Regine Tschan

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.

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.

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.

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.

Implementing Panic-Focused Psychodynamic Psychotherapy into Clinical Practice

Objective: To determine the effectiveness of manualized panic-focused psychodynamic psychotherapy (PFPP) in routine care in Germany. Method: German psychoanalysts were trained according to the PFPP manual. Fifty-four consecutive outpatients with panic disorder (with or without agoraphobia) were randomly assigned in a 2:1 ratio to PFPP or cognitive-behavioural therapy (CBT) plus exposure therapy. Subjects (female 57.4%; mean age 36.2 years) had high rates of psychiatric (68.5%) and somatic (64.8%) comorbidity, and previous psychiatric treatments (57.4%). Assessments were performed pre- and posttreatment and at 6-month follow-up. The primary outcome measure was the Panic Disorder Severity Scale. Results: Both treatments were highly effective. In patients randomized to PFPP, remission was achieved in 44.4% at termination and by 50% at follow-up (CBT 61.1 % and 55.6%, respectively). No significant differences were found. Emotional awareness, a posited moderator of good outcome in psychotherapies, was significantly higher in the CBT group at baseline. It was found to be a strong moderator of treatment effectiveness in both treatments. After adjusting for initial Levels of Emotional Awareness Scale (LEAS) scores, effect sizes (ESs) for the primary outcome were Cohen d = 1.28, from pre- to posttreatment, and d = 1.03, from pretreatment to follow-up, for PFPP, and d = 1.81 and 1.28 for CBT, respectively. Conclusions: PFPP was implemented effectively into clinical practice by psychoanalysts in the community in a sample with severe mental illness with large ESs. Assessment of LEAS may facilitate the identification of patients suitable for short-term psychotherapy. (Clinical Trial Registration Number: German Clinical Trials Register, DRKS00000245; Universal Trial Number, U1111-1112-4245)

Standfest? Erste Ergebnisse der Entwicklung eines kognitiv-verhaltenstherapeutischen Gruppenschulungsprogramms zur Behandlung des somatoformen Schwindels

The aim of the study was to evaluate a psychotherapeutic intervention for somatoform vertigo regarding illness perception, severity and psychopathology.Patients underwent a waiting-list control group design (n=10 control group; n=14 intervention group with diagnostics at baseline, post-intervention, 3- and 12-month follow-up). Psychometric assessments comprised the Illness Perception Questionnaire, Vertigo Symptom and Handicap Questionnaire, Hospital Anxiety and Depression Scale, and Physical Health Questionnaire.The intervention group improved in personal control (p=0.046; d=0.46), and coherency (p=0.087; d=0.42). Illness beliefs in organic deteriorations could be corrected towards psychosomatic attributions.Steadfast decreased dysfunctional illness representations and increased patient empowerment.

[Screening for depersonalization-derealization with two items of the cambridge depersonalization scale].

Depersonalization (DP) and derealization (DR) are considered to be highly underdiagnosed. Therefore the development of screening instruments is important. From the Cambridge Depersonalization Scale (CDS) two items were extracted discriminating best patients with clinical significant DP from patients without DP. These two Items were assembled to a short version of the CDS. This short version (CDS-2) was tested in a sample of 38 patients with clinical significant DP-DR and 49 patients without or only mild DP-DR. Scores were compared against clinical diagnoses based on a structured interview (gold standard). The CDS-2 was able to differentiate patients with clinical significant DP well from other groups (cut-off of CDS-2>or=3, sensitivity=78.9%, specifity=85.7%) and also showed high reliability (Cronbachs alpha=0.92). Therefore the CDS-2 can be considered as a useful tool for screening and identification of DP-DR.

Complaints of Sleep Disturbances Are Associated with Cardiovascular Disease: Results from the Gutenberg Health Study

Background Despite their high prevalence, sleep disorders often remain unrecognized and untreated because of barriers to assessment and management. The aims of the present study were to examine associations of complaints of sleep disturbances with cardiovascular disease, related risk factors, and inflammation in the community and to determine the contribution of sleep disturbances to self-perceived physical health. Method The sample consists of n = 10.000 participants, aged 35 to 74 years of a population based community sample in Germany. Cross-sectional associations of complaints of sleep disturbances with cardiovascular risk factors and disease, biomarkers of inflammation, depression, anxiety, and physical health status were analyzed. Results 19% of our sample endorsed clinically significant sleep disturbances. In the unadjusted analyses severity of sleep disturbances increased with female sex, low socioeconomic status, living without a partnership, cardiovascular disease, depression, anxiety, poor physical health, increased levels of C-reactive protein and fibrinogen. After multivariate adjustment robust associations with coronary heart disease, myocardial infarction and dyslipidemia remained. Complaints of sleep disturbances were strong and independent contributors to self-perceived poor physical health beyond depression, anxiety and medical disease burden. Conclusions Given the high prevalence of complaints of sleep disturbances and their strong impact on health status, increased efforts should be undertaken for their identification and treatment.

Depersonalization experiences are strongly associated with dizziness and vertigo symptoms leading to increased health care consumption in the German general population.

Abstract This study investigated the association of depersonalization (DP) experiences with dizziness and its impact on subjective impairment and health care use. Trained interviewers surveyed a representative sample of 1287 persons using standardized self-rating questionnaires on dizziness, DP, and mental distress. Symptoms of dizziness were reported by 15.8% (n = 201). Thereof, 62.7% endorsed at least one symptom of DP, 40% reported impairment by symptoms of DP, and 8.5% reported clinically significant DP. Regression analyses identified DP as a significant, independent predictor for dizziness symptom severity, health care use, and impairment by dizziness. With regard to the Vertigo Symptom Scale, DP explained 34.1% (p < 0.001) of the variance for severity of symptoms of dysfunction in the balance system. In conclusion, symptoms of DP, highly prevalent in patients complaining of dizziness and vertigo, were independently associated with increased impairment and health care use. The presence of DP symptoms should actively be explored in patients complaining of dizziness.

Why Do Subjective Vertigo and Dizziness Persist over One Year after a Vestibular Vertigo Syndrome

The overlap and interlinkage of dizzy symptoms in patients with psychiatric and vestibular vertigo/dizziness disorders is the subject of an ongoing debate. In a one‐year follow up in 68 patients with vestibular vertigo syndromes, the persistency of vertigo and dizziness symptoms was examined and correlated with vestibular parameters and results from a psychiatric evaluation. Patients with vestibular migraine showed poorest improvement of vertigo and dizziness symptoms over time. In addition, patients who developed anxiety or depressive disorder after the onset of the vestibular disorder showed poor improvement and high persistency of symptoms.