Panic disorder with vestibular dysfunction: Further clinical observations and description of space and motion phobic stimuli

doi:10.1016/0887-6185(89)90006-6

Journal of Anxiety Disorders

Volume 3, Issue 2, 1989, Pages 117-130

https://doi.org/10.1016/0887-6185(89)90006-6 Get rights and content

Abstract

The phenomenology of panic was examined in eight patients with panic disorder referred for vestibular and audiological testing due to symptoms of dizziness or imbalance between or during panic attacks. It was found that all patients had otoneurological abnormalities; half of the patients showed abnormalities consistent with dysfunction of the peripheral vestibular organ. An analysis of situations or activities that elicited anxiety and/or discomfort revealed a “space and motion phobic” stimulus pattern. Space and motion stimuli are characterized by one of the following attributes: (a) excessive vestibular stimulation; (b) lack of visual orienting or fixation cues; (c) unusual, incongruous, or complex movements of both the visual surround and self. A case description is included to illustrate the longitudinal development of panic vestibular symptoms. The relationship between panic disorder and vestibular disorders and its implications for treatment are discussed.

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Dizziness is a common symptom among patients in primary care, general neurology, and headache clinic practices. Vestibular migraine is conceptualized as a condition of recurrent attacks of vestibular symptoms attributed to migraine. It is now considered the most common cause of spontaneous episodic vertigo. Persistent postural-perceptual dizziness (PPPD) has more recently been defined based on four previous clinical entities as a syndrome of chronic daily dizziness, unsteadiness, or nonspinning vertigo that fluctuates and is exacerbated by postural, motion, or visual factors. Although PPPD is more often precipitated by other conditions causing vertigo, unsteadiness, or dizziness, it is discussed at length in this chapter because vestibular migraine is among the most common triggers for development of PPPD. Pathophysiology of each is incompletely understood, and with lack of biomarkers, the diagnosis of each rests on consensus-derived, symptom-based criteria. Areas of uncertainty exist regarding some overlapping symptoms that may create potential diagnostic confusion between the conditions. This chapter provides a comprehensive review of the current state of vestibular migraine and PPPD, including diagnostic and management guidance for when they occur separately, together, or along with other common comorbidities.
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Cognitive behavioral therapy (CBT) has been applied to persistent postural-perceptual dizziness (PPPD), a functional vestibular disorder in which the condition is maintained after acute balance symptoms without readaptation of the balance system. Antidepressants, vestibular rehabilitation, and CBT are known treatments for PPPD, and only CBT for PPPD-related disease has been tested for its effectiveness in randomized controlled trials. Targeting hypervigilance and negative appraisals for dizziness and related sensations may be the key factor in CBT for PPPD, and thus CBT for PPPD is similar to CBT for panic disorder and health anxiety. The typical CBT for PPPD consists of psychoeducation followed by relaxation techniques, cognitive techniques (e.g., behavioral experiment), and behavioral techniques (e.g., interoceptive exposure). Acceptance and commitment therapy, which aims to accept symptoms without trying to control them, has recently been tried for PPPD.
Vestibular migraine and persistent postural perceptual dizziness: Handicap, emotional comorbidities, quality of life and personality traits
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To compare vestibular migraine (VM) and persistent postural-perceptual dizziness (PPPD) regarding dizziness associated handicap, emotional and somatic disorders, health-related quality of life (QoL) and personality traits.
Thirty patients for each group [VM, PPPD and healthy volunteers (HC)] were studied. Dizziness Handicap Inventory (DHI), Beck depression and anxiety scales, Somatic Symptom Scale-8 (SSS-8), Short Form (36) Health Survey (SF 36) and the Big Five Inventory (BFI) were used.
DHI sub-scores were significantly high in both patient groups in comparison with the HC (p < 0.001 for all). Emotional (p = 0.001) and functional (p = 0.022) sub-scores of the PPPD patients were worse. Anxiety and somatic symptom scores of VM (p = 0.026 and p < 0.001 respectively) and PPPD (p < 0.001 for both) and depression scores of the PPPD (p = 0.003) were higher than the HC. Both anxiety (p = 0.009) and somatization (p = 0.005) scores of the PPPD patients were higher than the VM. SF-36subscales were affected in both groups (p < 0.05). Vitality (p = 0.002), mental health (p = 0.045) and social role functioning (p = 0.006) of the PPPD group were worse than the VM. Higher scores for neuroticism (p < 0.001) was present for both groups. Scores for extraversion was low in PPPD patients (p = 0.010) in comparison with the HC.
Dizziness associated handicap, anxiety and somatic symptom burden is high in both groups, even higher in PPPD with additional depression. Severe impairment in QoL is present with more severe impairment in emotional aspects in patients with PPPD. Neuroticism is a common personality trait for both groups with additional introversion in PPPD.
Video head impulse test in bilateral vestibulopathy
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Citation Excerpt :
All subjects were evaluated using Videonystagmography (VNG) and vHIT. Scoring of the dizziness complaint was performed using a translated form of the SVQ.13 The SVQ is a 19 item questionnaire aiming specifically at recognizing visual vertigo, in which patients present with increased visual dependence because of poor vestibular compensation.14
Bilateral vestibulopathy is a rare chronic condition with multiple etiologies. Bilateral vestibulopathy is characterized mainly by unsteadiness when walking or standing, which worsens in darkness, as well as oscillopsia. The degree of handicap caused by bilateral vestibulopathy is variable and remains controversial.
To determine the value of the video Head Impulse Test in quantifying vestibular deficit and to establish its impact on the quality of life.
Twenty patients (mean age, 41.9 years; range 14–80 years) fulfilling the recent Barany criteria of bilateral vestibulopathy, responded to the Situational Vertigo Questionnaire and underwent vestibular examination including fixation, positional tests, oculomotor test battery and video head impulse test.
The relation between each of the video head impulse test parameters and the scores from the questionnaire were statistically analyzed. We observed that patients with covert saccades on the video head impulse test were more likely to have a better quality of life than those with both covert and overt saccades, regardless of the vestibulo-ocular reflex gain in each semicircular canal. The presence of covert saccades was found to be associated with an improved quality of life regardless of the severity of vestibule ocular reflex-deficit. Our conclusion was that vestibule ocular reflex gain, measured by video head impulse test, does not quantify the severity of affection of quality of life in patients with bilateral vestibulopathy.
Covert saccades are strategies aiming at minimizing the blurring of vision during head movement, that is an adaptive mechanism that improves quality of life. Therefore, we recommend that video head impulse test should be a part of the routine diagnostic workup of bilateral vestibulopathy.
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^☆: Supported in part by grant MH 40757 from the National Institute of Mental Health, U.S.A., and by grant MH 00921 from the National Institute of Health, U.S.A.

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Case reportPanic disorder with vestibular dysfunction: Further clinical observations and description of space and motion phobic stimuli☆

Abstract

Journal of Psychosomatic Research

Psychiatry Research

Psychiatric Clinics of North America

Lancet

Caloric testing: Effect of different conditions of ocular fixation

Ann Otolology Rhinology and Laryngology

Psychological treatment of panic

Vestibular reflexes in rabbits: Reduction by intravenous injection of diazepam

Archives of Neurology

Modification of vestibular reflexes induced by diazepam: Experiments in the macaque

Archives of Otolaryngology

The multisensory physiological and pathological vertigo syndromes

Annals of Neurology

A cognitive model of panic