Cognitions associated with anxiety in Ménière’s disease
Running head: Anxiety in Ménière’s disease
School of Psychology, University of Southampton, UK
Sarah. E. Kirby, PhD, and Lucy Yardley, PhD
Address correspondence to: Sarah Kirby, School of Psychology, University of
Southampton, Highfield, Southampton SO17 1BJ, UK. Tel: +44 (0)23 8059 2581
Fax: +44 (0)2380 594597. E-mail: Sarah.Kirby@soton.ac.uk
Anxiety in Ménière’s disease 2
Abstract
Objectives: The purpose of this longitudinal study was to identify cognitions
associated with anxiety and maintenance of anxiety in people with Ménière’s disease.
Method: At baseline participants completed the Hospital Anxiety and Depression
Scale (HADS), the Revised Illness Perception Questionnaire, the Dizziness Beliefs
Scale, the Fear Avoidance Beliefs Questionnaire, the Intolerance of Uncertainty Scale,
and measures of demographic and illness characteristics. Participants were then
randomised to no treatment or to receive one of two self-help booklets, and completed
the HADS again at 3 month follow-up. Results: After controlling for symptom
severity, baseline anxiety was associated with intolerance of uncertainty, fearavoidance of physical activity, the belief that dizziness would develop into a severe
attack of vertigo, and several illness perception subscales (emotional representations,
consequences, psychological causes, and perceived treatment effectiveness). Anxiety
at follow-up was predicted by higher baseline levels of autonomic/somatic symptoms
and intolerance of uncertainty, and reporting less understanding of the illness. These
longitudinal relationships were found in those who did and did not receive self-help
booklets. Conclusions: Our findings suggest that intolerance of uncertainty is
associated with anxiety in Ménière’s disease. A controlled trial is needed to see
whether anxiety might be reduced in Ménière’s disease by helping patients to tolerate
and cope with uncertainty.
Keywords: anxiety disorder, vestibular, Ménière’s disease, attitudes, questionnaire
design.
Anxiety in Ménière’s disease 3
Introduction
Ménière’s disease is an incurable chronic disorder of the inner ear, characterised by
recurrent spontaneous attacks of severe vertigo (a strong sense of spinning),
progressive hearing loss that becomes permanent in one or both ears, a sense of
fullness or pressure in the ear(s), and intermittent spells of loud tinnitus (a buzzing,
ringing or roaring sound) [1]. There are close neurological links between the
vestibular and autonomic systems, with the consequence that vestibular disturbance
directly provokes autonomic symptoms such as nausea, pallor and sweating (as in
motion sickness). Following an acute attack of vertigo, dizziness gradually
diminishes as the central balance system habituates to the change in vestibular
function. However, residual dizziness can still be provoked by unaccustomed
movements and disorienting situations [2;3]. Autonomic symptoms can also be
induced by anxiety arousal [4-6]. Both illness and anxiety provoked symptoms have
the potential to create a vicious cycle of prolonged symptomatology and distress, as
symptoms can be augmented by anxiety, and in turn fuel further anxiety [6-9].
Indeed, high levels of anxiety are often reported among those who experience vertigo
[10-12], and elevated levels of anxiety and distress have been found in people with
Ménière’s disease [13-15]. It would be helpful to be able to identify modifiable
factors that are associated with anxiety in order to try to limit the exacerbation of this
vicious cycle.
Cognitive behavioural approaches to chronic illness suggest that cognitions
about illness and its consequences are important in how people with chronic illness
respond emotionally to their illness [16;17]. Therefore, if the cognitions that
contribute to anxiety in Ménière’s disease can be identified, this should assist in the
identification of the forms of support and therapy that are most likely to reduce
Anxiety in Ménière’s disease 4
anxiety in people with Ménière’s disease. This study considers the relevance to
Ménière’s disease of three groups of cognitions found to be related to anxiety among
other chronic illnesses: illness perceptions, dizziness related fears and beliefs, and
intolerance of uncertainty. Anxiety is likely to be related partly to realistic negative
cognitions, but in chronic illness anxiety is also often related to excessive and
catastrophic concerns, which may be amenable to modification.
Illness perceptions [18;19] have been found to play a significant role in
relation to a variety of outcomes, including anxiety [20]. Chronically ill people
experience more psychological distress if they have a strong illness identity (i.e.
attribute many symptoms to the illness), a stronger emotional response to illness, feel
they do not understand their illness well, and believe that their illness has serious
consequences, will last a long time and cannot be easily controlled [21-23]. These
perceptions of illness may be common Ménière’s disease. A strong illness identity
could develop if symptoms of anxiety arousal and residual dizziness were attributed to
active disease. Moreover, some people with the disease may have to make significant
lifestyle changes, including changing or giving up work or certain social or leisure
activities, or becoming unable to drive or travel. Therefore people may well view the
disease as having serious consequences, depending on the extent to which it has
impacted on their family and finances, and social and occupational areas of life. The
disease is incurable and treatment options are limited, as little is known about what
causes the disease. Therefore people with Ménière’s disease may correctly expect
their illness to be long-lasting, and may also believe that they do not understand their
illness very well, and that the symptoms cannot be easily controlled.
Dizziness related fears and beliefs have also been found to contribute to
anxiety. In Ménière’s disease, as severe vertigo attacks are experienced which are
Anxiety in Ménière’s disease 5
unpleasant and frightening, and result in a sense of loss of control and helplessness.
As noted above, milder symptoms of residual or movement-provoked dizziness can
also be experienced between attacks. When people with Ménière’s disease experience
any dizziness, they may interpret this catastrophically, misinterpreting the symptoms
as the beginning of a severe attack. Dizziness may also lead to fear that they will be
in physical danger (as attacks carry a risk of injury from stumbling or falling), or a
fear of embarrassment about having an attack in public or letting people down
[24;25]. Negative beliefs about the consequences of vertigo have been shown to be
more disabling than the symptoms themselves, leading to high levels of disability and
handicap [9;26]. If people with Ménière’s disease believe that movement-provoked
dizziness may develop into a severe attack, they may also believe that movement is
therefore bad for them and should be avoided. This belief that physical activity may
be harmful and subsequent avoidance of physical activity has also been reported
among people with other chronic symptoms [16;27].
Thirdly, intolerance of uncertainty has been found to be relevant to anxiety.
Many chronic illnesses result in increased levels of uncertainty with regard to the
occurrence or severity of symptoms, prognosis, or the effectiveness of treatment.
Uncertainty has been well noted anecdotally in Ménière’s disease and chronic vertigo
[13;28;29], as attacks can occur unexpectedly, impacting on every area of life.
Individual differences may occur in how people tolerate these uncertainties and adapt
their lives to accept and incorporate their presence and consequences. Dugas and
colleagues [30] describe someone who is intolerant of uncertainty as having “an
excessive tendency to find uncertain situations stressful and upsetting, to believe that
unexpected events are negative and should be avoided, and to think that being
uncertain about the future is unfair” (p. 58). Intolerance of uncertainty has been
Anxiety in Ménière’s disease 6
reported to lead to inaccurate appraisals of threat [30;31] and result in a greater use of
vigilance and avoidance behaviours [32]. If people with Ménière’s disease believe
that the unpredictable nature of their illness is stressful, unfair, and reflects badly on
their character (e.g. making them appear to be disorganised or to under-perform), they
may respond anxiously to all uncertain situations. They may also try to avoid
situations in which unexpected attacks may occur. This may also contribute to
anxiety as, due to the nature of the disease, any situation could potentially be
appraised as uncertain.
The purpose of this study was firstly to investigate whether illness perceptions,
dizziness related fears and beliefs and intolerance of uncertainty are associated with
clinical levels of anxiety, and secondly, to identify what combination of cognitions
predict the maintenance of anxiety over time. Our multivariate analyses were
designed to examine and control for the effects of symptom severity, in order to
isolate the additional effects of these cognitions.
This study was nested within a randomised controlled trial (RCT) of vestibular
rehabilitation (VR) or symptom control (SC) therapy presented in the form of selfmanagement booklets for people with Ménière’s disease [33]. VR involves
stimulating the balance system using a series of head movements, causing movementprovoked dizziness. The balance system gradually habituates to these movements,
leading to a gradual reduction in provoked dizziness [2]. SC therapy involves the use
of applied relaxation, controlled breathing and stress management strategies; the
rationale is that since arousal and stress may aggravate symptoms of dizziness,
reducing stress can improve adjustment and relieve symptoms [3]. By combining an
observational study with this RCT we were able to examine whether the longitudinal
Anxiety in Ménière’s disease 7
predictors of anxiety differed in those undertaking different self-management
programmes.
It was hypothesised that in line with previous research on illness perceptions,
anxiety would be associated with the belief that the illness has serious consequences,
belief in a chronic timeline, low perceived control, less understanding of the illness
and greater emotional response. Greater levels of anxiety were also hypothesised to
be associated with negative beliefs about dizziness, and a greater intolerance of
uncertainty. Finally, it was hypothesised that these associations would be moderated
by intervention group. As the VR intervention requires the deliberate provocation of
unpleasant symptoms, stronger associations were hypothesised to occur within the VR
intervention group than the SC or control groups.
Method
Participants and Procedure
Participants were 358 members of the Ménière’s Society with current dizziness
symptoms but reporting no acute attack in the previous six weeks. They were
randomised to receive a self-management booklet on vestibular rehabilitation (VR) or
symptom control (SC), or were assigned to a waiting list control group [33].
Questionnaire measures for this study were sent with the baseline and 3 month followup measures for the RCT.
Measures
Anxiety.
Anxiety was assessed by the anxiety subscale of the Hospital Anxiety and Depression
Scale (HADS) [34]. The HADS was chosen because it does not include somatic
Anxiety in Ménière’s disease 8
symptoms of anxiety that are analogous with secondary symptoms of dizziness.
Anxiety scores at baseline and follow-up were dichotomised for analysis, with
participants being classified as having clinical levels of anxiety if they scored eight or
more [35].
Illness perceptions.
Illness perceptions were measured by eight of the nine subscales of the Revised
Illness Perception Questionnaire (IPQ-R) [18]. The ‘timeline acute/chronic’
subscale assesses how long the respondent expects the illness to last, and the ‘timeline
cyclical’ subscale asks respondents if the illness fluctuates or is unpredictable. The
‘consequences’ subscale measures respondents’ expectations of the effects of the
illness. The ‘personal control’ subscale measures respondents’ belief in personal
control over the illness, whereas the ‘treatment control’ subscale measures belief in
the effectiveness of treatments. The ‘illness coherence’ subscale assesses the extent to
which respondents believe they understand their illness. The ‘emotional
representations’ subscale measures the presence of emotional responses to the illness
(e.g. depression, anger, worry, anxiety and fear). The ‘causal’ dimension asks
respondents what may have caused their illness. Factor analysis (principal component
analysis with varimax rotation) was used to identify any meaningful clusters of
perceived causes that could be used as causal beliefs subscales. Only one clear factor
emerged, which related to the belief that Ménière’s disease was caused by
psychological state (e.g. stress, worry or personality), and corresponded to the
‘psychological attributions’ factor identified by Moss-Morris and colleagues [18].
Items loading over 0.5 on this factor were summed to create a subscale with good
internal consistency (Cronbach’s alpha = 0.84).
Anxiety in Ménière’s disease 9
Beliefs about dizziness.
Three of the four subscales of the Dizziness Beliefs Scale [25] were used to measure
the extent to which participants believed that dizziness would result in negative
consequences. The ‘physical danger’ subscale assesses the belief that dizziness will
result in being physically harmed. The ‘social incompetence’ subscale measures
beliefs about the social embarrassment of becoming dizzy in public and being unable
to behave normally. The ‘severe attack’ subscale measures concern that dizziness
will develop into a severe attack of vertigo. The ‘serious illness’ subscale, which
measures the belief that the dizziness is a sign of an underlying disease, was not used
in this study because participants knew that Ménière’s disease was the cause of their
dizziness.
The extent to which participants believed that their symptoms could be made
worse by physical activity was measured using the ‘physical activity’ subscale of the
Fear Avoidance Beliefs Questionnaire (FABQ) [27]. The FABQ was originally
designed for people with low back pain, and so the ‘physical activity’ subscale was
adapted for the purposes of this study by replacing references to the word ‘pain’ with
the word ‘vertigo’, and removing references to participants’ backs. The internal
reliability for the adapted scale was acceptable (α = .79).
Intolerance of uncertainty.
Intolerance of uncertainty was measured using the Intolerance of Uncertainty Scale
(IUS) [31]. The IUS assesses the emotional and behavioural consequences of
uncertainty for respondents, their expectations that future events should be predictable
and attempts to control future events.
Anxiety in Ménière’s disease 10
Demographic and illness characteristics.
Single items were used to assess length of time (in months) since symptoms began,
gender, and age. Vertigo was assessed using the long version of the Vertigo
Symptom Scale (VSS) [6]. The ‘vertigo severity’ subscale measures the frequency
and severity of symptoms of vestibular origin, such as vertigo, dizziness, and
imbalance. The ‘autonomic/somatic symptoms’ subscale measures autonomic
symptoms that are secondary to vestibular dysfunction and symptoms of somatic
anxiety and anxiety arousal. Hearing loss was assessed using five questions from the
Hearing Disability Questionnaire [36] that assessed subjective severity of hearing
impairment. Tinnitus and fullness in the ear were assessed using the Tinnitus Severity
Index and Aural Pressure Index [37;38].
Statistical Analyses
Initially, analysis of variance (ANOVA) was used to identify variables related
to anxiety (non-clinical vs. clinical) at baseline. Baseline anxiety was entered into the
analysis as a fixed factor, with each of the baseline variables being entered in turn as
the dependent variable. We then used ANOVA to determine whether the same
baseline variables predicted anxiety at follow-up, and whether intervention group (VR
vs. SC vs. control group) affected this relationship. For these analyses the ANOVAs
were repeated but baseline anxiety was replaced by anxiety at follow-up and treatment
group was added as a second fixed factor. No interactions were found in these
analyses, indicating that intervention group did not influence the relationship between
baseline variables and anxiety at follow-up, and therefore data for the intervention
groups were pooled for our final analyses.
Anxiety in Ménière’s disease 11
These initial analyses were intended to minimise Type II error (overlooking
variables related to anxiety), and so our focus was principally on the effect sizes of
each variable, rather than their statistical significance. To determine which variables
were associated with anxiety while controlling for Type 1 error (i.e. minimising the
likelihood that relationships were identified as significant by chance), all baseline
variables identified in the ANOVAs (shown in Table 1) as potentially significantly
related to anxiety were entered into two hierarchical logistic regressions with anxiety
at baseline and follow-up as the dependent variables. The logistic regression for
anxiety at follow-up controlled for baseline levels of anxiety by entering baseline
anxiety on the first step of the regression, thus allowing us to identify predictors of
change in anxiety from baseline [39]. In both regressions, demographic and illness
characteristics were entered together as covariates, to control for the effects of these
variables. The cognitions were lastly entered together on the final step. All statistical
analyses were carried out using the Statistical Package for the Social Sciences (SPSS),
version 14.0 for windows.
Results
Participant Characteristics
Of the 358 participants, 246 were female (68.7%) and 112 were male (31.3%). The
age range was 28-90 years. The length of time since their symptoms began ranged
from 18 to 660 months. Ten participants dropped out before the follow-up assessment
(five from the VR group, four from the SC group and one from the control group),
leaving 114 participants in the VR group, 115 in the SC group, and 119 in the control
group.
Anxiety in Ménière’s disease 12
Following the clinical cut off points recommended for the HADS [34], at
baseline 56.2% of participants had at least mild clinical levels of anxiety , and 27.4%
met the criteria for moderate to severe clinical levels of anxiety. At 3 month followup, 48.1% had at least mild clinical levels of anxiety, and 24.9% had moderate to
severe clinical levels of anxiety.
Bivariate Analyses
Bivariate analyses of the associations between baseline variables and anxiety at
baseline and follow-up are reported in Table 1. None of the baseline variables had
different patterns of association with anxiety at follow-up in the three intervention
groups (i.e. there were no significant interactions with intervention group), and so
pooled analyses for the whole sample are presented. In general, a similar pattern of
associations was found with anxiety at baseline and follow-up. Of the illness
characteristics, higher levels of autonomic/somatic symptoms were strongly
associated with clinical levels of anxiety, and anxiety was also higher among those
who reported worse symptoms of vertigo, fullness in the ear and hearing disability.
Among the cognitions, the variables most strongly associated with anxiety
were intolerance of uncertainty and emotional responses to the illness. Participants
who were clinically anxious also had stronger beliefs that dizziness could result in
them losing control and being physically harmed, embarrassed or unable to fulfil
social roles. Having a poor understanding of the illness and believing that it had more
severe consequences were moderately associated with higher levels of anxiety. Small
to moderate associations were found between anxiety and the belief that the illness
was caused by psychological factors and that dizziness would develop into a severe
attack of vertigo. The beliefs that treatment would not be effective in controlling their
Anxiety in Ménière’s disease 13
illness, and that physical activity could make symptoms worse also had small to
moderate associations with anxiety.
Predictors of Anxiety at Baseline and Follow-up
The results of the logistic regression indicated that 8 of the 14 variables that had been
identified by ANOVA as related to anxiety independently contributed to the
regression equation predicting baseline levels of clinical anxiety (see Table 2).
Clinical levels of baseline anxiety were most strongly associated with reporting
greater autonomic/somatic symptoms; severity of vertigo, fullness in the ear and
hearing disability were no longer related to anxiety after controlling for
autonomic/somatic symptoms. However, after controlling for illness severity,
baseline anxiety was strongly related to being more intolerant of uncertainty, and
having a greater emotional response to illness. Clinical levels of anxiety were also
associated with having stronger beliefs that the illness was caused by psychological
factors and that dizziness could be made worse by physical activity and would
develop into a severe attack of vertigo. Higher levels of anxiety were also related to
beliefs that their illness had greater consequences and that treatment would not be
effective in controlling their illness.
After controlling for baseline anxiety, anxiety at follow-up was no longer
related to severity of vertigo, hearing loss or tinnitus, and was also no longer related to
many of the baseline psychological measures that were significant in the bivariate
correlations (i.e. perceived consequences, treatment control, emotional
representations, psychological attributions, fear-avoidance and the belief that
symptoms might herald a severe attack). However, maintenance of anxiety was
predicted by three baseline variables (see Table 2). These were autonomic/somatic
Anxiety in Ménière’s disease 14
symptoms, a greater intolerance of uncertainty, and reporting less understanding of
their illness.
Discussion
The purpose of this study was to identify cognitions associated with anxiety, while
examining and controlling for the effects of symptom severity, in order to isolate the
additional effects of cognitions. At baseline, anxiety was related to the severity of all
symptoms of Ménière’s disease except for tinnitus, but was most closely related to
autonomic/somatic symptoms. The strength of this correlation is undoubtedly due in
part to the fact that autonomic and somatic symptoms are an intrinsic part of anxiety.
However, they can also be provoked by vestibular disorder. It seems likely that in this
study autonomic/somatic symptoms were partly related to the severity of Ménière’s
disease, since the other symptoms of Ménière’s disease were no longer related to
anxiety after controlling for severity of autonomic/somatic symptoms.
After controlling for symptom severity, most of the hypothesised relationships
between anxiety and cognitions were confirmed in the cross-sectional analyses.
Anxiety was associated with the belief that the illness has serious consequences,
negative beliefs about the consequences of dizziness, perceived lack of understanding
of the illness, a stronger emotional response to it and a greater intolerance of
uncertainty. The causal direction of associations cannot be determined from crosssectional correlations; consequently, it is not possible to be certain whether high
anxiety levels caused or resulted from these beliefs and attitudes.
After controlling for baseline anxiety, three baseline variables predicted the
maintenance of anxiety at follow-up, although it should be noted that the size of these
effects was small. Since the variance these variables shared with anxiety at baseline
Anxiety in Ménière’s disease 15
was partialled out, greater significance can be attached to their potential causal role in
maintaining anxiety. Moreover, these longitudinal relationships were found in all
three intervention groups, and the strength of the relationships was not affected by the
interventions.
After baseline anxiety, the next strongest predictor of persisting anxiety at
follow-up was autonomic/somatic symptoms. Given the conceptual overlap between
autonomic/somatic symptoms and anxiety (as measured by the HADS), it is not
surprising that they were strongly associated. Nevertheless, it was essential to include
autonomic/somatic symptoms in order to control for illness severity when measuring
the effects of the psychological variables. Of more interest, therefore, is the finding
that intolerance of uncertainty predicted persisting anxiety after controlling for
baseline anxiety and autonomic/somatic symptoms. This provides for the first time an
indication that the strong association with anxiety observed in the cross-sectional
analyses at baseline (and in another study [40]) may reflect a causal relationship,
whereby the predisposition to react negatively to uncertainty may contribute to
anxiety. In addition, a perceived lack of comprehension of the illness at baseline
predicted persisting anxiety, suggesting that anxiety is maintained not only by the
sense that symptoms are unpredictable but also by the sense that they are inexplicable.
The findings of this study cannot be generalised to all people with Ménière’s
disease, as the RCT was limited to participants from the Ménière’s Society who had
current dizziness but were not experiencing frequent spontaneous attacks of acute
vertigo. Members of the Ménière’s society may not be representative of the general
medical population of people with Ménière’s disease. For example, members may
have wanted to join the society as a result of higher levels of anxiety than non
members. Therefore, these findings need to be replicated in a sample who have not
Anxiety in Ménière’s disease 16
joined a self-help group. A further limitation of this study is that we were only able to
analyse and report associations with one aspect of the distress caused by Ménière’s
disease. It is probable that other key aspects of distress, such as depression and
handicap, are related to different patterns of symptoms and cognitions [40]. Most
importantly, while longitudinal prediction of changes in anxiety provides stronger
evidence of possible causality than can be inferred from cross-sectional associations,
it cannot confirm a causal relationship. In order to do this it would be necessary to
show that the outcome of an intervention that was successful in reducing anxiety was
mediated by a reduction in autonomic/somatic symptoms and intolerance of
uncertainty.
About half of the participants in our RCT had possible clinical levels of
anxiety at baseline. This observation is consistent with the findings of Savastano and
colleagues [41], who identified distressed and non-distressed subgroups, and suggests
that whereas some people with Ménière’s disease are able to successfully adjust to
having the disease, others may need support to achieve this. In the RCT in which this
study was embedded [33], vestibular rehabilitation (VR) resulted in a reduction in
symptoms (assessed by a scale that measured both vertigo and autonomic/somatic
symptoms) and a decrease in anxiety (measured by the HADS). Since VR requires
patients to deliberately and repeatedly provoke dizziness (in order to stimulate
neurological adaptation), undertaking VR teaches patients that residual symptoms are
tolerable, and partly predictable and controllable, and that it is not necessary to avoid
activity. It has therefore been suggested that VR can function as a form of cognitivebehavioural therapy, interrupting the vicious cycle of symptoms and anxiety about
symptoms [3;33;42]. Indeed, in the trial associated with this study, VR also resulted
in a reduction in negative beliefs about dizziness. Nevertheless, benefits obtained
Anxiety in Ménière’s disease 17
using the self-help booklets were modest, and further research is needed to identify
additional therapy components that might improve outcomes.
The cognitions found to be relevant to anxiety in this study are consistent with
results found among populations with chronic pain [22], multiple sclerosis [23] and
dizziness [25;43], and suggest that there may be a pattern in how people perceive and
think about chronic illness that is related to poor adjustment and increased distress.
Emotions, bodily symptoms, cognitions and behaviours seem to become linked in a
strong and unhelpful way, and it may be necessary for cognitive-behavioural therapy
to address all of these components of the illness experience. However, this study has
identified intolerance of uncertainty as a reaction that may be particularly important to
address in therapy for Ménière’s disease. Action and contingency plans might be
useful coping tools. However, McCracken and Eccleston [44] suggest that
interventions that focus on acceptance rather than coping with chronic illness may be
more beneficial in improving adjustment. As uncertainty cannot be avoided in
Ménière’s disease, support could be focused on helping people with Ménière’s disease
to accept that at times they may not be able to do certain things. A controlled trial is
needed to test whether anxiety can be reduced by successfully treating intolerance of
uncertainty.
Acknowledgments
This study was funded by the Ménière’s Society, UK.
Anxiety in Ménière’s disease 18
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