.com