no longer chronic subjective dizziness: new insights into ... · ©2013 mfmer | slide-1 no longer...

©2013 MFMER | slide-1

No Longer Chronic Subjective Dizziness:

New Insights into the Mechanisms of Persistent Vestibular Symptoms

Jeffrey P. Staab, MD, MSAssociate Professor of Psychiatry

27 April 2016

British Society of AudiologyAnnual Conference


Disclosures

• Commercial support

• None

• Grant support

• US National Institutes of Health

• Mayo Clinic

• Disclaimer

• Chair, Behavioral Subcommittee

• Committee for Classification Vestibular Disorders of the Bárány Society (CCBS)

• Off-label medical use

• No medications are approved by any regulatory agency to treat functional vestibular disorders.

• SSRIs/SNRIs for persistent postural-perceptual dizziness


Overview

1. Review history of physical & psychological interactions in patients with vestibular and balance symptoms

• 19th century observations

• 20th century symptoms and syndromes

• 21st century classification

2. Describe emerging data on pathophysiologic mechanisms

• Clinical applications – evaluation, education and treatment

3. Guiding principle

“Patients want an explanation for their suffering, but do not want to be laughed at, or worse, considered to be insane.”

- Carl Westphal, 1871


Die Agoraphobie (fear of marketplace)

Kuch and Swinson, Can J Psychiatry, 1992

“Patients find it impossible to cross open squares and walk along certain streets. Fear restricts their mobility, [but] they insist that they are not aware of any reasons for their anxiety. It seems to arise as an alien force as soon as a square is crossed or approached. With the anxiety, as part of one process, occurs the thought of not being able to cross and a perception of an enormous expanse of space.”

Carl Westphal, 1871

“cross squares and

walk along streets”

“Fear restricts

mobility”

“thought of not being

able to cross”

“enormous expanse of

space”

Locomotion

Conscious motor

control

Spatial

orientation

Instinctive threat

response

“part of one process”


19th century

20th century

From Die Agoraphobia to psychogenic dizziness

Psychogenic

dizziness

Die Agoraphobia

(fear of marketplace)

1871

Platzschwindel

(vertigo in plaza)

1870

Platzangst

(fear in plaza)

1872

Otologic triggers

Anxious predisposition

1898

Habituation by

systematic exposure

1873

Chronic

vestibulopathyAgoraphobia

Balaban and Jacob,

J Anxiety Disorders, 2001


From psychogenic dizziness to 20th century syndromes

• 1870 – Platzschwindel

• 1871 – Die Agoraphobia

• 1872 – Platzangst

• 1975-1985 – Supermarket syndrome, Space phobia,

Motorist’s vestibular disorientation syndrome

• 1986 – Phobic postural vertigo (Munich)

• 1993 – Space-motion discomfort (Pittsburgh)

• 1995 – Visual vertigo (London)

• 2004 – Chronic subjective dizziness (Philadelphia)

Psychogenic dizziness


20th century syndromes – key features

• Phobic postural vertigo (PPV)

• Dizziness or unsteadiness

• When upright or exposed to certain environments

• Phobic avoidance behaviors

• Space-motion discomfort (SMD), space-motion phobia (SMP)

• Rocking or swaying unsteadiness

• Heightened sensitivity to motion of self or surroundings

• Uneasiness about balance

• Visual vertigo (Visually induced dizziness – VID)


• When exposed to complex or moving visual stimuli

• Chronic subjective dizziness (CSD)


• Complex motion environments, precision visual tasks


Four blind men and an elephant

a hose

a tree

a rope

a fan


Four research groups and a syndrome

Visual vertigo

Phobic postural vertigo

Chronic

Subjective

Dizziness

Space-motion discomfort


Organization of 20th century symptoms and syndromes

Symptom or syndrome Complex symptom Clinical syndrome

Longitudinal course EpisodicEpisodic

+ chronicFluctuating Chronic

Triggering

events

Medical conditions

PPV

CSD

Psychological stress

SMD

Vestibular syndromes

VID

Primary

symptoms

Dizziness, unsteadiness,

non-spinning vertigo

Provocative

factors

Visual stimuli

Motion of self

Upright posture

Phobic

symptoms

Minor

SMP

Anxiety

disorder

sMajor


Classification of 21st century functional vestibular disorders

Persistent postural-perceptual dizziness (PPPD)Phobic postural dizziness (PPD)

Functional vestibular disorders

Longitudinal coursePersistent with

situational provocation

Triggering

events

Vestibular syndromes

PPPD

PPD

Psychological stress

Other medical conditions

Primary

symptoms

Dizziness, unsteadiness,

non-spinning vertigo

Provocative

factors

Visual stimuli

Motion of self

Upright posture

Phobic

symptoms

Minor

Major Anxiety disorders


Structural-

cellularFunctional

21st Century Vestibular Disorders

Dieterich, Staab, Brandt, “Dizziness” in Hallett et al., eds.,

Functional Neurologic Disorders, in press


Structural-

cellularPPPD

21st Century Vestibular Disorders

PPD


A. One or more symptoms of dizziness, unsteadiness, or non-spinning vertigo are present on most days for 3 months or more.1,2

1. Symptoms are persistent, but wax and wane.

2. Symptoms often increase as the day progresses, but may not be active throughout the entire day.

3. Momentary flares may occur spontaneously or with sudden movements.

B. Symptoms are present without specific provocation, but are exacerbated by:3

1. Upright posture,

2. Active or passive motion without regard to direction or position,

3. Exposure to moving visual stimuli or complex visual patterns.4

Persistent Postural and Perceptual Dizziness (PPPD)

1 Symptoms must be present for more than 15 of every 30 days. The

overwhelming majority of patients experience daily symptoms.

2 Symptoms need not be continuous, but must be present for prolonged (hours-long) periods throughout the day. Momentary symptoms alone do not fulfill this criterion.

3 Factors B.1.-3. may not be equally provocative.

4 Provocative visual stimuli may be encountered during performance of sedentary activities that require sustained visual focus.


C. The disorder typically begins shortly after an event that causes acute vestibular symptoms or problems with balance.5

1. Precipitating events include acute or episodic vestibular syndromes, other neurologic or medical illnesses, and acute psychological distress.

2. Symptoms usually are present from initial onset as described in criterion A, but they may occur intermittently at first, and then consolidate into a persistent course.

3. A slow, gradual onset occurs less often.

D. Symptoms cause significant distress or functional impairment.

E. Symptoms are not better attributed to another disease or disorder.6

Persistent Postural and Perceptual Dizziness (PPPD)

5 The most common precipitating events are peripheral or central vestibular conditions, vestibular migraine, panic attacks or generalized anxiety with dizziness, concussion, orthostatic intolerance, and dysrhythmias. It may not be possible to identify a specific trigger in all cases. Slow onset occurs with slowly developing triggers.6 PPPD may co-exist with other diseases or disorders. Evidence of another active illness does not necessarily exclude this diagnosis, but may indicate the presence of a comorbid condition.


PPPD (CSD) – Triggering events

Anxiety disorder

- panic attacks 15%

- generalized anxiety 15%

Acute vestibular syndromes

- with/without secondary anxiety 25%

Neurologic Illnesses

- migraine 20%

- traumatic brain injury 15%

- orthostatic intolerance 7%

Other Medical Conditions

- dysrhythmias, adverse drug reactions 3%

Staab & Ruckenstein,

Arch Oto-HNS, 2007

N=345


Pathophysiologic mechanisms – emerging data

1. High demand postural control strategy

• Stiffened – high frequency, low amplitude sway

• Lower threshold for closed loop feedback

2. Altered sensory integration

• Visual dependence

• Somatosensory dependence

3. Increased involvement of threat (anxiety) systems

• Initial process – high initial anxiety drives #1 and #2

• Sustaining mechanism – failure to readapt


Acute vestibular neuritis

(N=75)

Vestibular tests

Compensated (N=20)

Non-compensated (N=2)

Recovered

(N=53)

Chronic dizziness

(N=22)

1 year

Heinrichs, et al., Psychol Med, 2007;

Best, et al., Neuroscience, 2009;

Mahoney, et al., Am J Otolaryngol, 2013;

Cousins, et al., forthcoming

Acute anxiety (85%)

Acute vestibular syndrome + anxiety chronic dizziness

Godemann, et al., J Psychiatric Res, 2005;


High-demand postural control

Davis JR, et al., J Neurophysiol, 2011; Ödman & Maire, Acta Oto-Laryngol, 2008

3.2m platformFloor level

Stiffer postural control

due to co-contraction of

ankle musculature

Normal CSD CSD

Detected in:

• Normal individuals

(at height)

• Patients with:

• Fear of heights

• Fear of falling

• PPPD (PPV & CSD)


Effect of anxious personality traits on postural control

Hainaut J-P, et al., Gait & Posture, 2011

Increased threat:

Eyes closed

Mental stress

Higher trait anxiety

decreased threshold

for shifting into a high-

risk (stiffer) postural

control strategy

Very low

trait anxiety

Intermediate

trait anxiety


Increased visual dependence in patients with persistent dizziness handicap

Cousins, et al., PLoS 2014;

Cousins, et al., forthcoming

Prospective follow-up:

6 months after acute

vestibular neuritis

Primary predictor of

visual dependence:

Acute anxiety


Neurophysiology of PPPD – fMRI study

Anterior insula/inferior frontal gyrus

Posterior insula/superior temporal gyrus (PIVC)

Middle occipital cortex

HippocampusAnterior cingulate cortex

local

response

in PPPD

functional connectivity in PPPD Indovina, et al., Front

Behav Neuro, 2015


Recovery• Neuro-otologic• Medical• Psychological

Pathophysiologic Processes of PPPD

Staab JP, Continuum, 2012

Psychiatric Comorbidity• Anxiety• Phobia• Depression

Provoking Factors• Upright posture• Motion• Visual stimuli

High-risk postural control (pathological)

Failure to Readapt

Precipitants• Vestibular• Psychological• Neurologic• Other medical

Predisposing Factors• Temperament

(neurotic introvert)• Pre-existing

anxiety

Acute Adaptation• High-risk postural

control (physiological)• Stiffer gait and stance• Visual dependence


Treatment – Education & Physical Therapy

• Retrospective review N=26 – home exercises after 1 PT visit

• Education about the disorder

• Normal and high-risk postural control strategies

• Failure to readapt

• 22/26 – helpful or very helpful

• Vestibular habituation therapy

• Plan -- habituation exercises

• Head/body movement and visual stimuli

• Performed twice daily at home

• Follow-up at 6+ months (mean 27.5 mo)

• 14/26 – helpful or very helpful

Thompson, et al., J Vest Res, 2015


0

5

10

15

20

0 2 4 8 12 16 LOCF

Physical

Functional

Emotional

Sertraline treatment (66-84% response rate)D

izzin

ess H

an

dic

ap

In

ve

nto

ry s

co

res

Weeks of Treatment

*p<0.05 **p<0.01

*

****

***

*

****

**

Staab et al., Laryngoscope, 2004

8 open trials

• All 6 SSRIs

• 2 of 6 SNRIs

ovenlafaxine, milnacipran

• PPPD-type dizziness

• Not mediated by anxiety, depression


Treatment – Psychotherapy

• Cognitive behavior therapy (CBT)

• Long-standing PPV (PPPD)

• 8-12 sessions of CBT + self-directed exposure exercises > exercises alone

• Benefits were lost at 1 year

Emerging CSD (PPPD)

• 3 sessions of CBT > wait list control

• Large benefits were maintained at 1 and 6 months follow-up.

Holmberg, et al., J Neurol, 2007;

Mahoney, et al., Am J Otolaryn, 2013


Conclusion – Functional vestibular disorders (PPPD and its phobic subtype PPD)

• Definition

• Distilled from clinical observations made 145 years ago

• Revived independently starting 30 years ago by 4 teams

• Formal diagnostic criteria contained in ICD-11 draft (2017)

• Treatments help

• Vestibular habituation

• SSRIs/SNRIs

• CBT done early

• Putative pathophysiologic mechanisms

• Sustained used of high-risk postural control

• Visual (somatosensory) dependence

• Mediated by anxiety-related processes

• Possibly associated with reduced higher level (cortical) integration


Questions & Discussion

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