Abstract
Introduction
Care of patients with vestibular symptoms focuses primarily on physical otoneurologic disorders; however, psychological factors can sustain symptoms, confound assessment, and adversely affect treatment. Health anxiety is a particularly pernicious process that simultaneously magnifies physical symptoms and inhibits medical care.
Objective
To demonstrate the excess morbidity caused by vestibular health anxiety and its successful management in a patient with otoneurologic disease.
Method
Report of a 41-year-old woman with recurrent benign paroxysmal positional vertigo, vestibular migraine, and chronic subjective dizziness, who expressed grave concerns about her health, repeatedly questioned her otoneurologic diagnoses, and failed physical therapy and medication treatment until her health anxiety and otoneurologic illnesses were addressed simultaneously.
Conclusion
Health anxiety is an empirically validated concept that explains troublesome health-related beliefs and behaviors. It is frustrating for patients and health care teams, but can be treated successfully in otoneurology practice, thereby reducing physical symptoms, emotional distress, functional impairment, and health care overutilization.
1
Introduction
Patients with vestibular and balance complaints are often divided into those with clinical signs of active vestibular or neurological disorders and those without. The absence of physical findings at the time of examination does not necessarily rule out otoneurologic disease as a cause of patients’ problems, and the presence of otoneurologic deficits may not explain the full extent of their symptoms . Psychological factors such as anxiety and depressive disorders, which are known to exist in at least one-third of tertiary care otoneurology patients, may affect clinical presentations and therapeutic outcomes . There have been numerous investigations of anxiety and depression in patients with otoneurologic disorders, but health anxiety has not been studied in patients with vestibular complaints. Health anxiety (aka illness anxiety) is an empirically validated concept that is likely to replace the older notion of hypochondriasis in the psychiatric nomenclature in 2013 . Health anxiety is a condition in which patients maintain high levels of attention to physical symptoms (body vigilance), focus on thoughts and images of disease (disease preoccupation) worry about becoming ill (disease fears), misinterpret bodily sensations as evidence that they are afflicted with malignant illnesses (disease conviction), and are not easily reassured by the results of medical evaluations . Patients with high levels of health anxiety overutilize medical care by repeatedly requesting evaluations of physical symptoms (reassurance seeking) . Paradoxically, they may avoid medically necessary appointments because of worries that their disease convictions will be confirmed. Health anxious individuals function poorly in social, occupational, and home settings because they avoid activities that they believe could adversely affect their health (disease-related avoidance) . Health anxiety may co-exist with other psychiatric disorders such as anxiety or depression, though its psychological features are unique . It is not a diagnosis reserved for patients who lack identifiable medical problems as it may occur in individuals with or without active physical illnesses . Indeed, several features of otoneurologic diseases may be particularly troublesome for patients prone to health anxiety. These include the appearance of sudden and dramatic physical symptoms (e.g., acute vertigo attacks) or, conversely, vague and nagging symptoms that are difficult to describe and evaluate (e.g., chronic dizziness). The possibility, however small, that such symptoms could be caused by a life-threatening condition (e.g., stroke) is especially difficult for health anxious patients to tolerate. In such situations, the clinicians’ diagnosis of a benign condition that is easily treated (e.g., benign paroxysmal positional vertigo, BPPV) can be strikingly at odds with patients’ worries about serious disease. Patients’ attempts to avoid physical symptoms may thwart therapeutic interventions, especially those that may transiently provoke symptoms (e.g., canalith repositioning maneuvers, CRM). We present here an illustrative case of a patient with severe vestibular health anxiety that seriously compromised management of her co-existing recurrent BPPV, vestibular migraine (VM), and chronic subjective dizziness (CSD). A treatment plan that incorporated behavioral interventions for health anxiety into otoneurologic therapies succeeded in having the patient utilize home CRM effectively, tolerate and receive benefit from migraine prophylactic and CSD medications, return to work, and accept discharge from tertiary care.
2
Case Report
A 41 year old woman presented with a 20 year history of vestibular symptoms, including intermittent episodes of brief positional vertigo and recurrent attacks of migrainous headaches lasting for several hours accompanied by unsteadiness and motion sensitivity. She developed persistent non-vertiginous dizziness and hypersensitivity to motion that were exacerbated in environments with complex visual stimuli. She also had a longstanding history of generalized anxiety that was treated with extended release bupropion, but that medication may have increased her headaches. Trials of several other anxiolytic antidepressants had been discontinued in the past due to unacceptable side effects (e.g., weight gain, low libido). On referral to our center, the patient underwent a multidisciplinary evaluation, including audiometric and vestibular laboratory testing, otoneurologic and psychiatric consultation, and physical therapy assessment.
Audiometric evaluation was unremarkable. Comprehensive vestibular and balance function evaluation consisting of videonystagmography, rotational chair, cervical vestibular evoked myogenic potentials (cVEMPs), computerized dynamic posturography and postural evoked responses was entirely normal. Her history of intermittent brief positional vertigo was consistent with recurrent BPPV, which was not active at the time of evaluation. Her migrainous headaches with vestibular symptoms were diagnosed as VM and her daily dizziness and motion sensitivity were diagnosed as CSD. The patient was given a multimodality treatment plan that included training in the use of home CRM for recurrences of BPPV, daily home vestibular habituation exercises (head movements, exposure to visual motion stimuli, and walking with head turning exercises) to reduce her sensitivity to motion stimuli, and gradual introduction of sertraline for treatment of CSD with a plan to follow that with migraine prophylactic or abortive medications for VM. The patient also was advised to obtain cognitive behavior therapy for her co-existing generalized anxiety disorder.
Despite this comprehensive plan, the patient failed to improve. She continued to have episodic vestibular symptoms indicative of recurrent BPPV and VM and daily symptoms of CSD. She was impatient with the titration of medications and reported unacceptable side effects for each of three successive medication trials. She shifted her focus to taking supplements that she researched on the Internet. She varied the prescribed vestibular habituation exercises and then discontinued them altogether due to doubts about the benefit. A neurology consultation was arranged for headache management, but the patient dropped the migraine diet and abandoned the medication recommendations, which she felt were not helpful. She did not follow-up with her established psychiatrist. During follow-up visits to our center, she repeatedly questioned her diagnoses and requested more testing. She interpreted her continuing symptoms as evidence of an undetected malignant illness. Over the course of a year, she contacted our center more than 40 times by e-mail or telephone with similar inquiries. This failed to improve her adherence to treatment and did not assuage her increasing worries about having a serious neurologic disease. We contemplated dismissing her from our practice, but opted instead to engage her in a structured treatment plan that simultaneously limited her health anxious behaviors and established a consistent regimen of medications and vestibular exercises. Elements of that plan are outlined in Table 1 . The patient gradually grew accustomed to the plan’s focus and limits, which were implemented strictly, but respectfully. Over the span of a few months, she restarted prescription medications (citalopram and bupropion) and consistently performed her vestibular exercises. She became competent in self-assessment of symptom flare-ups and successfully used home CRM and migraine abortive medications for recurrences of BPPV and episodes of VM, respectively. The frequency of her e-mails and telephone calls decreased dramatically and the few remaining contacts between scheduled office visits were for straightforward reasons. She was able to meet all of her family and work obligations. One year after implementation of this treatment plan she was discharged successfully from tertiary care.
| Features | Clinical Manifestations | Intervention strategies |
|---|---|---|
| Body Vigilance | • Heightened attention to physical symptoms • Repeated checking of body for signs of disease | Structured format for symptom reports • Implemented a daily symptom log that included a 5-point severity rating scale for vertigo, dizziness, and headache. • Required that all symptoms be recorded in log, which was reviewed at each office visit. • Using symptom log, taught patient to recognize patterns of BPPV, VM, and CSD. Structured response to symptom flare-ups • Had patient perform home CRM for all episodes of brief vestibular symptoms |
| Disease Preoccupation | • Recurrent thoughts and images of disease | Focused on known diagnoses and treatment plan • Refocused discussions to treatment plan |
| Disease Fears | • Fear of having or contracting a disease • Anxiety about possible contact with disease related stimuli (e.g., dirt, blood) | • Taught patient to counter disease fears by identifying patterns of BPPV, VM, and CSD symptoms in daily log. |
| Disease Conviction | • Belief about having a serious illness | • Quickly countered all queries with firm, but polite restatement of known diagnoses • Declined to debate alternative diagnoses |
| Reassurance Seeking | • Excessive checking of sources of health information (e.g., Internet) • Repeated consultations with medical professionals regarding health status | Placed firm limits on reassurance seeking • Provided written material on diagnoses and treatment strategies, including home CRM, vestibular habituation, medications • Discouraged reading of other information • Politely, but firmly, refused to review other information brought or sent by patient • Declined all requests to re-evaluate symptoms caused by known diagnoses • Agreed to evaluate new or significantly different symptoms (none developed) |
| Disease-Related Avoidance | • Avoidance of disease-related stimuli (varies from passive avoidance such as limiting activities that may provoke symptoms or risk disease exposure to active measures such as use of medically dubious preventative measures) | Systematically countered avoidance • Home-based vestibular habituation exercises (started at 2 min twice daily) • Motion exposure exercises outside the home (incorporated into necessary activities such as shopping and return to work) • Refused to discuss use of unproven remedies to prevent vertigo and dizziness |
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