Transcript CASE STUDY - D270435 - The British Academy of Audiology

CASE STUDY
PSYCHOGENIC
VESTIBULAR DISORDER
Date = 06/05/08
Summary of Referral Information
Summary of Letter from GP;
‘This young man has had unsteadiness and vertigo over the
last six months. He has failed to respond to betahistine and
prochloroperazine and has become very fed-up and down with
this. He has also had panic attacks. Interestingly, he had a
similar problem when his parents were separating as a child.
He is a fairly self-critical and tense individual who has low self
esteem. I would be most grateful if you could advise further on
his dizziness.
Plan for Session
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Check Medications
History
Questionnaires
Audiogram
Tympanometry
Balance Testing
Debrief
General History
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Attended with girlfriend
24 years old
Applying to police force
Personal adviser
Not working due to dizziness
Claustrophobic
History
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Vague Historian
Symptoms started as a teenager, 14 years old
General sense of disorientation
no distinct episodic dizziness or rotatory vertigo
Feels better when sat still
Motion sensitive
Symptoms are constant
Loss of appetite and nausea since dizziness began
Anxiety and depression
Suffers from panic attacks
History cont…..
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Constant light-headed and faint feeling
Increase in anxiety and depression symptoms
since events started
Hyperventilating during attacks
Clinical Appearance
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Gait and balance looked normal
Tired and emotional
Anxious
Comments like ‘life wouldn’t be worth living’ if
continued
Medical History
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Colds and Sinus Problems
No other significant history
Medications
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Beta-Blockers for Anxiety
General Tests
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Otoscopy
Audiometry
Tympanometry
GHQ questionnaire
Balance Assessment
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Spontaneous and Gaze Assessment
Saccades
Smooth Pursuit
Dix Hallpike
Head Roll testing
Caloric testing
Summary of Results
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Otoscopy - No abnormalities observed bilaterally
Audiometry -Thresholds within normal limits
bilaterally
Tympanometry - Raised middle ear compliance on
right and pressure within normal limits bilaterally
Gait and balance – Informal observation revealed
normal gait and no obvious unsteadiness on walking
into clinic
Spontaneous and Gaze – did not reveal any
nystagmus or symptoms
Saccades and Pursuit – did not reveal any nystagmus
or symptoms
Results Continued..
Dix-Hallpike and Head Rolls = did not reveal any
nystagmus or symptoms, negative in all positions
 Warm Calorics (44º) - symmetrical – No significant
Canal Paresis or DP observed
 GHQ = score = 9 (low for depression)
the 28-items "scaled" version (has four subscales:
somatisation, social dysfunction, anxiety, and
depression)
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Conclusions
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No evidence of peripheral or central cause of
dizziness
Complete set of normal vestibular testing results
Suggests panic and anxiety may be contributing
significantly to the patient’s symptoms
May be Psychogenic in nature
Psychogenic Dizziness
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No organic disease is present
Large amount of psychological disability in
persons with vertigo
Difficult diagnoses to reach
Clinical Manifestations
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dizzy sensation is typically persistent and continuous
punctuated by episodes of hyperventilation
provocative factors may be identified, such as the
presence of crowds, driving, or being in confined places
“manifestations of anxiety, including apprehension,
dread, nervousness, tension, restlessness, and
autonomic manifestations”
Episodes are often poorly described
Panic attacks
(all fits in with current patient)
Management
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Psychotherapeutic approaches such as cognitive
behavioural therapy
Medications – to treat depression and anxiety (betablockers)
Perform tests - reassure the patient that no organic disease
is present
Referrals to Psychiatry / Neurology
Vestibular Rehabilitation – possible breathing control
exercises
Multi-disciplinary team which includes ENT, audiologists,
hearing therapist, clinical psychologists, and
physiotherapists
Other Useful tests…
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Hyperventilation Test - The early literature suggested
that this was a sign of psychogenic (psychiatric)
disturbance (Drachman and Hart, 1972), but later
workers using better technology to monitor eye
movements suggest that nystagmus induced by
hyperventilation is a good sign of vestibular disease
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Must be emphasised positive hyperventilation does not
rule out vestibular disorder
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use of the Nijmegen Questionnaire
Evidence Base
“A close association between anxiety and
dizziness was emphasized by Sigmund Freud in
an early paper on anxiety neurosis” (Freud 1895)
Studies: Simon et al (1998)
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Psychosomatic model -- a primary psychiatric
disturbance causes dizziness
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hyperventilation and hyper arousal increased vestibular
sensitivity
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Somato-psychic model -- a primary inner ear
disturbance causes anxiety, signals from the inner ear
are misinterpreted as signifying immediate danger,
which increases anxiety. Increased anxiety increases
misinterpretation. Conditioning makes it persistent
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The chicken or the egg, difficult to know which
Studies cont……
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Staab and colleagues (2003) Laryngoscope. 2003;
113:1714-8
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345 men and women age 15 to 89 (average age 43.5) dizziness
for three months or longer due to unknown causes. “All but six
patients were diagnosed as having psychiatric or neurologic
conditions, including anxiety disorders, migraine, traumatic brain
injury and neurally mediated dysautonomias”
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Anxiety disorders were associated with 60 percent of the chronic
dizziness cases
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33 percent of the subjects with psychogenic dizziness had a
primary psychiatric diagnosis
Staab et al. 2003
3 patterns emerged;
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Anxiety disorders can be sole cause of dizziness
Neurotologic condition can trigger the development of anxiety
and phobic behaviours
A neurotologic condition was responsible for the onset of
dizziness but also exacerbated pre-existing or anxiety symptoms
N.B; Depression was considerably less common than
anxiety and was never a primary cause of dizziness
Evidence Base
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Lanska, D.J; Psychophysiological vertigo. (psychogenic
vertigo) Neurology 2006 (www.medlink.com)
Staab JP, Ruckenstein MJ. A psychiatric approach to
chronic dizziness. Psychiatric Annals 2005 35(4): 330-8.
Staab JP, Ruckenstein MJ. Which comes first?
Psychogenic dizziness versus otogenic anxiety.
Laryngoscope 2003 113:1714-8, 2003.
Hain, T.C. Vertigo and Psychological Disturbances
December 26, 2007
Simon NM, Pollack MH, Tuby KS, Stern TA. Dizziness
and Panic disorder: A review of the association between
vestibular dysfunction and anxiety. Annals Clin Psych 10,
1998, 2, 75-80
Drachman D, Hart CW. Neurology 1972, 22, 323-334
Hain, T.C website: www.dizzinessandbalance.com