Abstract
Objective
Psychologic studies in patients with benign paroxysmal positional vertigo (BPPV) are scarce, considering the high frequency of the disorder. We performed a repeated-measures design questionnaire study in a cohort of patients with BPPV before and after treatment to investigate the dynamics of the psychologic findings and possible treatment consequences.
Methods
Thirty-seven consecutive patients with idiopathic BPPV participated in the study. During the first visit and 2 to 3 months after therapy, the patients completed 4 questionnaires: the Dizziness Handicap Inventory, the Illness Perception Questionnaire-Revised, the Intolerance of Uncertainty Scale, and the State-Trait Anxiety Inventory.
Results
The scores for all questioned items did not change before and after treatment except for the physical handicap scores. Correlation was found between the grade of functional and emotional impact of the disease and belief in consequences as well as anxiety levels of the patients. Moreover, uncertainty scores were in correlation with emotional impact, anxiety levels, and perceived consequences of the disease. The belief in personal control of the condition was correlated with the belief in treatment control and understanding of the disease.
Conclusion
The main finding in this study is the lack of a significant change in beliefs and emotional reactions in patients with BPPV after treatment of their condition. Physicians dealing with BPPV should be aware that the disease is not solely a somatic condition but has a serious impact on the patient’s mental state. Selected patients might benefit from anxiolytic medication.
1
Introduction
One of the most common and treatable causes of vertigo in the adult population is benign paroxysmal positional vertigo (BPPV) . It is characterized by rotational vertigo induced by head position changes in the plane of one of the semicircular canals of the vestibular labyrinth. The diagnosis is confirmed by positioning testing that reveals a characteristic nystagmus. Benign paroxysmal positional vertigo is considered to be caused by canalithiasis and cupulolithiasis. Otoconial debris, derived from the utricular macula, loosens and becomes trapped in one of the semicircular canals or its cupula. This causes inappropriate stimulation of the sensory hair cells of the affected canal and results in vertigo and nystagmus.
Particle repositioning maneuvers, aimed to remove the otoconial debris from the particular semicircular canal, are a simple and highly effective treatment of the condition . Complete resolution of the symptoms can be achieved in 75% to 100% of patients after a single or couple of treatments. However, the condition recurs in up to 50% of patients within 5 years of follow-up .
The close relationship of dizziness or vertigo and psychiatric disturbances has been readily recognized . Dizziness or vertigo can be a complaint in depression, generalized anxiety disorder, somatization disease, and panic disorder. The link between psychic changes and dizziness is supported by neurophysiologic studies that showed the influence of increased arousal and hyperventilation, associated with anxiety, on various vestibular laboratory parameters . On the other hand, vestibular lesions of distinct etiologies can trigger the onset of a psychiatric illness especially in predisposed individuals. They typically provoke an exaggerated emotional reaction sometimes persisting for a long period after the vestibular symptoms have resolved .
Anatomical and functional connections between the vestibular system and structures involved in the pathogenesis of panic disorder or conditioning of fear responses, such as locus coeruleus and raphe nucleus of the brainstem, further support this concept .
Although psychologic findings in some vestibular disorders, such as Ménière disease, vestibular migraine, and vestibular neuronitis, have been extensively reported, psychologic studies in patients with BPPV are surprisingly scarce, considering the high frequency of the disorder . In one study where the Hospital Anxiety-Depression scoring was applied, anxiety was found in 73.5% and depression in 41% of patients with BPPV .
We performed a repeated-measures design study in a cohort of patients with BPPV before and after treatment to investigate the dynamics of the psychologic findings and possible treatment consequences.
2
Methods
2.1
Patients
Thirty-seven consecutive patients with idiopathic BPPV, diagnosed and treated at an outpatient clinic during the years 2008 and 2009, participated in the study. Their mean age was 59.2 ± 14.5 years; 14 were men, and 23 were women. Thirty-two patients had a posterior canal BPPV, and 5 had a horizontal canal involvement.
Patients with a physical disorder such as orthopedic disorders, surgical disorders, grave internal diseases, aphasia, agraphia, alexia, dementia and severe depression or psychosis, or previous otological disease were excluded. Patients with a history of mental illness, regardless to present medication intake, were also excluded.
After the diagnostic test (Dix-Hallpike maneuver for the posterior and roll test for the horizontal canal type of BPPV), the patients received a detailed explanation of their condition and were treated by an appropriate particle repositioning maneuver during the same session. Patients were seen again within 1 week after the treatment. If necessary, the treatment was repeated in 3- to 7-day intervals until the nystagmus disappeared.
The study was performed in accordance with the Helsinki declaration and approved by the local ethics committee of the Assaf Harofeh Medical Center.
2.2
Methods
Four questionnaires were administered:
- 1.
The Dizziness Handicap Inventory (DHI) was developed to measure self-perceived levels of handicap associated with the symptoms of dizziness. It has 25 items, with 3 response levels subgrouped into 3 domains: functional (DHI-f), emotional (DHI-e), and physical (DHI-p). The possible score ranges from 0 to 100, a higher score indicating worse handicap. The maximum possible scores are 28 for DHI-p, 36 for DHI-f, and 36 for DHI-e subscores. Test-retest reliability ( r = 0.92–0.97) and internal consistency ( α = .72–.89) have been demonstrated to be high .
- 2.
The Illness Perception Questionnaire-Revised (IPQ-R) (second part) measures patients’ cognitive and emotional representations of their illness. It consists of 38 statements using 5-point Likert scales (“strongly agree” to “strongly disagree”). It gives separate scores for the timeline (short- vs long-term IPQ-R-1), unpredictability (IPQ-R-2), consequences (IPQ-R-3), personal and treatment control (IPQ-R-4 and IPQ-R-5), illness coherence (IPQ-R-6), and emotional representation (IPQ-R-7). High scores indicate strong beliefs in serious consequences of the disease, chronicity and/or recurrence of the disease, the patients’ own ability to control symptoms, and effectiveness of treatment in controlling the disease. High scores on the illness coherence scale indicate a high degree of patients’ belief in a good understanding of their medical condition, and high scores on the emotional representation scale indicate a strong emotional response to the illness. The internal reliability of the test has been shown to range from 0.71 to 0.90 for the distinct subscales .
- 3.
The Intolerance of Uncertainty Scale (IUS) is a 27-item measure that assesses emotional, cognitive, and behavioral responses to ambiguous situations, implications of being uncertain, and attempts to control the future. Items are scored on a 5-point scale. The responses are summed as a total scale score, ranging from 27 to 135. The test has demonstrated a good internal consistency ( α = .94) and a good test-retest reliability ( r = 0.74) .
- 4.
The State-Trait Anxiety Inventory (STAI) consists of 40 items: 20 designed to assess state anxiety, that is, anxiety level at the time of examination (S scale), and further 20 items to assess trait anxiety, that is, general anxiety of the individual (T scale). High scores mean more trait or state anxiety. The reliability of the tests has been reported to range from 0.65 to 0.86 for the trait anxiety subscale and from 0.16 to 0.62 for the state anxiety subscale .
Patients completed the questionnaires twice: the first time during their first visit and the second time 2 to 3 months later while free of vertigo symptoms.
2.3
Statistical methods
Paired samples test (paired t test) was applied to investigate the differences of questionnaires’ results before and after treatment.
Pearson correlation coefficient investigated for internal consistency as well as interrelations between scores and subscores of the distinct questionnaires.
The statistical power ( P ) was considered significant if less than .05.
2
Methods
2.1
Patients
Thirty-seven consecutive patients with idiopathic BPPV, diagnosed and treated at an outpatient clinic during the years 2008 and 2009, participated in the study. Their mean age was 59.2 ± 14.5 years; 14 were men, and 23 were women. Thirty-two patients had a posterior canal BPPV, and 5 had a horizontal canal involvement.
Patients with a physical disorder such as orthopedic disorders, surgical disorders, grave internal diseases, aphasia, agraphia, alexia, dementia and severe depression or psychosis, or previous otological disease were excluded. Patients with a history of mental illness, regardless to present medication intake, were also excluded.
After the diagnostic test (Dix-Hallpike maneuver for the posterior and roll test for the horizontal canal type of BPPV), the patients received a detailed explanation of their condition and were treated by an appropriate particle repositioning maneuver during the same session. Patients were seen again within 1 week after the treatment. If necessary, the treatment was repeated in 3- to 7-day intervals until the nystagmus disappeared.
The study was performed in accordance with the Helsinki declaration and approved by the local ethics committee of the Assaf Harofeh Medical Center.
2.2
Methods
Four questionnaires were administered:
- 1.
The Dizziness Handicap Inventory (DHI) was developed to measure self-perceived levels of handicap associated with the symptoms of dizziness. It has 25 items, with 3 response levels subgrouped into 3 domains: functional (DHI-f), emotional (DHI-e), and physical (DHI-p). The possible score ranges from 0 to 100, a higher score indicating worse handicap. The maximum possible scores are 28 for DHI-p, 36 for DHI-f, and 36 for DHI-e subscores. Test-retest reliability ( r = 0.92–0.97) and internal consistency ( α = .72–.89) have been demonstrated to be high .
- 2.
The Illness Perception Questionnaire-Revised (IPQ-R) (second part) measures patients’ cognitive and emotional representations of their illness. It consists of 38 statements using 5-point Likert scales (“strongly agree” to “strongly disagree”). It gives separate scores for the timeline (short- vs long-term IPQ-R-1), unpredictability (IPQ-R-2), consequences (IPQ-R-3), personal and treatment control (IPQ-R-4 and IPQ-R-5), illness coherence (IPQ-R-6), and emotional representation (IPQ-R-7). High scores indicate strong beliefs in serious consequences of the disease, chronicity and/or recurrence of the disease, the patients’ own ability to control symptoms, and effectiveness of treatment in controlling the disease. High scores on the illness coherence scale indicate a high degree of patients’ belief in a good understanding of their medical condition, and high scores on the emotional representation scale indicate a strong emotional response to the illness. The internal reliability of the test has been shown to range from 0.71 to 0.90 for the distinct subscales .
- 3.
The Intolerance of Uncertainty Scale (IUS) is a 27-item measure that assesses emotional, cognitive, and behavioral responses to ambiguous situations, implications of being uncertain, and attempts to control the future. Items are scored on a 5-point scale. The responses are summed as a total scale score, ranging from 27 to 135. The test has demonstrated a good internal consistency ( α = .94) and a good test-retest reliability ( r = 0.74) .
- 4.
The State-Trait Anxiety Inventory (STAI) consists of 40 items: 20 designed to assess state anxiety, that is, anxiety level at the time of examination (S scale), and further 20 items to assess trait anxiety, that is, general anxiety of the individual (T scale). High scores mean more trait or state anxiety. The reliability of the tests has been reported to range from 0.65 to 0.86 for the trait anxiety subscale and from 0.16 to 0.62 for the state anxiety subscale .
Patients completed the questionnaires twice: the first time during their first visit and the second time 2 to 3 months later while free of vertigo symptoms.
2.3
Statistical methods
Paired samples test (paired t test) was applied to investigate the differences of questionnaires’ results before and after treatment.
Pearson correlation coefficient investigated for internal consistency as well as interrelations between scores and subscores of the distinct questionnaires.
The statistical power ( P ) was considered significant if less than .05.
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