CASE STUDY

1. CASE STUDY PSYCHOGENIC VESTIBULAR DISORDER Date = 06/05/08

2. Summary of Referral Information Summary of Letter from GP; ‘This young man has had unsteadiness and vertigo over the last six months. He has failed to respond to betahistine and prochloroperazine and has become very fed-up and down with this. He has also had panic attacks. Interestingly, he had a similar problem when his parents were separating as a child. He is a fairly self-critical and tense individual who has low self esteem. I would be most grateful if you could advise further on his dizziness.

3. Plan for Session • Check Medications • History • Questionnaires • Audiogram • Tympanometry • Balance Testing • Debrief

4. General History • Attended with girlfriend • 24 years old • Applying to police force • Personal adviser • Not working due to dizziness • Claustrophobic

5. History • Vague Historian • Symptoms started as a teenager, 14 years old • General sense of disorientation • no distinct episodic dizziness or rotatory vertigo • Feels better when sat still • Motion sensitive • Symptoms are constant • Loss of appetite and nausea since dizziness began • Anxiety and depression • Suffers from panic attacks

6. History cont….. • Constant light-headed and faint feeling • Increase in anxiety and depression symptoms since events started • Hyperventilating during attacks

7. Clinical Appearance • Gait and balance looked normal • Tired and emotional • Anxious • Comments like ‘life wouldn’t be worth living’ if continued

8. Medical History • Colds and Sinus Problems • No other significant history

9. Medications • Beta-Blockers for Anxiety

10. General Tests • Otoscopy • Audiometry • Tympanometry • GHQ questionnaire

11. Balance Assessment • Spontaneous and Gaze Assessment • Saccades • Smooth Pursuit • Dix Hallpike • Head Roll testing • Caloric testing

12. Summary of Results • Otoscopy - No abnormalities observed bilaterally • Audiometry -Thresholds within normal limits bilaterally • Tympanometry - Raised middle ear compliance on right and pressure within normal limits bilaterally • Gait and balance – Informal observation revealed normal gait and no obvious unsteadiness on walking into clinic • Spontaneous and Gaze – did not reveal any nystagmus or symptoms • Saccades and Pursuit – did not reveal any nystagmus or symptoms

13. Results Continued.. • Dix-Hallpike and Head Rolls = did not reveal any nystagmus or symptoms, negative in all positions • Warm Calorics (44º) - symmetrical – No significant Canal Paresis or DP observed • GHQ = score = 9 (low for depression) the 28-items "scaled" version (has four subscales: somatisation, social dysfunction, anxiety, and depression)

14. Conclusions • No evidence of peripheral or central cause of dizziness • Complete set of normal vestibular testing results • Suggests panic and anxiety may be contributing significantly to the patient’s symptoms • May be Psychogenic in nature

15. Psychogenic Dizziness • No organic disease is present • Large amount of psychological disability in persons with vertigo • Difficult diagnoses to reach

16. Clinical Manifestations • dizzy sensation is typically persistent and continuous • punctuated by episodes of hyperventilation • provocative factors may be identified, such as the presence of crowds, driving, or being in confined places • “manifestations of anxiety, including apprehension, dread, nervousness, tension, restlessness, and autonomic manifestations” • Episodes are often poorly described • Panic attacks (all fits in with current patient)

17. Management • Psychotherapeutic approaches such as cognitive behavioural therapy • Medications – to treat depression and anxiety (beta-blockers) • Perform tests - reassure the patient that no organic disease is present • Referrals to Psychiatry / Neurology • Vestibular Rehabilitation – possible breathing control exercises • Multi-disciplinary team which includes ENT, audiologists, hearing therapist, clinical psychologists, and physiotherapists

18. Other Useful tests… • Hyperventilation Test - The early literature suggested that this was a sign of psychogenic (psychiatric) disturbance (Drachman and Hart, 1972), but later workers using better technology to monitor eye movements suggest that nystagmus induced by hyperventilation is a good sign of vestibular disease • Must be emphasised positive hyperventilation does not rule out vestibular disorder • use of the Nijmegen Questionnaire

19. “A close association between anxiety and dizziness was emphasized by Sigmund Freud in an early paper on anxiety neurosis” (Freud 1895) Evidence Base

20. Studies: Simon et al (1998) • Psychosomatic model -- a primary psychiatric disturbance causes dizziness • hyperventilation and hyper arousal increased vestibular sensitivity • Somato-psychic model -- a primary inner ear disturbance causes anxiety, signals from the inner ear are misinterpreted as signifying immediate danger, which increases anxiety. Increased anxiety increases misinterpretation. Conditioning makes it persistent • The chicken or the egg, difficult to know which

21. Studies cont…… • Staab and colleagues (2003) Laryngoscope. 2003; 113:1714-8 • 345 men and women age 15 to 89 (average age 43.5) dizziness for three months or longer due to unknown causes. “All but six patients were diagnosed as having psychiatric or neurologic conditions, including anxiety disorders, migraine, traumatic brain injury and neurally mediated dysautonomias” • Anxiety disorders were associated with 60 percent of the chronic dizziness cases • 33 percent of the subjects with psychogenic dizziness had a primary psychiatric diagnosis

22. Staab et al. 2003 3 patterns emerged; • Anxiety disorders can be sole cause of dizziness • Neurotologic condition can trigger the development of anxiety and phobic behaviours • A neurotologic condition was responsible for the onset of dizziness but also exacerbated pre-existing or anxiety symptoms • N.B; Depression was considerably less common than anxiety and was never a primary cause of dizziness

23. Evidence Base • Lanska, D.J; Psychophysiological vertigo. (psychogenic vertigo) Neurology 2006 (www.medlink.com) • Staab JP, Ruckenstein MJ. A psychiatric approach to chronic dizziness. Psychiatric Annals 2005 35(4): 330-8. • Staab JP, Ruckenstein MJ. Which comes first? Psychogenic dizziness versus otogenic anxiety. Laryngoscope 2003 113:1714-8, 2003. • Hain, T.C. Vertigo and Psychological Disturbances December 26, 2007 • Simon NM, Pollack MH, Tuby KS, Stern TA. Dizziness and Panic disorder: A review of the association between vestibular dysfunction and anxiety. Annals Clin Psych 10, 1998, 2, 75-80 • Drachman D, Hart CW. Neurology 1972, 22, 323-334 • Hain, T.C website: www.dizzinessandbalance.com