Anxiety disorders and other psychiatric subgroups in patients complaining of dizziness

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Abstract

Two hundred and two consecutive patients with dizziness were evaluated using blind neuro-otological testing and examination, blind psychiatric examination, including structured interviews (according to DSM-IV), the Symptom Check-List (SCL 90 R), and the State-Trait Anxiety Inventory (STAI). In 28% of the patients (N=50) dizziness was of organic origin (O group); in 55.3% (N=99) of psychogenic origin (P group) and in 16.8% comorbid psychiatric disorders were found (Mixed group). In 5.3% (N=10) neither organic nor psychiatric results could be found, which could explain the dizziness (Ideopathic group). Compared with the Organic group the patients with psychiatric disorders (P and Mixed group) had much more extensive workups for dizziness, intense emotional distress (anxiety, depression), greater handicaps, and high somatization scores. In the P and Mixed groups three main subgroups of psychiatric disorders could be found: anxiety (N=56), depressive (N=20), and somatoform disorders (N=53). Patients with anxiety and depressive disorders showed the greatest emotional distress and handicaps. The results indicate that psychiatric disorders, above all anxiety disorders, should be included in the differential diagnosis in patients with a long duration of dizziness and great handicaps. An interdisciplinary treatment (including psychiatric treatment) would be superior to an exclusive somatic one.

Introduction

Dizziness is one of the most frequent general medical symptoms presenting in hospitals and medical practices. After headaches, dizziness is the most commonly occurring chief symptom in neurology (Brandt, 1996). In 20–50% of all dizziness states, psychiatric disorders appear to exert an important influence on the course of the illness (Alvord, 1991, Clark et al., 1994b; Eagger, Luxon, Davies, Coelho, & Ron, 1992; Kroenke et al., 1992; McKenna, Hallam, & Hinchcliffe, 1991; Yardley, Beech, & Weinman, 2001; Yardley & Redfern, 2001; Yardley et al., 1999). In longitudinal studies, patients with mixed physical and psychological symptoms are the ones most likely to remain symptomatic and handicapped (Kroenke et al., 1992, Yardley, 2000), while at the same time having the highest levels of handicap.

Dizziness patients may, on the one hand, develop reactive psychic disorders. This particularly affects those who demonstrate delayed vestibular compensation following a vestibular lesion (i.e., Neuritis vestibularis) or have a latent vestibular disorder, such as Mal de debarquement Syndrome (Murphy, 1993), or those in whom “space phobia” (Marks, 1981) is suspected and then often suffer from unspecific symptoms such as space and motion discomfort, and/or subjective postural imbalance and unsteadiness of gait, inter alia (Bronstein, 1995; Jacob, Lilienfeld, Furman, Durrant, & Turner, 1989; Jacob et al., 1993; Jacob, Redfern, & Furman, 1997b; Mair, 1996). On the other hand, the combination of psychic and somatic disorders (in the presence of an acute psychiatric illness) can have an especially negative effect on the course of the illness, leading to chronification and greater handicap. Particularly in these cases a comorbid or reactive psychiatric disorder is often overlooked and consequently left untreated.

Until now, the following psychiatric disorders have been described in patients with dizziness illnesses: anxiety disorders, depressive, and somatoform disorders (Eckhardt-Henn, Hoffmann, Tettenborn, Thomalske, & Hopf, 1997; Yardley, 2000).

Anxiety patients comprise the best-examined and most important subgroup of those suffering from dizziness. A number of empirical studies determined high values for anxiety in patients who complained primarily of dizziness (Asmundson, Larsen, & Stein, 1998; Brandt, 1996, Clark et al., 1993; Clark, Hirsch, Smith, Furman, & Jacob, 1994a; Eagger et al., 1992, Eckhardt et al., 1996, Kroenke et al., 1992; Nazawa, Imamura, Hashimoto, & Murakami, 1998; Nedzelski, Barber, & McIlmoyl, 1986; Stein, Asmundson, Ireland, & Walker, 1994).

The percentage of anxiety disorders reported in different studies for patients with vestibular dysfunction varies between 3% (Sullivan, Clark, & Katon, 1993) and 41% (Eagger et al., 1992) and for patients without vestibular dysfunction between 6% (Sullivan et al., 1993) and 76% (Simpson, Nedzelski, Barber, & Thomas, 1988). These differences underline the need for more reliable percentages of anxiety-disorder patients based on larger samples of dizziness patients.

The connection between anxiety and dizziness is relatively well researched. Various interesting perspectives exist on this connection. For instance, it has been hypothesized that dizziness and panic symptoms may co-occur as a result of central-neurologic links between the vestibular and the autonomic systems (Balaban & Porter, 1997; Balaban & Thayer, 2001; Clark et al., 1994a, Clark et al., 1994b; Furman, Jacob, & Redfern, 1998; Gorman, Liebowitz, Fyer, & Stein, 1989; Sklare, Konrad, Maser, & Jacob, 2001; Sklare, Stein, Pikus, & Uhde, 1990). For a more detailed review of recent literature concerning the relation between anxiety disorders and vestibular disturbance we refer the reader to Asmundson et al. (1998), Simon, Pollack, Tuby, and Stern (1998), Balaban and Jacob (2001), Jacob and Furman, 2001a, Jacob and Furman, 2001b, and Furman and Jacob (2001). Regarding the existence of other psychiatric disorders in patients with dizziness as the chief symptom, few details are available.

The depressive disorders found range from 6% (Kroenke et al., 1992) to 62% (Eagger et al., 1992; Frommberger, Schmidt, Dieringer, Tettenborn, & Buller, 1994; Sullivan et al., 1993). One report mentioned presence of somatoform disorders (Yardley, 2000), but no details were given. As far as we know, at the present time no studies have been conducted on large patient collectives (more than 100 patients) attempting to systematically classify dizziness patients into potential psychiatric subgroups according to the widely accepted criteria of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV) (1994). Better knowledge about proportions of clinically relevant subgroups in dizziness collectives is needed, as is knowledge about the differences between subgroups. Most of the existing studies fail to provide a differentiated clinical–psychiatric diagnosis based on DSM-IV criteria. With few exceptions (Frommberger et al., 1994), data on the psychic disorders were usually gathered using individual psychometric instruments. In accordance with Asmundson et al. (1998), we believe that a replication and extension of existing epidemiological and clinical studies is warranted.Thus, the main purpose of our investigation is to estimate or replicate the proportions of somatic and psychiatric disorders in dizziness patients as reported in the literature using a comparatively large sample, and to answer the following questions:

  • Can differences be identified or replicated with regard to emotional distress, handicap, and the course of illness between patients with organic dizziness, non-organic dizziness, organic dizziness plus comorbid psychiatric disorders, and ideopathic dizziness?

  • How high is the respective percentage of potential psychiatric subgroups in patients with non-organic dizziness and in those with comorbid psychiatric disorders (anxiety and phobic disorders, depressive and somatoform disorders)?

  • Can any differences be found along psychosocial dimensions (psychometric measures) between the resulting psychiatric subgroups?

Detailed knowledge of such differences would be of great importance for the early differentiated psychotherapeutic/psychiatric diagnosis of psychically caused dizziness, thereby allowing specific interdisciplinary treatment for patients with complex dizziness disorders. In doing so, this could prevent possible chronification with the accompanying restrictions in work and daily life as well as the high medical costs.

Section snippets

Subjects

The data presented in this paper were derived from a larger project exploring psychiatric aspects of dizziness.1

The study subjects were unscreened patients consecutively referred over a 3-year period to a neurologic outpatient clinic (Johannes Gutenberg

Control variables

The four subgroups (O, M, I, P) did not differ significantly in terms of sex distribution (χ2=6.079, df=3, P=.11) or age (ANOVA, F=2.436, df=3, P=.66).

Psycho-organic groups: proportions and differences

Assignment of the 189 patients based on the groups described above resulted in the following proportions: Organic group: 50 patients (26.6%), Mixed group: 30 patients (16%), Psychiatric group: 99 patients (52.1%), Ideopathic group: 10 patients (5.3%). Neurologic diagnoses that describe the somatic diagnoses of the sample, or to be more precise,

Discussion

Among the patients we investigated, all of whom had the chief symptom of dizziness, we found four major subgroups: (1) patients with organic dizziness states who showed no psychiatric disorder, (2) patients with dizziness states who showed an acute psychiatric disorder but no organic lesion, (3) patients who showed both an organic lesion as well as an acute psychiatric disorder, and (4) an idiopathic group in whom neither organic nor psychopathological abnormalities could be detected. We were

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