The Coronavirus Disease-19 (COVID-19) emerged in China and rapidly spread to almost all the countries worldwide. The World Health Organization (WHO) declared the COVID-19 pandemic on March 11th, 2020 and this pandemic continues to exert its effects as a global health problem.1 COVID-19 is an infectious and potentially fatal respiratory disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2).

Vertigo can be defined as spatial orientation and motion perception disturbance, including rotational illusion or a sense of imbalance.2 Additionally, it is a hallucination of motion, and the patient supposes the motion of themselves or their surroundings. Vertigo is a major health problem that affects approximately 20%–30% of the general population,3–5 and is associated with severe loss of functionality and workforce.6 Pathologies with symptoms of vertigo are divided into the following two groups in general which those caused by the peripheral nervous system (peripheral vertigo) and those caused by the central nervous system (central vertigo).7,8 Vertigo associated with peripheral vestibular causes (benign paroxysmal positional vertigo, vestibular neuritis, Ménière’s disease, and others) accounts for the majority of vertigo cases in total. In contrast, central vertigo (vestibular migraine, cerebrovascular diseases, tumors, multiple sclerosis, and others) is less prevalent (approximately 10%).4,8,9

Psychiatric disorders are common in patients with vertigo. The rate of patients with vertigo, in whom the psychological factors are considered to influence the etiology, is approximately 30%–50%.10–12 Patients with anxiety are the most comprehensively studied and most important group of patients, who experience vertigo. High levels of anxiety are common in vertigo patients. Relevant studies reported anxiety disorders prevalence rates that ranged from 15% to 76%.11,13–16 Furthermore, it is well-established that the severity of anxiety is higher in patients with peripheral vertigo compared to patients with central vertigo.17

Contracting a new disease during pandemics increases the sources of fear and anxiety across the general population. Increased levels of anxiety may affect the mental health of individuals and trigger several psychological problems.18,19 Health anxiety is described as the excessive misinterpretation of the usual bodily sensations, although there is no organic bodily disease.20 There are two main components of health anxiety; the preconception that one has a serious disease and that the supposedly serious disease would lead to adverse consequences.21 Health anxiety is defined as the anxious form of hypochondriasis. A significant concern about having a serious medical condition, the concern persists despite assurances from medical professionals that there is no medical threat, preoccupation with health causes significant impairment in functioning, and for at least 6-months persistence is known as hypochondriasis.20 The fact that health anxiety is defined as a condition separate from hypochondriasis is based on the suggestion that it is a disorder primarily associated with anxiety. Nevertheless, hypochondriasis includes a much wider range of symptoms, including depressive and psychotic symptoms.22

Coronavirus anxiety was defined to determine the dysfunctional anxiety and anxiety symptom levels related to the COVID-19 pandemic.23 Concerns such as catching the virus, transmitting the virus to others, and dying due to COVID-19 increase the coronavirus anxiety in the population. High levels of coronavirus anxiety can cause psychological problems.24

Although there have been many studies in the literature reporting that increased stress and anxiety due to the current pandemic cause psychiatric problems or an increase in existing symptoms in the general population,25,26 the number of studies on patients with vertigo is limited. To the best of our knowledge, the present study is the first to investigate health anxiety, which may be associated with a significant loss in psychosocial functionality in patients with vertigo, and coronavirus anxiety, a specific type of anxiety associated with the current outbreak. We included patients diagnosed with peripheral vertigo owing to the fact that peripheral vertigo was more prevalent in the general population and that the effect of anxiety on the course of the disease was more prominent in patients with peripheral vertigo.

In summary, we aimed to evaluate anxiety symptom levels, coronavirus anxiety, and health anxiety in patients with vertigo during the COVID-19 pandemic, and to examine the effects of anxiety levels and demographic variables on vertigo and the severity of vertigo in this study.

The study was designed as an observational cross-sectional study. The study population included patients, who presented to the Ear, Nose, and Throat (ENT) clinic of Antalya Training and Research Hospital between May 15th and November 15th in 2021, with vertigo complaint and recruited by simple random sampling method. 118 patients were included in the study after diagnosed with peripheral vertigo upon detailed audiological examination, neurological examination (cranial, cerebellar, and postural tests), vestibulo-ocular and vestibulo-spinal tests, balance tests (Romberg test, Fukuda test, tandem stance test and tandem walking), position tests (Dix-Hallpike maneuver), and caloric tests and required differential diagnostic evaluations by ENT specialists with field experience. Among the 118 patients with peripheral vertigo in the patient group, 41 had Benign Paroxysmal Positional Vertigo (BPPV), 34 had Ménière’s disease, 14 had Vestibular Neuritis (VN), and 29 had other forms of peripheral vertigo. The control group consisted of 82 healthy volunteers who were similar to the patient group in terms of age and gender, did not have a history or complaint of vertigo, and did not have a psychiatric disease. The relevant psychiatric examinations were performed by a psychiatric clinician with field expertise. Sociodemographic data form and vertigo survey form were filled with all individuals who agreed to participate in the study. The participants were administered the Coronavirus Anxiety Scale (CAS), Hospital Anxiety Depression Scale-Anxiety Subscale (HAD-A), and Short Health Anxiety Inventory (SHAI). Furthermore, Vertigo Symptom Scale- Short Form (VSS-SF) was applied to the patient group to assess the severity of the vertigo symptoms.

Criteria for inclusion in the study as follows; aged over 18-years old, mentally capable of reading comprehension, complaint of vertigo for at least 1-month, and consent to participate in the study. Exclusion criteria as follows; examination findings supporting central vertigo diagnosis and/or a history of certain diseases (central nervous system disease, vestibular migraine, cerebrovascular diseases, tumors, demyelinating diseases such as multiple sclerosis, and history of a trauma), regular drug intake affecting Central Nervous System (CNS), ongoing neuropsychiatric treatment, serious ear pathology (perforation, surgery, and infection), serious neuro-psychiatric disorders (dementia, schizophrenia, psychosis, substance addiction or abuse, etc.), chronic diseases (hypertension, diabetes mellitus, etc.), and having received psychiatric treatment within the last 3-months. This study was conducted according to the principles of the Helsinki Declaration and approved by the Ethics Committee of Antalya Training and Research Hospital (Approval Number: 2021‒118).

The mean ages of the patient and control groups were 45.88 ± 16.43 years (between aged of 18‒72) and 42.51 ± 13.75 (between aged of 19‒70), respectively. There were 55 men (46.6%) and 63 women (53.4%) in the patient group and 39 men (47.6%) and 43 women (52.4%) in the control group. No significant difference between the groups in terms of the distribution of age (p = 0.68) and sex (p = 0.85) (p > 0.05). Sociodemographic data of participants are shown in Table 1. In the patient group, 59.3% of the participants were married (n = 70), 38.1% were university graduated (n = 45), 18.6% (n = 22) had history of psychiatric disorder, 16.1% (n = 19) had family history of psychiatric disorder, 14.4% (n = 17) had history of COVID-19, 27.1% (n = 32) had family history of COVID-19, and 15.3% (n = 18) were living alone (Table 1). In the control group, 65.9% of the participants were married (n = 54), 62.2% were university graduated (n = 51), 23.2% (n = 19) had history of psychiatric disorder, 19.5% (n = 16) had family history of psychiatric disorder, 24.4% (n = 20) had history of COVID-19, 42.7% (n = 35) had family history of COVID-19, and 14.6% (n = 12) were living alone (Table 1).

A total of 76.3% (n = 90) of patients reported that the vertigo symptoms emerged during the pandemic. On the other hand, 23.7% (n = 28) of the patients reported that they experienced vertigo before the pandemic, and also 82.1% (23/28) of them reported that the severity of vertigo during the pandemic was higher compared to the pre-pandemic. When asked the thought about whether the vertigo is a symptom of a serious illness, the rates of yes, no, and not sure answers given by the patients were 24.6% (n = 29), 21.2% (n = 25) and 54.2% (n = 9), and also were 8.5% (n = 7), 52.4% (n = 43), and 39.1% (n = 32) in the control group, respectively. There was a significant difference between the groups in terms of the responses of ‘yes’ (p = 0.001), ‘no’ (p = 0.001), and ‘not sure’ (p = 0.001).

The mean total score of the CAS was higher in the patient group (p < 0.05) (Table 2). Furthermore, the rate of coronavirus anxiety was found to be 20.3% (n = 24) in the patient group, and 5.1% (n = 6) in the control group using the cut-off score of ≥ 5 on the CAS.30

The mean total score of the HAD-A was higher in the patient group (p < 0.05) (Table 2). Additionally, the rate of anxiety disorder was found to be was 32.2% (n = 38), and 8.5% (n = 7) in the control group using the cut-off score of > 10 on the HAD-A.32

The mean total score of the SHAI was higher in the patient group (p < 0.05) (Table 2).

The mean total score of the VSS-SF was 23.18 ± 13.21 in the patient group. The majority of patients (n = 95; 80.5%) experienced severe level of vertigo using the cut-off score of ≥ 12 on the VSS-SF.28 The mean total score was 12.42 ± 7.23 in the VSS-V subscale and 10.72 ± 8.41 in the VSS-A subscale. The comparison of VSS-SF total, VSS-V, and VSS-A scores according to sociodemographic data is demonstrated in Table 3. As a result, there was significant difference in terms of total VSS-SF score and VSS-SF subscales scores in the patients with history of psychiatric disorder, family history of psychiatric disorder, history of COVID-19, and family history of COVID-19 (p < 0.05).

The relationship between the scores of the scales which used in the study was examined by Spearman correlation analysis. There was a positive correlation between the VSS-SF score with CAS (r = 0.531; p < 0.05), SHAI (r = 0.370; p < 0.05), and HAD-A (r = 0.665; p < 0.05) scores. Similarly, there was a positive correlation between the CAS score with SHAI (r = 0.224; p < 0.05) and HAD-A (r = 0.368; p < 0.05) scores, and also positive correlation between with SHAI score and HAD-A (r = 0.325; p < 0.05) score (Table 4).

The COVID-19 pandemic is a serious public health problem that threatens people’s lives. Given the very high rates of COVID-19 cases and the relatively higher mortality rates, individuals with elevated health anxiety and pandemic-related anxiety symptoms are at high risk of psychosocial exposure and loss of functionality. Therefore, the present study investigated vertigo, which could induce significant psychosocial problems, considering the negative effects of the pandemic on physical and mental health. Vertigo is a prevalent symptom that affects about one-third of the general population at a time in their lives.36,37 Moreover, vertigo may cause serious workforce losses if left untreated.6 In limited studies reported that the COVID-19 pandemic was associated with an increase in vestibular disorders.38,39 In a survey study conducted during the pandemic, 63.2% of the respondents reported increased severity of vertigo symptoms.40 Accordingly, with a higher rate, 82.1% of the patients reported that the severity of vertigo increased compared to the pre-pandemic period in this study. Furthermore, the majority (80.5%) of the patients, who participated in the present study, suffered a severe level of vertigo. These findings are remarkable and indicative of the fact that the pandemic had an adverse effect on the physical health of patients with vertigo. In our study, sociodemographic characteristics of patients with vertigo were compared in order to identify groups at risk for severe vertigo symptoms. Accordingly, there was no significant difference in sex, marital status, and educational status. Nevertheless, the severity of vertigo was significantly higher in the patients with a history of psychiatric disorder, family history of psychiatric disorder, history of COVID-19, and family history of COVID-19. Notably, there was a strongly significant difference in both the anxiety (VSS-A) and Vestibular Symptom (VSS-V) levels, in participants with a history of psychiatric disorder, and a history of COVID-19. Consistent with the finding of this study, Best et al. (2009) found that the severity of vertigo increased in participants with a history of psychiatric disorders.41 The fact because patients with a history of psychiatric disorders are more susceptible and sensitive to the psychological impact, they are more likely to have high levels of anxiety. Factors such as social isolation, quarantine process, perceived danger, uncertainty, physical discomfort, drug side effects, fear of death, and fear of transmitting the virus to others contribute to the increased rate of anxiety and vestibular symptoms in patients with a history of COVID-19. Consistently with our result, in a survey study by Smith et al., it has been reported that patients infected with the coronavirus have worse symptoms of autonomic anxiety than those who did not have the infection.39

The increased anxiety levels due to the current pandemic have adversely affected the mental health and well-being of the general population.18,26,42,43 Given the causal/triggering relationship between high anxiety levels and vertigo,44,45 it is crucial to assess the anxiety levels in patients presenting with complaints of vertigo. It is estimated that the frequency of anxiety is approximately 50% of the psychiatric comorbidities in patients with vertigo.41,44

As expected, in a study conducted during the current pandemic on patients with Ménière’s disease, it was found that the anxiety levels increased during the pandemic compared to the pre-pandemic period.46 The present study found that the severity of anxiety was significantly higher in patients with vertigo compared to healthy volunteers. Additionally, the rate of anxiety disorder was found to be 32.2%. Given that the pandemic is still ongoing, these rates are likely to increase even more.

It was reported in one of the limited studies on coronavirus anxiety that excessive COVID-19-related anxiety was associated with impaired psychological function.47 The results of our study suggested that patients with vertigo had significantly higher levels of coronavirus anxiety. Additionally, there was a remarkable result that 20.3% of the patients had coronavirus anxiety. These results indicate the fact that patients with vertigo experienced higher levels of coronavirus anxiety. It may be suggested that the rate of coronavirus anxiety will increase over time and will be an important mental health problem, considering the uncertainty about the duration of the outbreak. However, no comparison could be made because there was no study with a similar design in the literature. Therefore, further studies are required on the subject of the present study. To the best of our knowledge, this is the first study that has investigated coronavirus anxiety in patients with vertigo.

Health anxiety is a multifaceted phenomenon consisting of obsessive health-related thoughts, physiological arousal, perceived danger, and avoidance behaviors. This type of anxiety significantly increases especially during pandemic periods due to infectious diseases.48 Health anxiety is an important mental health problem that increasingly becomes more prevalent in society and is associated with greater costs to health services through unnecessary medical contacts.49,50 Furthermore, individuals with high levels of health anxiety fail to attend their appointments or check-ups out of the fear of COVID-19 infection and thus their treatment is disrupted, even when they have severe symptoms.51 Both frequent presentation to the hospital out of the fear of disease, and disrupting treatment out of the fear of disease transmission, negatively affect the daily lives and functionality of people. Therefore, an assessment of health anxiety in patients with vertigo is critical for the prognosis of the disease. In the present study, the health anxiety levels were significantly higher in patients with vertigo compared to the healthy volunteers. Otherwise, there were higher levels of health anxiety in this study compared to a study conducted on the general population during the current pandemic.52,53 In addition, 24.6% of the patients in our study reported that vertigo complaints could be a sign of a serious disease. This rate was remarkably lower in healthy controls (8.5%). The increased anxiety and sensitivity about health issues, fear of contamination, fear of getting the disease, and exaggerated thoughts about the negative consequences of being sick due to the COVID-19 pandemic may constitute the main factors that increase the levels of health anxiety. To our knowledge, this is the first study to investigate health anxiety in patients with vertigo during the current pandemic.

The present study investigated the vertigo symptom severity with VSS-SF, anxiety symptom levels with HAD-A, coronavirus anxiety with CAS, and health anxiety with SHAI. There was a positive correlation between vertigo symptom severity with anxiety symptom levels, coronavirus anxiety, and health anxiety. This result indicates that vertigo symptom severity may be perceived as more disturbing in patients due to increased anxiety levels as a result of the pandemic. Similarly, there was a positive correlation between coronavirus anxiety with anxiety symptom levels and health anxiety. This finding indicates that the increased levels of anxiety in general also increase the levels of specific types of anxiety, such as health and coronavirus anxiety, with a synergistic interaction.

Our study has some limitations. First, this is a single-center study with a comparatively small sample. Thus, multi-center studies with larger samples are required to determine comprehensively the psychological impact of the pandemic on vertigo patients. Second, as a limitation of the study design, the results only reflect the psychological conditions at a given time, and a longitudinal study is required to provide information on whether the observed impact will last for longer periods. Lastly, due to the limited number of studies with vertigo patients using similar design and evaluation tools as our study, comparisons could not be made adequately. Despite these limitations, there are remarkable findings in this study that will contribute to future studies.

In conclusion, in this study it was found that vertigo patients experienced high levels of anxiety, coronavirus anxiety, and health anxiety during this pandemic. Another remarkable result of our study is that the COVID-19 pandemic has an important role in increasing the severity of vertigo. Considering the psychophysiological negative consequences of high anxiety on vertigo, psychiatric assessment is necessary for vertigo patients. Additionally, psychological counseling and guidance services should be provided to them with psychopathological problems. Lastly, we suggest that a multidisciplinary approach consisting of ENT specialists, psychiatrists, and psychologists will be more effective.

Mustafa Altıntaş: Conceptualization; Methodology; Investigation; Software; Visualization; Writing.

Süleyman Korkut: Supervision; Conceptualization; Methodology; Writing-Reviewing and Editing.

This study approved by the Ethics Committee of Antalya Training and Research Hospital (Approval Number: 2021-118).

The authors declared that they covered the financial expenses of the study. This study has not been supported by any funding.

The patient provided written informed consent for publication of this study for scientific purposes.

The authors declare no conflicts of interest.