BITTAR RS,SOHSTEN LINS E M.Clinical characteristics of patients with persistent postural-perceptual dizziness[J].Braz J Otorhinolaryngol,2015,81(3):276-282.
[本文引用:2]
[2]
STAAB JP,BALABAN CD,FURMAN JM.Threat assess-ment and locomotion:clinical applications of an integrated model of anxiety and postural control[J].Semin Neurol,2013,33(3):297-306.
Interactions between anxiety and vestibular symptoms have been described since the late 1800s. Typically, they have been conceptualized as bidirectional effects of one condition on the other (i.e., anxiety disorders as a cause of vestibular symptoms and vestibular disorders as a cause of anxiety symptoms). Over the past 30 years, however, a steady progression of neurophysiological investigations of gait and stance under conditions of postural threat, neuroanatomical studies of connections between threat assessment and vestibular pathways in the brain, and clinical research on anxiety-related vestibular conditions has offered the building blocks of a more integrated model. In this newer concept, threat assessment is an integral component of spatial perception, postural control, and locomotion in health and disease. It is not imposed on the vestibular system from the outside or simply reactive to vestibular dysfunction, but an inherently necessary part of every aspect of mobility. In this article, the authors review evidence that supports this model and then use it to examine common neurotologic conditions in which anxiety-related processes play important roles ear of falling, primary and secondary anxiety disorders in patients with vestibular symptoms, and chronic subjective dizziness.
KAPFHAMMER HP,MAYERC,HOCKU,et al.Course of illness in phobic postural vertigo[J].Acta Neurol Scand,1997,95(1):23-28.
Forty-two patients with phobic postural vertigo took part in a neurological and psychiatric follow-up study. During the follow-up time of about 2.5 years the neurological diagnosis remained stable (41 of 42 patients). PPV can be assigned to various psychiatric categories according to DSM-III-R. Although an association of PPV with anxiety disorders is evident, not all patients present with symptoms of anxiety or panic during attacks of vertigo. However most patients develop a disabling "phobic-avoidance pattern" with recurrent attacks. Important psychosocial stressors can be identified at the onset of the condition. Motives of secondary gain have also to be taken into consideration. The course of illness varies depending on the neurological syndrome of vertigo, on the one hand, and concomitant psychopathological syndromes, on the other. Despite a considerable rate of improvement in vertigo complaints (79%), the group of patients with phobic postural vertigo as a whole presented with significant psychological problems at follow-up term (74%), requiring specific psychiatric and/or psychotherapeutic interventions. Dependent or avoidant personality, and hypochondria were prognostic of a more negative course of illness.
HUPPERTD,STRUPPM,RETTINGERN,et al.Phobic postural vertigo——a long-term follow-up (5 to 15 years) of 106 patients[J].J Neurol,2005,252(5):564-569.
Abstract One hundred and six patients diagnosed between 1987 and 1998 to have somatoform phobic postural vertigo were examined in a follow-up study with a self-evaluating questionnaire. The improvement rate after a mean follow-up time of 8.5 years (5 to 15.9 years) was 75% (27% of the patients reported a complete remission). While the majority of these patients experienced improvement or remission during the first year after assessment of diagnosis and a short-term psychotherapeutic approach, some patients also had considerable improvement even after two or more years. There was a negative correlation between the duration of the condition before assessment of the diagnosis and the improvement/regression rate. The improvement/regression rate was independent of gender, age, preceding vestibular or non-vestibular organic disorders, and the various medical, physical, or psychotherapeutic interventions. Transient relapses occurred in 47% of the improved patients once or repeatedly. The probability of developing a relapse remained constant throughout the entire follow-up. None of the patients required a revision of the initial diagnosis on the basis of the questionnaire.
STAAB JP,RUCKENSTEIN MJ.Expanding the different-ial diagnosis of chronic dizziness[J].Arch Otolaryngol Head Neck Surg,2007,133(2):170-176.
To improve treatment outcomes for patients with chronic dizziness by identifying clinical conditions associated with persistent symptoms and delineating key diagnostic features that differentiate its causes and direct attention to specific treatments. Prospective cohort study from 1998 to 2004. Tertiary care balance center. A total of 345 men and women, aged 15 to 89 years, referred for evaluation of chronic dizziness (duration of > or =3 months) of uncertain cause. Patients were systematically directed through multiple specialty examinations until definitive diagnoses were made. Final diagnoses associated with dizziness. Nearly all patients with chronic subjective dizziness were diagnosed with psychiatric or neurologic illnesses. These included primary and secondary anxiety disorders (n = 206 [59.7%]) and central nervous system conditions (n = 133 [38.6%]), specifically migraine headaches, mild traumatic brain injuries, and neurally mediated dysautonomias. A small number of patients (6 [1.7%]) had dysrhythmias. Four of 5 patients with migraine or dysrhythmias had comorbid anxiety. Chronic dizziness has several common causes, including anxiety disorders, migraine, traumatic brain injuries, and dysautonomia, that require different treatments. Key features of the clinical history distinguish these illnesses from one another and from active neurotologic conditions. The high prevalence of secondary anxiety may give a false impression of psychogenicity.
Chronic subjective dizziness (CSD) is a neurotologic disorder of persistent non-vertiginous dizziness, unsteadiness, and hypersensitivity to one's own motion or exposure to complex visual stimuli. CSD usually follows acute attacks of vertigo or dizziness and is thought to arise from patients' failure to re-establish normal locomotor control strategies after resolution of acute vestibular symptoms. Pre-existing anxiety or anxiety diathesis may be risk factors for CSD. This study tested the hypothesis that patients with CSD are more likely than individuals with other chronic neurotologic illnesses to possess anxious, introverted personality traits.Data were abstracted retrospectively from medical records of 40 patients who underwent multidisciplinary neurotology evaluations for chronic dizziness. Twenty-four subjects had CSD. Sixteen had chronic medical conditions other than CSD plus co-existing anxiety disorders. Group differences in demographics, Dizziness Handicap Inventory (DHI) scores, Hospital Anxiety and Depression Scale (HADS) scores, DSM-IV diagnoses, personality traits measured with the NEO Personality Inventory - Revised (NEO-PI-R), and temperaments composed of NEO-PI-R facets were examined.There were no differences between groups in demographics, mean DHI or HADS-anxiety scores, or DSM-IV diagnoses. The CSD group had higher mean HADS-depression and NEO-PI-R trait anxiety, but lower NEO-PI-R extraversion, warmth, positive emotions, openness to feelings, and trust (all p<0.05). CSD subjects were significantly more likely than comparison subjects to have a composite temperament of high trait anxiety plus low warmth or excitement seeking.An anxious, introverted temperament is strongly associated with CSD and may be a risk factor for developing this syndrome.
STAAB JP,RUCKENSTEIN MJ,SOLOMOND,et al.Ser-otonin reuptake inhibitors for dizziness with psychiatric symptoms[J].Arch Otolaryngol Head Neck Surg,2002,128(5):554-560.
To investigate the efficacy and tolerability of selective serotonin reuptake inhibitors (SSRIs) for the treatment of patients with dizziness and major or minor psychiatric symptoms, with or without neurotologic illnesses. Review of 60 consecutive cases of patients with dizziness who were treated with an SSRI for at least 20 weeks during the 30-month period from July 1998 to December 2000. Tertiary care, multidisciplinary referral center. Sixty men and women, aged 13 to 81 years, with (1) psychogenic dizziness, (2) dizziness due to a neurotologic condition, as well as significant psychiatric symptoms, or (3) idiopathic dizziness. Open-label treatment with an SSRI titrated to 1 of 3 end points: optimal clinical benefit, intolerable adverse effects, or no therapeutic response. Change in dizziness and psychiatric symptoms measured by the 7-point, clinician-rated, Clinical Global Impressions-Improvement Scale. Thirty-eight (63%) of 60 patients in the intent-to-treat sample and 32 (84%) of 38 patients who completed treatment improved substantially. The response rates did not differ between patients with major psychiatric disorders and those with lesser psychiatric symptoms. Patients whose only diagnosis was a psychiatric disorder and those with coexisting peripheral vestibular conditions or migraine headaches fared better than patients with central nervous system deficits. Before being treated with an SSRI, two thirds of the study patients took meclizine hydrochloride and/or benzodiazepines, with minimal benefit. Treatment with SSRIs relieved dizziness in patients with major or minor psychiatric symptoms, including those with peripheral vestibular conditions and migraine headaches. Patients fared far better with SSRI treatment than with treatment with vestibular suppressants or benzodiazepines.
STAAB JP,RUCKENSTEIN MJ,AMSTERDAM JD.A prospective trial of sertraline for chronic subjective dizziness[J].Laryngoscope,2004,114(9):1637-1641.
Objectives/Hypothesis: The authors previously reported that selective serotonin reuptake inhibitors (SSRIs) reduce chronic subjective dizziness in patients with and without psychiatric illnesses. To extend those preliminary findings and test the hypothesis that SSRIs may offer a novel treatment for chronic subjective dizziness, the authors conducted a prospective study of sertraline in patients with dizziness for more than 6 months, in the absence of active physical neurotologic illness. Study Design: Sixteen-week, prospective, open-label, flexible-dose clinical trial. Methods: Twenty-four patients with subjective dizziness for more than 6 months and no active physical neurotologic illness were studied. Eighteen patients had major anxiety disorders. Six had minor frustration or worry that did not warrant a psychiatric diagnosis. Sertraline was administered at a daily dose of 25 mg, which was increased to a maximum daily dose of 200 mg. Dizziness, functional impairment, and psychological distress were measured using the Dizziness Handicap Inventory (DHI) and Brief Symptom Inventory-53 (BSI-53). Treatment outcomes were analyzed using repeated-measures multivariate analyses of variance, with last observations carried forward. Results: Three patients were excluded from data analysis for disqualifying medical conditions, one for protocol violations. Fifteen (75%) patients completed treatment. Five (25%) withdrew for adverse effects or lack of efficacy. The median daily dose of sertraline was 100 mg. Sertraline significantly reduced scores on all three DHI subscales and the BSI-53. Eleven of 15 (73%) patients who completed treatment had a positive response, including 8 of 11 (73%) with major anxiety disorders and 3 of 4 (75%) with no psychopathological conditions. Six patients enjoyed a full remission of symptoms. Conclusion: Sertraline significantly reduced chronic subjective dizziness in patients without active physical neurotologic illness, including those with and without psychiatric comorbidity.
STAAB JP.Clinical clues to a dizzying headache[J].J Vestib Res,2011,21(6):331-340.
Recent years have witnessed an upsurge of interest in migraine as a cause of vestibular symptoms. Starting with 1970s case reports linking migraine to childhood vertigo, neurotologists worldwide have increasingly diagnosed migraine. Various syndromes of vestibular migraine (VM) have been described, diagnostic criteria proposed, epidemiologic data collected, and neurophysiologic models developed. Yet, the concept that migraine causes vestibular symptoms rests on a surprisingly thin research database. Current concepts of VM are based on expert opinion, not empirical data. No general consensus exists about the definition of VM. No studies have analyzed its essential features. Just one well-controlled medication trial has been published. No biomarkers are known. To stimulate more rigorous research, this paper poses three questions about clinical investigations into migraine and vestibular symptoms: What variables should be measured? What patients should be studied? How might clinical trials yield both clinically useful results and greater insights into pathophysiologic processes? Using these questions, the limits of current knowledge are explored. Applicable research methods from epidemiology to genetics are examined. Pilot data demonstrating pharmacologic and genetic dissection techniques are presented. Ambitious, but practical, near-term clinical research goals are enumerated, including rigorous validation of diagnostic criteria and development of empirically derived management guidelines.
HORIIA,MITANIK,KITAHARAT,et al.Paroxetine,a selective serotonin reuptake inhibitor,reduces depressive symptoms and subjective handicaps in patients with dizziness[J].Otol Neurotol,2004,25(4):536-543.
Abstract OBJECTIVE AND STUDY DESIGN: When treating dizzy patients, the psychiatric aspect should be carefully addressed regardless of whether a well-defined organic disease is present. In this prospective study, we aimed to elucidate the role of paroxetine, a selective serotonin reuptake inhibitor, in the treatment of dizziness. SETTING AND PATIENTS: Forty-seven patients who complained of dizziness were treated with 20 mg of paroxetine per day. The depressive state of the patient was evaluated by the Zung Self-Rating Depression Scale (SDS). Treatment outcomes were measured with self-assessment of subjective handicaps in daily life using a dizziness and unsteadiness questionnaire. The questionnaire consisted of five factors related to emotional or bodily dysfunction that could be affected by dizziness. Changes in Self-Rating Depression Scale scores and subjective handicaps were assessed at 4 and 8 weeks after the start of paroxetine. RESULTS: In patients having well-defined organic diseases with high Self-Rating Depression Scale scores, paroxetine improved all five subjective handicap factors as well as Self-Rating Depression Scale scores. The decline in Self-Rating Depression Scale scores showed a significant correlation with improvement of subjective handicaps, which was related to emotional problems but not factors related to bodily dysfunction. Paroxetine was also effective for an improvement of factors related to emotional problems and Self-Rating Depression Scale scores in patients not having organic diseases but with high Self-Rating Depression Scale scores. In patients either with or without organic diseases with low Self-Rating Depression Scale scores, paroxetine had no effect on any subjective handicap factors and Self-Rating Depression Scale scores. CONCLUSION: In the treatment of dizzy patients, paroxetine was effective at relieving subjective handicaps caused by dizziness, specifically, in patients with high Self-Rating Depression Scale scores.
SIMON NM,PARKERSW,WERNICK-ROBINSONM,et al.Fluoxetine for vestibular dysfunction and anxiety:a prospective pilot study[J].Psychosomatics,2005,46(4):334-339.
Abstract Anxiety states and disorders amplify the symptoms and impairment associated with vestibular dysfunction. Five patients with inner ear vestibular dysfunction and anxiety were prospectively treated with fluoxetine, 20-60 mg/day, and received an extensive battery of assessments at baseline and after 12 weeks of treatment. Fluoxetine led to significant or near significant reductions in anxiety measures and in impairment due to dizziness; improvements in clinical balance function and vestibular function were less clear. The data add to the literature suggesting a role for selective serotonin reuptake inhibitors in the treatment of dizziness and anxiety.
HORIIA,UNOA,KITAHARAT,et al.Effects of fluvoxa-mine on anxiety,depression,and subjective handicaps of chronic dizziness patients with or without neuro-otologic diseases[J].J Vestib Res,2007,17(1):1-8.
Abstract A prospective, open-label clinical trial was conducted for two aims: first, to evaluate the role of fluvoxamine, one of selective serotonin reuptake inhibitors, in the treatment of dizziness for the first time and to investigate its effective mechanisms. Second, to test the hypothesis that dizziness in patients without abnormal neuro-otologic findings would be induced by psychiatric disorders rather than by unnoticed neuro-otologic diseases. Nineteen patients with neuro-otologic diseases (Group I) and 22 patients in whom standard vestibular tests revealed no abnormal findings (Group II) were treated by fluvoxamine (200 mg/day) for eight weeks. Subjective handicaps due to dizziness using a questionnaire, anxiety and depressive symptoms measured with the Hospital Anxiety and Depression Scale (HADS), and stress hormones (vasopressin and cortisol) were examined before and 8 weeks after treatment. Overall, fluvoxamine decreased subjective handicaps of both Groups I and II. Fluvoxamine decreased HADS of only patients whose subjective handicaps were reduced (=responders) in both groups, suggesting that fluvoxamine was effective for dizziness via psychiatric action rather than a recovery of vestibular function through serotonergic activation. In non-responders of Group II, pre-treatment HADS was higher than in Group I non-responders and it was not decreased by the treatment, suggesting that dizziness of Group II non-responders was due to severe psychiatric disorders rather than unnoticed neuro-otologic diseases. Anxiety and depression components of HADS showed a good correlation at both pre- and post-treatment periods. No post-therapeutic decrease was observed in either vasopressin or cortisol even in responders, suggesting that dizziness was not the sole cause of stress in chronic dizziness patients. In conclusion, patients with or without physical neuro-otologic deficits who report chronic dizziness accompanied by anxiety and depression (as measured by HADS) showed improvements across a full range of subjective handicaps and psychological distress, while patients with physical neuro-otologic defects and minimal anxiety or depression did not benefit. The main causes of dizziness in patients without physical neuro-otologic findings were psychiatric disorders.
TSCHANR,BESTC,BEUTELME,et al.Patients’ psyc-hological well-being and resilient coping protect from secondary somatoform vertigo and dizziness (SVD) 1 year after vestibular disease[J].J Neurol,2011,258(1):104-112.
Secondary somatoform dizziness and vertigo (SVD) is an underdiagnosed and handicapping psychosomatic disorder, leading to extensive utilization of health care and maladaptive coping. Few long-term follow-up studies have focused on the assessment of risk factors and little is known about protective factors. The aim of this 1-year follow-up study was to identify neurootological patients at risk for the development of secondary SVD with respect to individual psychopathological disposition, subjective well-being and resilient coping. In a prospective interdisciplinary study, we assessed mental disorders in n = 0259 patients with peripheral and central vestibular disorders ( n = 0215 benign paroxysmal positional vertigo, n = 0215 vestibular neuritis, n = 028 Menière’s disease, n = 0224 vestibular migraine) at baseline (T0) and 102year after admission (T1). Psychosomatic examinations included the structured clinical interview for DSM-IV, the Vertigo Symptom Scale (VSS), and a psychometric test battery measuring resilience (RS), sense of coherence (SOC), and satisfaction with life (SWLS). Subjective well-being significantly predicted the development of secondary SVD: Patients with higher scores of RS, SOC, and SWLS at T0 were less likely to acquire secondary SVD at T1. Lifetime mental disorders correlated with a reduced subjective well-being at T0. Patients with mental comorbidity at T0 were generally more at risk for developing secondary SVD at T1. Patients’ dispositional psychopathology and subjective well-being play a major predictive role for the long-term prognosis of dizziness and vertigo. To prevent secondary SVD, patients should be screened for risk and preventive factors, and offered psychotherapeutic treatment in case of insufficient coping capacity.
GOTOF,TSUTSUMIT,OGAWAK.Treatment of chronic subjective dizziness by SSRIs[J].Nihon Jibiinkoka Gakkai Kaiho,2013,116(11):1208-1213.
It has been reported that the dizziness or vertigo in about 10 to 30 patients visiting an otolaryngologist is of psychiatric origin. Since otolaryngologists are not familiar with the treatment for these patients, such treatment is usually not adequate. The clinical entity of chronic subjective dizziness (CSD) is one of psychiatric dizziness proposed by Staab and Ruckenstein. Fourteen percent (40/285) of patients were diagnosed as having psychiatric dizziness in Hino Municipal Hospital last year. Among them we had 7 cases with CSD. We report herein on the result of the clinical examinations and pharmacological treatment. In most of the cases, subjective symptoms were significantly improved after the pharmacological treatment with SSRIs (Serotonin reuptake inhibitors). From these results, CSD is important clinical entity treatable by otolaryngologist with SSRIs. To prescribe SSRIs, it is important to know the common adverse reactions associated with SSRIs. These include gastrointestinal symptoms including nausea and activation syndromes especially in early stage of treatment. CSD is an important clinical entity, which should be diagnosed and is treatable by otolaryngologists.
STAAB JP,ECKHARDT-HENNA,HORIIA,et al.prog-ress report of the behavioral subcommittee of the committee on classification of the barany society[J].J Vestib Res,2014,24(2):93-94.
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田军茹. 精神源性眩晕[J].临床医学进展,2012,2(2):11-16.
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RUCKENSTEIN MJ,STAAB JP.Chronic subjective dizziness[J].Otolaryngol Clin North Am,2009,42(1):71-77.
HORIIA,IMAIT,KITAHARAT,et al.Psychiatric comor-bidities and use of milnacipran in patients with chronic dizziness[J].J Vestib Res,2016,26(3):335-340.
Abstract Psychiatric comorbidities are an important issue in the treatment of chronic dizziness patients. OBJECTIVE: To test the correlation between psychiatric status and subjective handicaps and to examine the effects of milnacipran on handicaps. METHODS: Hospital anxiety and depression scale (HADS) and handicaps were assessed by a questionnaire before and eight weeks after milnacipran treatment (50 mg/day) in 29 consecutive patients with chronic dizziness. Effects of milnaciplan were compared with fluvoxamine (200 mg/day). RESULTS: A significant correlation was found between anxious and depressive scale scores and also between HADS and handicaps. Duration of symptomswas longer in the anxious/depressive group(HADS 鈮 13) than in the non-anxious/depressive group. Handicaps and HADS were significantly decreased after treatment only in the anxious/depressive group. There were no overall differences in drug effects between milnaciplan and fluvoxamine. However, the rate of patients with a post/pre ratio of handicaps <80% was higher in milnaciplan group compared with the fluvoxamine group. CONCLUSIONS: Not only anxiety disorders but also depression should be considered as comorbid psychiatric disorders in patients with chronic dizziness. Dizzy patients with psychiatric comorbidities have a longer duration of symptoms and more handicaps than those without psychiatric disorders. Milnacipran may be chosen as a treatment for patients with chronic dizziness with comorbid psychiatric disorders in case of and insufficient response to SSRIs.
LI VOLSIG,LICATAF,FRETTOG,et al.Influence of serotonin on the glutamate-induced excitations of secondary vestibular neurons in the rat[J].Exp Neurol,2001,172(2):446-459
The excitatory responses evoked by glutamate and its agonists in secondary vestibular neurons of the rat were studied during microiontophoretic application of 5-hydroxytryptamine (5-HT). Ejection of 5-HT modified neuronal responsiveness to glutamate in 86% of the studied units, the effect being a depression of the excitatory responses in two-thirds of cases and an enhancement in the remaining third. 5-HT was also effective in modifying 94% of the responses evoked by N-methyl-d-aspartate (NMDA), inducing a depressive effect in 76% of cases and an enhancement in the remaining ones. Quisqualate-evoked effects were depressed and enhanced by 5-HT in about the same number of cases; in contrast, kainate-evoked responses were enhanced. The depressive action of 5-HT was mimicked by application of alpha-methyl-5-hydroxytryptamine (alpha-Me-5-HT), a 5-HT(2) receptor agonist, whereas the enhancing effect could be evoked by application of 8-hydroxy-2(di-n-propylamino)tetralin (8-OH-DPAT), a selective 5-HT(1A) receptor agonist. The 5-HT(2) receptor antagonist ketanserin was able to reduce, but not to block totally, the depressive action of 5-HT on glutamate- or NMDA-evoked responses. No significant difference was detected between neuronal responses in the lateral and the superior vestibular nucleus. These results indicate that 5-HT is able to modulate the responsiveness of secondary vestibular neurons to excitatory amino acids. Its action is mostly depressive, involves 5-HT(2) receptors, and is exerted on NMDA receptors. A minor involvement of other 5-HT receptors (at least 5-HT(1A)) and other glutamate receptors (for quisqualate and kainate) in the modulatory action of 5-HT is plausible.
WHITNEY SL,WRISLEY DM,MARCHETTI GF,et al.The effect of age on vestibular rehabilitation outcomes[J].Laryngoscope,2002,112(10):1785-1790.
The purpose of the retrospective chart review was to compare vestibular rehabilitation outcomes in young versus older adults.Retrospective matched design.Twenty-three persons with vestibular disorders aged 20 to 40 years were matched by gender, vestibular diagnosis, and vestibular function test results to 23 older adults aged 60 to 80 years. The patients were treated with a custom-designed physical therapy exercise program. Patients completed the Dizziness Handicap Inventory, the Activities-Specific Balance Confidence (ABC) scale, and the Dynamic Gait Index; number of falls; and rated the severity of their dizziness. The two-sample test, the Mann-Whitney test, and McNemar's test for correlated proportions were used to determine whether there was a difference in scores between the two age groups at the beginning and end of physical therapy.During the initial evaluation, older adults reported having statistically greater space and motion discomfort and more severe symptoms on a scale of 0 to 100. Younger adults had more impaired DGI scores and a higher proportion of caloric testing abnormalities. After rehabilitation, overall improvement was seen in both the younger and older populations. There were no statistical differences between the two groups on the DHI, the DGI, reported symptoms at discharge, or number of falls. When only the complete matched-pair data were analyzed, there were no statistically significant differences between the age groups in the proportion of patients demonstrating clinical improvement.Age does not significantly influence the beneficial effects of vestibular rehabilitation for persons with vestibular disorders.
YARDLEYL,DONOVAN-HALLM,SMITH HE,et al.Eff-ectiveness of primary care-based vestibular rehabilitation for chronic dizziness[J].Ann Intern Med,2004,141(8):598-605.
Background: Dizziness is a very common symptom and is usually managed in prima ry care. Vestibular rehabilitation for dizziness is a simple treatment that may be suitable for primary care delivery, but its effectiveness has not yet been de termined. Objective: To evaluate the effectiveness of nurse delivered vestibula r rehabilitation in primary care for patients with chronic dizziness. Design: Si ngle blind randomized, controlled trial. Setting: 20 general practices in south ern England. Patients: 170 adult patients with chronic dizziness who were random ly assigned to vestibular rehabilitation (n = 83) or usual medical care (n = 87) . Intervention: Each patient received one 30 to 40 minute appointment with a p rimary care nurse. The nurse taught the patient exercises to be carried out dail y at home, with the support of a treatment booklet. Measurements: Primary outcom e measures were baseline, 3 month, and 6 month assessment of self reported sp ontaneous and provoked symptoms of dizziness, dizzi ness related quality of li fe, and objective measurement of postural stability with eyes open and eyes clos ed. Results:At 3 months, improvement on all primary outcome measures in the vest ibular rehabilitation group was significantly greater than in the usual medical care group; this improvement was maintained at 6 months. Of 83 treated patients, 56 (67%) reported clinically significant improvement compared with 33 of 87 (3 8%) usual care patients (relative risk, 1.78 [95%CI, 1.31 to 2.42]). Limitat io ns: Psychological elements of the therapy may have contributed to outcomes, and the treatment may be effective only for well motivated patients. Conclusions: V estibular rehabilitation delivered by nurses in general practice improves sympto ms, postural stability, and dizziness related handicap in patients with chronic dizziness.
MATHESON AJ,DARLINGTON CL,SMITH PF.Dizziness in the elderly and age-related degeneration of the vestibular system[J].N Z J Psychol,1999,28(1):10-16.
The peripheral and central vestibular systems exhibit an age-related structural deterioration which may be responsible for vestibular reflex deficits and dizziness in the elderly. However, it seems likely that the central nervous system is capable of compensating for a certain degree of decline in function, since not all elderly people are impaired to the extent that the clinical signs of vestibular dysfunction are apparent. Dizziness and other vestibular disorders may develop only when the degree of deterioration of the vestibular system exceeds the ability of the nervous system to compensate. If dizziness does eventuate, it can have profound psychological consequences, particularly in terms of loss of confidence in independent activity, and may lead to the development of anxiety disorders. Vestibular rehabilitation programs may help to minimise the effects of age-related deterioration of the vestibular system and its psychological impact.
MELIA,ZIMATOREG,BADARACCOC,et al.Effects of vestibular rehabilitation therapy on emotional aspects in chronic vestibular patients[J].J Psychosom Res,2007,63(2):185-190.
The VR therapy positively influences the emotional condition of chronic vestibular deficit patients without pharmacological or psychotherapy treatments.
STAAB JP.Behavioral aspects of vestibular rehabilitation[J].NeuroRehabilitation,2011,29(2):179-183.
Behavioral factors are an integral part of the overall morbidity of patients with vertigo, dizziness, and balance disorders. Anxiety, depression, and more importantly, loss of balance confidence and sense of debility and handicap beleaguer patients with acute and chronic vestibular symptoms. Vestibular rehabilitation originated as a physical therapy, but a careful look at its research development and clinical applications show it to be as much, or perhaps more, a behavioral intervention. More patients referred for vestibular rehabilitation require habituation to chronic vestibular symptoms and motion sensitivity than compensation for active peripheral or central vestibular deficits. Vestibular rehabilitation may exert a positive effect on behavioral morbidity, but the benefits are somewhat uneven and do not always correlate with physical improvements. Health anxiety (i.e., excessive worry about the cause and consequences of physical symptoms) is an emerging concept in clinical psychiatry and psychology. It may offer an important key to understanding the debility and handicap experienced by many patients with vestibular symptoms and enhance the ability of vestibular rehabilitation to ameliorate their suffering.
THOMPSON KJ,GOETTING JC,STEEB JP,et al.Retro-spective review and telephone follow-up to evaluate a physical therapy protocol for treating persistent postural-perceptual dizziness:A pilot study[J].J Vestib Res,2015,25(2) :97-103.
Persistent postural-perceptual dizziness (PPPD) (formerly chronic subjective dizziness) may be treated using the habituation form of vestibular and balance rehabilitation therapy (VBRT), but therapeutic outcomes have not been formally investigated. This pilot study gathered the first data on the efficacy of VBRT for individuals with well-characterized PPPD alone or PPPD plus neurotologic comorbidities (vestibular migraine or compensated vestibular deficits). Twenty-six participants were surveyed by telephone an average of 27.5 months after receiving education about PPPD and instructions for home-based VBRT programs. Participants were queried about exercise compliance, perceived benefits of therapy, degree of visual or motion sensitivity remaining, disability level, and other interventions. Twenty-two of 26 participants found physical therapy consultation helpful. Fourteen found VBRT exercises beneficial, including 8 of 12 who had PPPD alone and 6 of 14 who had PPPD with co-morbidities. Of the 14 participants who found VBRT helpful, 7 obtained relief of sensitivity to head/body motion, 5 relief of sensitivity to visual stimuli, and 4 complete remission. Comparable numbers for the 12 participants who found VBRT not helpful were 1 (head/body motion), 3 (visual stimuli), and 0 (remission). This pilot study offers the first data supporting the habituation form of VBRT for treatment of PPPD.
BRANDTT,HUPPERTD,DIETERICHM.Phobic postural vertigo:a first follow-up[J].J Neurol,1994,241(4):191-195.
Seventy-eight patients with phobic postural vertigo (PPV) and 17 patients with psychogenic disorder of stance and gait (PSG) were asked to evaluate their condition 6 months to 5.5 years after their original referral and short-term psychotherapy. Two results seem most important: (1) PPV had a favourable course with a 72% improvement rate (22% of patients becoming symptom free), whereas the majority of patients with PSG (52%) remained unchanged; (2) the majority of patients with PPV experienced complete remission or considerable improvement even if their condition had lasted between 1 and 20 years prior to diagnosis. Complete remission of PSG was observed only if the disorder had been present less than 4 months; there was no improvement if it had lasted longer than 2 years. PPV can be defined as a distinct clinical entity with a relatively benign course. It can be reliably diagnosed on the basis of typical features.
JOHANSSONM,AKERLUNDD,LARSON HC,et al.Randomised controlled trial of vestibular rehabilitation combined with cognitive behaviour therapy for dizziness in older people[J].Otolaryngol Head Neck Surg,2001,125(3):151-156.
Objective: To evaluate the effectiveness of vestibular rehabilitation combined with cognitive behavioral therapy in the treatment of dizziness in older people. Study Design and Setting: A randomized controlled design was used with patients recruited via an advertisement. Nine patients completed treatment and 10 served as waiting-list controls. The intervention lasted 7 weeks with 5 weekly group sessions and consisted of vestibular exercises. Cognitive behavioral therapy components were added to promote relaxation, reduce anxiety, and avoidance of feared situations and movements. Results: Statistically significant improvements on walking time, 2 dizziness provocative movements, and on the Dizziness Handicap Inventory, but no effects on the Romberg or anxiety and depression. Of the treated patients, 89% reached statistical significant improvement on the total inventory score. Conclusion: Cognitive behavioral therapy combined with vestibular rehabilitation decreases dizziness in older people. Significance: These findings indicate that cognitive behavioral therapy can be combined with vestibular rehabilitation in the treatment of dizziness. (Otolaryngol Head Neck Surg 2001;125:151-6.)
ANDERSSONG,ASMUNDSON GJ,DENEVJ,et al.A controlled trial of cognitive behaviour therapy with vestibular rehabilitation in the treatment of dizziness[J].Behav Res Ther,2006,44(9):1265-1273.
HOLMBERGJ,KARLBERGM,HARLACHERU,et al.Treatment of phobic postural vertigo.A controlled study of cognitive-behavioral therapy and self-controlled desensitization[J].J Neurol,2006,253(4):500-506.
In balance clinic practice, phobic postural vertigo is a term used to define a population with dizziness and avoidance behavior often as a consequence of a vestibular disorder. It has been described as the most common form of dizziness in middle aged patients in dizziness units. Anxiety disorders are common among patients with vestibular disorders. Cognitive-behavioral therapy is an effective treatment for anxiety disorders, and vestibular rehabilitation exercises are effective for vestibular disorders. This study compared the effect of additional cognitive-behavioral therapy for a population with phobic postural vertigo with the effect of self-administered vestibular rehabilitation exercises. 39 patients were recruited from a population referred for otoneurological investigation. Treatment effects were evaluated with the Dizziness Handicap Inventory, Vertigo Symptom Scale, Vertigo Handicap Questionnaire, and Hospital Anxiety and Depression Scale. All patients had a self treatment intervention based on education about the condition and recommendation of self exposure by vestibular rehabilitation exercises. Every second patient included was offered additional cognitive behavioral therapy. Fifteen patients with self treatment and 16 patients with cognitive- behavioral treatment completed the study. There was significantly larger effect in the group who received cognitive behavioral therapy than in the self treatment group in Vertigo Handicap Questionnaire and the Hospital Anxiety and Depression scale and its subscales. Cognitive-behavioral therapy has an additional effect as treatment for a population with phobic postural vertigo. A multidisciplinary approach including medical treatment, cognitive-behavioral therapy and physiotherapy is suggested.
HOLMBERGJ,KARLBERGM,HARLACHERU,et al.One-year follow-up of cognitive behavioral therapy for phobic postural vertigo[J].J Neurol,2007,254(9):1189-1192.
Abstract BACKGROUND: Phobic postural vertigo is characterized by dizziness in standing and walking despite normal clinical balance tests. Patients sometimes exhibit anxiety reactions and avoidance behavior to specific stimuli. Different treatments are possible for PPV, including vestibular rehabilitation exercises, pharmacological treatment, and cognitive behavioral therapy. We recently reported significant benefits of cognitive behavioural therapy for patients with phobic postural vertigo. This study presents the results of a one-year follow-up of these patients. METHODS: Swedish translations of the following questionnaires were administered: (Dizziness Handicap Inventory, Vertigo Symptom Scale, Vertigo Handicap Questionnaire, and Hospital Anxiety and Depression Scale) were administered to 20 patients (9 men and 11 women; mean age 43 years, range 23-59 years) one year after completion of cognitive behavioral therapy. RESULTS: Test results were similar to those obtained before treatment, showing that no significant treatment effects remained. CONCLUSION: Cognitive behavioral therapy has a limited long-term effect on phobic postural vertigo. This condition is more difficult to treat than panic disorder with agoraphobia. Vestibular rehabilitation exercises and pharmacological treatment might be the necessary components of treatment.
A 3-session psychologic intervention based on the CBT model can produce significant improvements in dizziness-related symptoms, disability, and functional impairment among patients with chronic subjective dizziness. This suggests that treatment of this condition may be reasonably simple and cost-effective for most of the patients.
MAHONEYA,EDELMANS,D CREMER P.Cognitive behavior therapy for chronic subjective dizziness:longer-term gains and predictors of disability[J].Am J Otolaryngol,2013,34(2):115-120.
A brief CBT intervention for patients with CSD produced improvements in physical symptoms, disability, and functional impairment which were sustained at one month and six months post intervention. Patients with high levels of anxiety prior to treatment had higher levels of disability at six months post-treatment. It is possible that more focused interventions that specifically target anxiety might produce further benefits for this cohort.
Retro-spective review and telephone follow-up to evaluate a physical therapy protocol for treating persistent postural-perceptual dizziness:A pilot study
, 曹效平
