Researchers in Israel noted that patients hospitalized for acute vestibular dysfunction of different causes were more upset by their illness than patients with other, more disabling and disastrous, neurological symptoms, such as acute hemiparesis or paraparesis. (Otolaryngology -- Head and Neck Surgery, Jun-2003)
20 June, 2003
American Academy of Otolaryngology Head and Neck Surgery (AAOHNS)
New treatment recommendations are offered for anxiety accompaning first onset of vestibular disorders.
The medical community has been long aware of the close relationship of dizziness, vertigo and psychiatric disturbances. Panic disorder, generalized anxiety states, depressive states and psychological disorders of unknown origin all may be associated with a complaint of dizziness. In panic disorder dizziness even constitutes an important characteristic for diagnosis.
Dysfunction of the vestibular system, in turn, can trigger the onset of a psychiatric illness in a previously mentally healthy person. Anatomical and functional connections between the vestibular system and structures involved in the pathogenesis of panic disorder or conditioning of fear responses have been identified.
A new study from Israel provides the first assessment of the psychological impact of an acute, first attack of vertigo. Researchers in Israel noted that patients hospitalized for acute vestibular dysfunction of different causes were more upset by their illness than patients with other, more disabling and disastrous, neurological symptoms, such as acute hemiparesis (weakness of one side of the body) or paraparesis (weakness of the lower extremities). They consequently conducted a comparative questionnaire study to find out if patients with acute vestibular dysfunction experience more anxiety and depression and/or subjective disability than patients with other acute non vestibular neurological deficits.
The authors of "Anxiety in the First Attack of Vertigo" are Lea Pollak MD, Colin Klein MD, Kossych Vera MD, Jose Martin Rabey MD, .all from the Department of Neurology, The Assaf Harofeh Medical Center (affiliated to the Sackler School of Medicine, Tel-Aviv University, Israel) and Stryjer Rafael MD, at the Mental Health Hospital, Beer Yaakov, Israel. Their findings appear in the June 2003 edition of Otolaryngology--Head and Neck Surgery http://www.mosby.com/Mosby/Periodicals/Medical/OHNS/hn.html, the scientific journal of the American Academy of Otolaryngology--Head and Neck Surgery http://www.entnet.org.
Thirty patients hospitalized in a general neurological department for a first attack of illusion of movement (true vertigo), lasting less than one week and who also demonstrated positive findings on neurootological examination, were included in the study. Thirteen were men and 17 women with a mean age of 58.1 years. Patients with dizziness of cardiovascular origin or disequilibrium of nonvestibular origin were not included. Patients with a previous history of psychiatric disease, neurological or severe medical or surgical illness, as well as patients receiving psychotropic drugs, were also excluded.
Each vertigo patient underwent a detailed physical and neurological examination with particular attention to the neurootological examination. This included examination of stance and gait and a detailed eye movement examination with cover test, examination of range of movements, smooth pursuit, saccades, doll's eye maneuvre and head thrust test, as well as evaluation of nystagmus during positional testing.
A comparative group consisted of 35 patients ( 18 men, 17 women, mean age 55.2) hospitalized with an acute, other than vestibular, neurological deficit lasting less than one week. Patients with pain, pure sensory symptoms, aphasia or agnosia and patients with the history of psychiatric, neurological or severe medical or surgical diseases were excluded.
The patients were informed that the aim of the study was to investigate the influence of their physical illness on their emotions and mood since the beginning of the symptoms. The questionnaire consisted of eight items concerning depression and eight concerning anxiety. The patients were also asked to assess their disability (both physical and psychological restriction) due to their present illness, using a scale from mild to moderate to severe disability. Finally, patients were interviewed about the level of their general anxiety before the onset of their illness and asked for self-estimation on a scale ranging from not anxious to mildly anxious or anxious.
Key findings were:
Whereas self -- estimated level of generalized anxiety before the illness was similar in both groups, patients with acute vertigo experienced significantly more anxiety during hospitalization than patients with non-vestibular neurological deficits. Surprisingly, vertigo patients felt more disabled by their present illness than non vestibular patients, even though all were able to walk with mild support during the acute phase of the illness. Among non-vestibular patients eight were found to have severe neurological deficits and were actually bed ridden. Subjective disability is thus proportional to experienced anxiety.
The finding of high anxiety levels in patients with vestibular dysfunction might have further therapeutic implication: They are:
* Benzodiazepins inhibit the vestibular nuclei and cerebellum and are used in treatment of acute vertigo because of their vestibular suppressant effects. However, anticholinergic agents, antihistaminics or neuroleptics are sometimes prefered because the feared potential of addiction to benzodiazepins. Nevertheless, addiction usually occurs after continued use of benzodiazepins during several weeks. In view of the high anxiety in patients with acute vertigo, benzodiazepins should be administered as the drug of choice during the first days of acute vertigo, due to both, their vestibular suppressant as well as anxiolytic action.
* Diazepam, phenobarbital and chlorpromazine have been reported to impair vestibular compensation and are therefore not recommended as chronic treatment of vertigo. Regarding the high anxiety levels in patients with chronic or recurrent dizziness, new non addictive anxiolytics, such as buspirone or venlafaxine, could be tried. These drugs are relatively free of anticholinergic effects and would be therefore supposed to have less negative influence on the process of vestibular compensation.
This study shows that patients with acute vertigo are under extreme
emotional pressure, which, in turn, makes them suffer more from their symptoms
and contributes to their feeling of severe disability. The researchers
believe further studies are necessary to elucidate the anatomical and physiological
connections between the brainstem vestibular structures, the vestibular
cortical areas and the limbic system, to explain the emotional disturbances
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