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Chronic Dizziness and Anxiety Effect of Course of Illness on Treatment Outcome

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Chronic Dizziness and Anxiety Effect of Course of Illness on Treatment Outcome ORIGINAL ARTICLE Chronic Dizziness and Anxiety Effect of Course of Illness on Treatment Outcome Jeffrey P. Staab, MD, MS; Michael J. Ruckenstein, MD, MSc Objective: To investigate the hypothesis that the effi- Interventions: Patients with CSD were treated with an cacy of selective serotonin reuptake inhibitors (SSRIs) for SSRI according to an established protocol for at least 8 chronic subjective dizziness (CSD) and anxiety depends weeks or until they proved intolerant to medication. on the longitudinal pattern of the patients’ symptoms. Main Outcome Measures: Changes in dizziness and Design: Prospective cohort study. anxiety as measured by the Clinical Global Impressions– Improvement scale. Setting: Tertiary care, multidisciplinary, balance center. Results: Patients with the otogenic and psychogenic pat- Patients: Eighty-eight consecutive patients treated with terns of illness had a more complete response to SSRI treat- an SSRI for CSD and anxiety between 1998 and 2003. All ment than did patients in the interactive group (PϽ.01). patients were referred for evaluation of unremitting dizzi- Rates of SSRI intolerance were similar for all 3 groups. ness. They entered SSRI treatment after comprehensive neu- rotologic and psychiatric evaluations revealed a syn- Conclusions: Selective serotonin reuptake inhibitors drome of CSD with accompanying anxiety. Patients were are effective for patients with CSD and anxiety. How- separated into 3 groups according to their longitudinal pat- terns of illness: (1) otogenic, defined as primary neuroto- ever, patients with clinically significant anxiety predat- logic conditions triggering secondary anxiety disorders; (2) ing neurotologic illness may require more intensive in- psychogenic, defined as anxiety disorders alone causing diz- terventions. ziness; and (3) interactive, defined neurotologic condi- tions exacerbating preexisting anxiety. Arch Otolaryngol Head Neck Surg. 2005;131:675-679 ESPITE ADVANCES IN NEU- tive sensations of imbalance. As opposed rovestibular testing and to true vertigo or ataxia, they may com- diagnostic imaging, the plain that the inside of their head is spin- evaluation of patients with ning or that they are swaying when stand- the chief complaint of diz- ing still. These symptoms are pervasive and ziness remains primarily predicated on the typically exacerbated in crowded environ- D1-3 clinical history. Obtaining an accurate his- ments with rich visual fields, such as gro- tory allows the clinician to distinguish cery stores and shopping malls. This clini- among specific symptom complexes that cal presentation is often diagnosed as define vestibular and nonvestibular etiolo- psychogenic dizziness, although recent re- gies of dizziness (eg, Ménière’s disease, be- search suggests that psychiatric illnesses nign positional vertigo, noncompensated are just as likely to be consequences of diz- vestibular loss, presyncope, and anxiety). ziness as they are its genesis.5-8 Diagnostic testing may be used to support In an effort to understand the relation- a specific diagnosis, but the clinical his- ships between dizziness and psychiatric tory remains preeminent in establishing the disorders, we recently studied the longi- cause of the patient’s complaints.4 tudinal course of illness in a large cohort Author Affiliations: Among the various vertiginous and of patients (N=132) who presented with Departments of Psychiatry and 9 Otorhinolaryngology–Head and nonvertiginous forms of dizziness is a clini- CSD and anxiety. We found 3 equally Neck Surgery and The Balance cal syndrome of chronic subjective dizzi- prevalent subgroups of patients that we Center, University of ness (CSD) accompanied by anxiety. Pa- called otogenic, psychogenic, and inter- Pennsylvania, Philadelphia. tients with this condition describe vague, active. Patients in the otogenic group had Financial Disclosure: None. nonspecific light-headedness and subjec- histories of transient or current neuroto- (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 131, AUG 2005 WWW.ARCHOTO.COM 675 ©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 logic illnesses (eg. vestibular neuronitis, Ménière’s dis- amination, audiometric assessment, balance function tests, and ease), but they developed persistent dizziness and anxi- magnetic resonance imaging of the head. Patients whose neu- ety for the first time after their acute neurotologic event. rotologic examination results demonstrated CSD accompa- Patients in the psychogenic group had primary anxiety nied by clinically significant anxiety were referred for psychi- disorders (eg, panic or generalized anxiety disorder) that atric assessment. Chronic subjective dizziness was identified as follows: presented with prominent dizziness in the absence of any neurotologic illness. Patients in the interactive group had v Persistent (Ն3 months) sensations of nonvertiginous diz- preexisting anxiety disorders or an anxiety diathesis (eg, ziness, light-headedness, heavy-headedness, or subjective im- balance present on most days; self-limited periods of excessive worry) without dizzi- v Ն ness. The developed chronic dizziness and an exacerba- Chronic ( 3 months) hypersensitivity to one’s own mo- tion or to movements of objects in the environment; tion of their psychiatric condition after they acquired a v Exacerbation of symptoms in settings with complex vi- physical neurotologic illness. sual stimuli (eg, grocery stores) or when performing precision Patients in the otogenic group tended to develop only visual tasks (eg, reading, using a computer); minor anxiety symptoms (eg, phobic behaviors related v Absence of active physical neurotologic illnesses, medi- just to their dizziness), whereas those in the psycho- cal conditions, or medications that may cause dizziness; genic and interactive groups had more serious anxiety v Normal radiographic images of the brain; and disorders (eg, fully developed panic disorder). Psychi- v Normal or nondiagnostic findings on balance function tests. atric factors appeared to play an integral role in sustain- Patients with previous neurotologic illnesses may have had ing patients’ dizziness in all 3 groups, regardless of the chronic vestibular deficits on balance function test results (eg, triggering events. This result was echoed in a recent patients with previous bouts of vestibular neuronitis whose re- study,10 which found that high levels of anxiety in the sults showed fully compensated, unilateral caloric weakness). early aftermath of a bout of vestibular neuronitis pre- These patients were included in the present study because their dicted a chronic course of dizziness. Thus, the longitu- physical neurotologic findings could not explain the full ex- tent of their long-standing symptoms (ie, CSD). Furthermore, dinal history of medical-psychiatric interactions ap- 12 pears to determine the severity and persistence of dizziness a previous investigation found that treating such patients with vestibular suppressants (eg, meclizine or benzodiazepines) was and anxiety in this patient population. 11,12 ineffective. Clinically significant anxiety symptoms included In 2 studies, we found that selective serotonin re- panic attacks with dizziness or light-headedness, avoidance of uptake inhibitors (SSRIs) were effective for patients with situations associated with dizziness, expectations of cata- chronic dizziness and major or minor anxiety and de- strophic outcomes when dizzy (eg, crashing the car), and ex- pression. Similarly, Horii et al13 reported that the SSRI cessive worry or chronic anxiety. paroxetine hydrochloride reduced chronic dizziness and In a previous study,16 the neurotologist’s ability to detect depression. However, all patients did not respond equally these symptoms was validated against a widely used psychiat- well to treatment. Some enjoyed a complete remission ric questionnaire and a formal psychiatric evaluation. In the of their symptoms, whereas others achieved only partial present investigation, psychiatric assessments followed the Struc- tured Clinical Interview for the Diagnostic and Statistical Manual relief, and 25% were unable to tolerate a therapeutic dose 17 11,12 of Mental Disorders, Fourth Edition, which is the standard for of medication. These results suggest that SSRIs may psychiatric diagnosis in clinical research. be an important advance in the treatment of patients with this challenging disorder, but investigations to find clini- cal predictors of incomplete medication response or in- LONGITUDINAL COURSE OF ILLNESS tolerance are needed to improve therapeutic outcomes. We undertook the present study to investigate the hy- The authors independently reviewed patients’ longitudinal his- pothesis that the longitudinal patterns of illness (ie, oto- tories to identify the first episodes of dizziness and the illness(es) genic, psychogenic, and interactive) would predict the responsible for those symptoms. Patients were classified as oto- efficacy and tolerability of SSRI treatment. We hypoth- genic, psychogenic, or interactive on the basis of the following 9 esized that patients with a psychogenic pattern of ill- criteria. Patients whose first symptoms of dizziness were caused ness would have a better therapeutic result with SSRIs by physical neurotologic illnesses that were documented in pre- because these medications are a first-line treatment for vious medical records or identified retrospectively using strict criteria1-4 were classified as otogenic. These patients
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