Otology Semina Psychogenic Dizziness 2005-1-19 R3 林正民 Background Simpson : Psychogenic dizziness—a clinical syndrome characterized by vague, persistent sensation of dizziness, subjective imbalance, lightheadedness, or fullness in the head without evidence of vestibular dysfuntion on NE or balance function tests. Bath: 20~25% patients with chronic dizziness psychogenic dizziness. Jacob: Psychogenic dizziness is significant related to panic disorder with or without agoraphobia. Some related to hyperventilation. Robichaud: Hyperventilation-induced nystagmus is significant related with retrocochlear pathology than with end-organ pathology. Murphy: Mal de Debarquement syndrome (MDDS)—an imbalance or rocking sensation lasts for 6-12 months after prolonged exposure to motion (most commonly after a sea cruise or a long airplane flight). Brandt: Phobic postural vertigo (PPV)—a somatoform disorder characterized by a chronic and subjective imbalance and short attacks of dizziness. Panic disorder with/without agoraphobia Diagnosis criteria for panic attacks in DSM-IV (≧4 symptoms) Symptoms develop abruptly and reached peak in 10`mins. 1. Palpitations, pounding heart, or accelerated heart rate 2. Sweating 3. Trembling or shaking 4. Sensations of shortness of breath or smothering 5. Feeling of choking 6. Chest pain or discomfort 7. Nausea or abdominal distress 8. Feeling dizzy, unsteady, lightheaded, or faint 9. Derealization (feelings of unreality) or depersonalization (being detached from oneself) 10. Fear of losing control or going crazy 11. Fear of dying 12. Paresthesias (numbness or tingling sensations) 13. Chills or hot flushes Agoraphobia: Axiety about being in places or situation which escape might be difficult. Yardley: 64% of dizzy patients need of psychological help. 8% had panic disorder. Co-morbid dizziness and anxiety is 11%. The concept of psychogenic dizziness Psychoanalytical view: Psychic conflicts can manifest as somatic symptoms. Psychogenic vertigo is often diagnosed as an anxiety concomitant, or an anxiety equivalent. Conflicts or stress in the life dizziness psychic defenses collapse trigger regressive mechanisms chronic dizziness The onset of Phobic postural vertigo (PPV) coincided with psychological conflicts associated with the feelings of existential threat. Bridges, empty rooms, the crowds concomitant anxiety and autonomic symptoms personality disorder, especially obsessional traits Revised taxonomy for vestibular disorders and for psychiatric dizziness Dizziness is either organic or psycogenic? Categories of dizziness etiologies: Syndromal vestibular disorders Non-syndromal vestibular disorders Subclinical vestibular disorders No vestibular disorder “Psychiatric dizziness”, on if it is part of a recognized psychiatric symptom complex, and cannot be explained by a vestibular disorder. Behavioral effects on vestibular (dys)function Psychological factors on vestibular function: Attention, cognitive activities, mental stress, and hyperventilation After hyperventilation, significant increase in body sway of normal individuals. Hyperventilation reductions in somatosensory input Hyperventilation induced nystagmus in patients with vestibular disorders Hyperventilation affects both affected nerve and central compensation. Caution us: Hyperventilation-induced dizziness not always psychogenic Somatopsychic effects: Can vestibular symptoms result in anxiety? Space and motion discomfort visual influence on balance Autonomic anxiety symptoms, including sweating, dry mouth, hot flash. Can a reduction of the symptoms/signs of vestibular dysfunction lead to a reduction in anxiety? Vestibular rehabilitaion and cognitive behavior therapy can improve patients with agoraphobia and vestibular dysfunction independently. Treatment Treatment of Panic Disorder with and without Agoraphobia Medication: anti-depressant (SSRI), anxiolytics(eg. Ativan, Xanax) Education about physical and mental symptoms (cognitive restructuring) Breathing retraining Interoceptive exposure (repeated hyperventilation to produce physical symptoms); and real life (In-vivo) exposure to feared situations. Reference 1. Bath AP, Walsh RM, Ranalli P, et al. Experience from a multidisciplinary “dizzy” clinic. Am J Otology 2000;21:92–97. 2. Yardley L. Overview of psychological effects of chronic dizziness and balance disorders. Otolaryngol Clin N Am 2000; 33:603–616. 3. Staab JP. Diagnosis and treatment of psychologic symptoms and psychiatric disorders in patients with dizziness and imbalance. Otolaryngol Clin N Am 2000;33:617–633. 4. Jacob RG, Furman JM, Durrant JD, Turner SM. Panic, agoraphobia, and vestibular dysfunction. Am J Psychiatry 1996;153:503–512. 5. Jacob RG, Furman JM. Psychiatric consequences of vestibular dysfunction. Curr Opin Neurol 2001;14:41–46. 6. Kapfhammer HP, Mayer C, Hock U, et al. Course of illness in phobic postural vertigo. Acta Neurol Scand 1997;95:23–28. 7. Nagarkar AN, Gupta AK, Mann SB. Psychological findings in benign paroxysmal positional vertigo and psychogenic vertigo. J Otolaryngol 2000;29:154–158. 8. Bance ML, O'Driscoll M, Patel N, Ramsden RT. Vestibular disease unmasked by hyperventilation. Laryngoscope. 1998 Apr;108(4 Pt 1):610-4. Erratum in: Laryngoscope 1998 Jun;108(6):948. 9. Jacob RG, Whitney SL, Detweiler-Shostak G, Furman JM. Vestibular rehabilitation for patients with agoraphobia and vestibular dysfunction: a pilot study. J Anxiety Disord. 2001 Jan-Apr;15(1-2):131-46.