Annegret Eckhardt-Henn

Quality of life in patients with chronic urticaria is differentially impaired and determined by psychiatric comorbidity

Background  Chronic urticaria (CU), one of the most common skin disorders, is characterized by spontaneous recurrent bouts of weals and pruritus and associated with severely impaired quality of life (QoL).

Psychiatric comorbidity in different organic vertigo syndromes

ObjectiveA high degree of psychiatric disorders has repeatedly been described among patients with organic vertigo syndromes and attributed to vestibular dysfunction. Yet almost no investigations exist which differentiate between various organic vertigo syndromes with regard to psychiatric comorbidity. The following prospective, interdisciplinary study was carried out to explore whether patients with different organic vertigo syndromes exhibit different psychological comorbidities.Methods68 patients with organic vertigo syndromes (benign paroxysmal positioning vertigo (BPPV) n = 20, vestibular neuritis (VN) n = 18,Menière’s disease (MD) n = 7, vestibular migraine (VM) n = 23) were compared with 30 healthy volunteers.All patients and control persons underwent structured neurological and neuro-otological testing. A structured diagnostic interview (-I) (SCID-I) and a battery of psychometric tests were used to evaluate comorbid psychiatric disorders.ResultsPatients with VM and MD showed significantly higher prevalence of psychiatric comorbidity (MD = 57%, VM = 65%) especially with anxiety and depressive disorders, than patients with VN (22%) and BPPV (15 %) compared to normal subjects (20 %). These elevated rates of comorbidities resulted in significantly elevated odds-ratios (OR) for the development of comorbid psychiatric disorders in general (for VM OR = 7.5, for MD OR = 5.3) and especially for anxiety disorders (for VM OR = 26.6, for MD OR = 38.7).ConclusionAs a consequence, a structured psychological and psychometric testing and an interdisciplinary therapy should be proceeded in cases with complex and prolonged vertigo courses, especially in patients with VM and MD. Possible reasons of these unexpected results in VM and MD are discussed.

Anxiety disorders and other psychiatric subgroups in patients complaining of dizziness

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.

Psychiatric morbidity and comorbidity in different vestibular vertigo syndromes

ObjectivesHigh rates of coexisting vestibular deficits and psychiatric disorders have been reported in patients with vertigo. Hence, a causal linkage between the vestibular system and emotion processing systems has been postulated. The aim of this study was to evaluate the impact of vestibular function and vestibular deficits as well as preexisting psychiatric pathologies on the course of vestibular vertigo syndromes over 1 year.MethodsThis interdisciplinary prospective longitudinal study included a total of 68 patients with vestibular vertigo syndromes. Four subgroups were compared: benign paroxysmal positioning vertigo (BPPV, n = 19), vestibular neuritis (VN, n = 14), vestibular migraine (VM, n = 27), and Menière’s disease (MD, n = 8). All patients underwent neurological and detailed neurootological examinations as well as two standardized interviews and a psychometric examination battery at five different times (T0–T4) over 1 year.ResultsThe prevalence of psychiatric disorders at baseline (T0) did not differ between the four subgroups. Only patients with VM showed significantly higher rates of psychiatric disorders (p = 0.044) in the follow-up over 1 year. Patients with a positive history of psychiatric disorders before the onset of the vestibular disorder had significantly increased rates of psychiatric disorders compared to patients with a negative history of psychiatric disorders (T1: p = 0.004, T3: p = 0.015, T4: p = 0.012). The extent of vestibular deficit or dysfunction did not have any influence on the further course of the vestibular disease with respect to the development of psychiatric disorders.ConclusionA positive history of psychiatric disorders is a strong predictor for the development of reactive psychiatric disorders following a vestibular vertigo syndrome. Especially patients with vestibular migraine are at risk of developing somatoform dizziness. The degree of vestibular dysfunction does not correlate with the development of psychiatric disorders.

Interaction of somatoform and vestibular disorders

Background: The high coincidence of organic vestibular and somatoform vertigo syndromes has appeared to support pathogenic models showing a strong linkage between them. It was hypothesised that a persisting vestibular dysfunction causes the development of anxiety disorders. Objective: To determine the relation between vestibular deficits and somatoform vertigo disorders in an interdisciplinary prospective study. Methods: Participants were divided into eight diagnostic groups: healthy volunteers (n = 26) and patients with benign paroxysmal positioning vertigo (BPPV, n = 11), vestibular neuritis (n = 11), Menière’s disease (n = 7), vestibular migraine (n = 15), anxiety (n = 23), depression (n = 12), or somatoform disorders (n = 22). Neuro-otological diagnostic procedures included electro-oculography with rotatory and caloric testing, orthoptic examination with measurements of subjective visual vertical (SVV) and ocular torsion, and a neurological examination. Psychosomatic diagnostic procedures comprised interviews and psychometric instruments. Results: Patients with BPPV (35.3%) and with vestibular neuritis (52.2%) had pathological test values on caloric irrigation (p<0.001). Otolith dysfunction with pathological tilts of SVV and ocular torsion was found only in patients with vestibular neuritis (p<0.001). Patients with Menière’s disease, vestibular migraine, and psychiatric disorders showed normal parameters for vestibular testing but pathological values for psychometric measures. There was no correlation between pathological neurological and pathological psychometric parameters. Conclusions: High anxiety scores are not a result of vestibular deficits or dysfunction. Patients with Menière’s disease and vestibular migraine but not vestibular deficits showed the highest psychiatric comorbidity. Thus the course of vertigo syndromes and the possibility of a pre-existing psychopathological personality should be considered pathogenic factors in any linkage between organic and psychometric vertigo syndromes.

Dizziness: Anxiety, health care utilization and health behavior—: Results from a representative German community survey

BACKGROUND Due to the lack of epidemiological data on the relation of dizziness and anxiety, we investigated the prevalence of dizziness and anxiety in a representative sample of the German population. We explored the consequences of comorbid anxiety for emotional distress, functional impairment, health care utilization, and health behavior in dizziness. METHODS By the end of 2006, we surveyed a total of 1287 persons between 14 and 90 years of age in their homes by trained interviewers with standardized self-rating questionnaires on anxiety (Patient Health Questionnaire, Generalized Anxiety Disorder Scale, Mini-Social Phobia Inventory) and dizziness (Vertigo Symptom Scale). The sample was representative for the German population in terms of age, sex, and education. RESULTS Symptoms of dizziness were reported by 15.8% of the participants. Of the participants with dizziness, 28.3% reported symptoms of at least one anxiety disorder (generalized anxiety, social phobia, panic). Persons with dizziness reported more somatic problems such as hypertension, migraine, diabetes, etc. Comorbid anxiety was associated with increased health care use and impairment. CONCLUSION Dizziness is a highly prevalent symptom in the general population. A subgroup with comorbid anxiety is characterized by an increased subjective impairment and health care utilization due to their dizziness. Because treatment options for distinct neurotologic disorders are also known to reduce psychological symptoms, and in order to avoid unnecessary medical treatment, early neurologic and psychiatric/psychotherapeutic referral may be indicated.

Psychiatric comorbidity and psychosocial impairment among patients with vertigo and dizziness

Background Vertigo and dizziness are often not fully explained by an organic illness, but instead are related to psychiatric disorders. This study aimed to evaluate psychiatric comorbidity and assess psychosocial impairment in a large sample of patients with a wide range of unselected organic and non-organic (ie, medically unexplained) vertigo/dizziness syndromes. Methods This cross-sectional study involved a sample of 547 patients recruited from a specialised interdisciplinary treatment centre for vertigo/dizziness. Diagnostic evaluation included standardised neurological examinations, structured clinical interview for major mental disorders (SCID-I) and self-report questionnaires regarding dizziness, depression, anxiety, somatisation and quality of life. Results Neurological diagnostic workup revealed organic and non-organic vertigo/dizziness in 80.8% and 19.2% of patients, respectively. In 48.8% of patients, SCID-I led to the diagnosis of a current psychiatric disorder, most frequently anxiety/phobic, somatoform and affective disorders. In the organic vertigo/dizziness group, 42.5% of patients, particularly those with vestibular paroxysmia or vestibular migraine, had a current psychiatric comorbidity. Patients with psychiatric comorbidity reported more vertigo-related handicaps, more depressive, anxiety and somatisation symptoms, and lower psychological quality of life compared with patients without psychiatric comorbidity. Conclusions Almost half of patients with vertigo/dizziness suffer from a psychiatric comorbidity. These patients show more severe psychosocial impairment compared with patients without psychiatric disorders. The worst combination, in terms of vertigo-related handicaps, is having non-organic vertigo/dizziness and psychiatric comorbidity. This phenomenon should be considered when diagnosing and treating vertigo/dizziness in the early stages of the disease.

Validation of the German version of the Vertigo Symptom Scale (VSS) in patients with organic or somatoform dizziness and healthy controls

ObjectiveThe objective of this study was to validate the German version of the Vertigo Symptom Scale (VSS) and to determine its ability to differentiate the type, frequency, and severity of balance disorders. The scale (34 items) was designed by Yardley and coworkers and has been already validated in its English and Spanish versions.Methods98 patients with organic vertigo syndromes, 90 patients with somatoform (psychogenic) dizziness and 56 healthy controls were evaluated with the VSS and additional standardized questionnaires regarding distress (SCL-90R), quality of life (SF-36), anxiety and depression (HADS). In order to differentiate organic from somatoform dizziness all patients underwent detailed clinical neurological and vestibular neurophysiological testing.ResultsThe two identified subscales ‘vertigo and related symptoms’ (VER) and ‘somatic anxiety and autonomic arousal’ (AA) had good internal consistencies (Cronbach’s alpha: VER 0.79; AA 0.89). Test-retest correlations were r = 0.75 for VER and r = 0.75 for AA. VER could discriminate well between dizziness patients and healthy controls. AA discriminated moderately between somatoform and organic dizziness. We found close relations between the AA scale and different measures of emotional distress. Correlations between VER and measures of emotional distress were weaker.ConclusionThe German version of the VSS has good reliability and validity in the detection of different vertigo syndromes. Measurement of anxiety symptoms can be helpful to identify patients with somatoform dizziness.

Somatoform vertigo syndrome

Nearly 50% of the patients in general medicine practice suffer from vertigo. In specialized vertigo clinics approximately 50% of the patients have either a primary or secondary somatoform vertigo, which develops after a peripheral vestibular disorder (in nearly 30%). The different subgroups of somatoform vertigo and a pathogenetic model for the two forms of somatoform vertigo are presented. Interesting interactions between neuro-anatomical, neurophysiological and psychological mechanisms concerning anxiety and vertigo are described. Therapeutic principles which are important for the treatment of patients with complex somatoform vertigo disorders are described.ZusammenfassungEtwa die Hälfte aller allgemeinmedizinischen Patienten leiden an Schwindel. In spezialisierten Kliniken haben etwa 50% der Patienten entweder einen primären oder sekundären Schwindel, der nach einer peripheren vestibulären Störung auftritt (bei nahezu 30%). Die verschiedenen Untergruppen des somatoformen Schwindels und ein pathogenetisches Modell werden dargestellt. Interessante Interaktionen zwischen neuroanatomischen, neurophysiologischen und psychologischen Mechanismen, die den Zusammenhang zwischen Angst und Schwindel betreffen, werden zusammengefasst. Therapeutische Prinzipien, die für die Behandlung von Patienten mit komplexen somatoformen Schwindelsyndromen wichtig sind, werden skizziert.SummaryNearly 50% of the patients in general medicine practice suffer from vertigo. In specialized vertigo clinics approximately 50% of the patients have either a primary or secondary somatoform vertigo, which develops after a peripheral vestibular disorder (in nearly 30%). The different subgroups of somatoform vertigo and a pathogenetic model for the two forms of somatoform vertigo are presented. Interesting interactions between neuro-anatomical, neurophysiological and psychological mechanisms concerning anxiety and vertigo are described. Therapeutic principles which are important for the treatment of patients with complex somatoform vertigo disorders are described.

Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the committee for the Classification of Vestibular Disorders of the Bárány Society

This paper presents diagnostic criteria for persistent postural-perceptual dizziness (PPPD) to be included in the International Classification of Vestibular Disorders (ICVD). The term PPPD is new, but the disorder is not. Its diagnostic criteria were derived by expert consensus from an exhaustive review of 30 years of research on phobic postural vertigo, space-motion discomfort, visual vertigo, and chronic subjective dizziness. PPPD manifests with one or more symptoms of dizziness, unsteadiness, or non-spinning vertigo that are present on most days for three months or more and are exacerbated by upright posture, active or passive movement, and exposure to moving or complex visual stimuli. PPPD may be precipitated by conditions that disrupt balance or cause vertigo, unsteadiness, or dizziness, including peripheral or central vestibular disorders, other medical illnesses, or psychological distress. PPPD may be present alone or co-exist with other conditions. Possible subtypes await future identification and validation. The pathophysiologic processes underlying PPPD are not fully known. Emerging research suggests that it may arise from functional changes in postural control mechanisms, multi-sensory information processing, or cortical integration of spatial orientation and threat assessment. Thus, PPPD is classified as a chronic functional vestibular disorder. It is not a structural or psychiatric condition.