Interactions between Stress and Vestibular Compensation – A Review
Yet, the pathway explaining the association between anxiety and vestibular disorder is complex. These two symptoms – anxiety and dizziness. Elevated levels of stress and anxiety often accompany vestibular dysfunction, while .. in models of the neuroanatomical linkage of balance and anxiety. Several possibilities exist in the relationships between psychiatric disorders and . the vestibular neuronitis, the BPPV, and their connection with anxiety are.
Most of them have a problem with self-consciousness. The presence of spontaneous nystagmus might show, that the patient has vestibular lesion, which is not compensated.
During the examination of positional vertigo most of the patients have aversion of motion.
A Matter of Balance: It's Not in Your Mind, It's in Your Ear
Most of the patients with BPPV have a resistance to the head motion, sometimes with a stiff neck. When the patient has a long lasting recurrent BPPV, the X-ray of the neck shows a compulsion port of vertebrae. After verbal persuasion we can examine the patients, meaning that the stiffness has a psychic but no neurological or rheumatologic reason. Not only in the typical BPPV, but in the central positional vertigo the patients might have aversion of motion.
In our vertiginous patients with anxiety disorder positional vertigo was observed in In patients without anxiety the ratio of positional nystagmus is It means that all of the positional types of vertigo can generate anxiety, not only the typical BPPV. We can explain it with the disturbing effect of head movement, which can generate short oscillopsia. During the caloric stimulation most of the patients with anxiety have a severe fear from the provoked vertigo.
The caloric test can provoke vertigo, even in lying position which could be very severe with vegetative symptoms. If the patient have a hyporeactivity of the vestibular end organ, the vertigo is not severe, and bearable in the cases of normal vestibular responsiveness.
In the cases of hyperaesthesia, hyperresponsiveness the feeling of vertigo is very unpleasant. In the patient with anxiety three type of mood can be observed during the caloric test. When the hyperresponsiveness of the vestibular end organ can be measured, the patients have severe vegetative symptoms. In these cases the uncomfortable feeling is almost normal, and based on the severe vegetative status uncomfortable level.
In patients with vegetative dystonia the vegetative symptoms are more severe, than we wait, based onto the vestibular responsiveness. In patients may have hyperreactivity with vegetative symptoms, but in patients with anxiety disorder we often see a normal or decreased responsiveness without vegetative symptoms, but more uncomfortable level told by the patients. These reactions without any vegetative symptoms can occurred in patients with anxiety; we mention it as a psychogenic reaction.
Sometimes the combinations of these findings occurred. Sometimes patients are shouting and crying during the three minutes of provoked vertigo, but vegetative symptoms are missing Figure 9. Twenty patients rejected the electronystagmographical examination after the information, that the complete ENG test might provoke vertigo four times during the caloric test. Caloric test analysis Analysis of the electronystagmographic results of the caloric weakness, and the directional preponderance are very important, which data are characteristical for the peripheral and central vestibular lesion.
The ENG results are shown on figure Canal paresis or caloric weakness shows, that the patient has peripheral lesion, the pathological ratio is almost the same in the anxiety and the non-anxiety groups. The directional preponderance is more frequent in the anxiety group, signalling the role of the central pathways in the pathomechanism not only in the central vestibular disorders but also in the anxiety disorders. The hypersensitivity or hyperresponsiveness of the vestibular end organ also shows the pathological function of the central vestibular pathways.
Interesting and unsettled question is which the primary dysfunction was. Whether the hypersensitive vestibular system cause the motion sickness of the patients, and this motion sickness generates anxiety disorder or the anxiety disorder modulates the central vestibular pathways to give hyperactive response for the caloric stimulus. The question needs further investigations. Anxiety in vestibular disorders 5. Patients with visual vertigo over rely on vision for balance i.
Pavlou et al, But when the patients have anxiety disorder, they often reject the visual stimulation and vestibular training as a therapeutical possibility. Most of the patients with migraine have motion sickness from the early young age. Patients with migraine frequently had abnormal caloric test responses, especially with a directional preponderance figure In the migraine attack the patients are presumed to have hypersensitivity of the labyrinth with nausea and vomiting, Szirmai What is the connection between the migraine, the motion sickness and the hypersensitivity of the labyrinth in the caloric test?
Directional preponderance to the right side on electronystagmogram Motion sickness was observed in In the everyday medical experience most of the patients accept the fact, that they have motion sickness from early childhood. When the anxiety disorder develops in these patients, the motion sickness is worsened, and become more disturbing. When the patients have migraine, they used to bear the nausea during the headache, but they cannot accept the same kind of nausea as a concomitant symptom of vertigo.
It suggests that the vertigo to the higher degree than migraine can provoke anxiety disorders.
Anxiety in Vestibular Disorders
According to the Committee of Hearing and Equilibrium,cit. During the attacks the patients may have a fear from death, especially at the beginning of the disease. Later the patients know that the symptoms will disappear after few hours. As the attacks become more frequent, the patients have constant anticipated anxiety, thinking: Because of the vegetative symptoms, the patients have a feeling of uncomfortableness during the attacks.
The attacks with vomiting can come unexpectedly, sometimes in an overcrowded place, or in the patients working place during a conference. Some patients have an attack at home with vomiting. Although the family is supporting them, the patients have anxiety of the situation. One of my patients told me: Although I use the toothbrush after the attack, but how can I kiss my dear wife with the same mouth?
I fear of that she will disgust me! The sensorineural hearing loss and the tinnitus are very disturbing for the patients. The sensorial hearing loss with the recruitment can decrease the speech discrimination. Most of the patients cannot recognise the direction of the sounds. The patients fear from becoming ridiculous because the hearing loss and of the misunderstanding speech.
Because of the recruitment the patients have an increased sensitivity of noise. This fact can results, that patients can disturbed by several frequencies of noise and speech.
Some interpersonal conflict situation can occurred because of this fact. While this is one of the speech frequencies, these facts can results severe deterioration of her interpersonal connections. Because of the recurrent attacks of vertigo and the communication problem caused by the hearing loss, the patient could have a depression or a fear from the loss of their job.
They could have problem with keeping of their living standards after becoming disabled.
A Matter of Balance: It's Not in Your Mind, It's in Your Ear
The tinnitus is fluctuating. Before the vertiginous attack the noise and fullness in the ear is increasing, forecasting the severe attack. When the patient is anxious, or tired, the tinnitus can increasing without attack of vertigo, but this increasing of the tinnitus can provoke an anticipatory anxiety, whether the attack is coming or not.
For these patients the silence is not golden, but very disturbing. These patients could be nervous and impatient with their family, and this fact can cause conflict situation in the family and in job. The co-morbidity causes further deterioration of the quality of life, and causes difficulties in the treatment and rehabilitation Figure In these cases the patient will stop taking medications.
The distribution of these co-existing psychiatric problems is shown in the figure Vertebrobasilar insufficiency Vertigo, tinnitus and hearing loss occurred very frequently in the vascular posterior fossa lesions. In a slow blood flow of the temporal lobe vessels, brainstem vessels and labyrinthine artery wide range of cochleovestibular dysfunction could be observed. The evaluation of the vascular risk factors is very important in the diagnostical procedure. In the patients with vertigo, hearing loss, and tinnitus the regional slow blood flow of the brain were diagnosed by MRI, or single photon emission computer tomography.
Figure 14 Szirmai Hypertension, atherosclerosis and cervical spondylosis could be a risk factor for the disease. In our cases We can evaluate fear from becoming completely deaf, and fear from the motion and public transport. Most of the patients have anxiety when they know the diagnosis, which defined as vascular disorder of the brain.
They have a fear from having a stroke, becoming paralysed, or going stupid because of the slow blood flow of the brain. Most of the patients have problem with the treatment, the antiaggregation therapy with aspirin could provoke stomach-ache.
When they read about dizziness in the side effect list of aspirin, some patients reject taking it. The patients have aversion of much pills, they want to stop the medical treatment. The doctors have to persuade them, that the treatment of all the risk-factors, co-morbid diseases and consecutive psychiatrical disorders are necessary.
Co-morbidity in vertebrobasilar insufficiency 5. Vestibular neuronitis Vestibular neuronitis is a considerably frightening disorder. The prevalence estimates of vestibular vertigo with aging range from 5. Vestibular problems, such as vertigo or benign paroxysmal positional vertigo BPPVare common in older adults, causing dizziness, and poor postural stability 2. Yet, such symptoms should not necessarily or immediately be attributed solely to aging processes of the inner ear.
They could be associated with primary psychological disturbances, such as anxiety 3. Elderly people often suffer from behavioral abnormalities or psychological disturbances, such as anxiety, stress, panic, and depression, which may accompany dizziness, feeling faint, unsteady or light-headed, or experiencing a swaying or spinning sensation i. Prevalence estimates of anxiety disorders in older ages range from 3. Anxiety is a psychological problem that sometimes should be considered as an adjunct problem to vestibular system impairments, such as dizziness and vertigo.
Yet, the pathway explaining the association between anxiety and vestibular disorder is complex. These two symptoms — anxiety and dizziness — share some neural pathways, which may help explain why dizziness occurs among many patients suffering from anxiety 7 — 9. Nevertheless, psycho-geriatric physicians can play a critical role in addressing the concerns and needs due to a vestibular disorder, by diagnosing and treating the psychological as well as the physical problems of older adults.
Three hypotheses might explain the pathways describing the association between anxiety and a vestibular disorder, such as dizziness, among older adults. The first is a psychogenic vestibular disturbance among patients who have normal vestibular tests and laboratory evaluations. The second is somatopsychic impairment of those who exhibit a primary inner ear disturbance causing anxiety In other words, a vicious cycle exists, where signals from the inner ear are misinterpreted by the central nervous system and signify an immediate threat, which increases anxiety.
A case report and literature review supported this hypotheses and showed that increased anxiety amplifies misinterpretation 11and the disturbances is even worse when the patient adopts this bad habituation, which makes dizziness along with anxiety a constant, coexisting symptom.
The third hypothesis is that of a psycho-cognitive problem Many elderly people complain of difficulty multitasking, meaning that their balance control is decreased due to a diversion of attention. This results in less mental availability for psychological processing and therefore causes anxiety.
- Anxiety in the Elderly Can be a Vestibular Problem
- Interactions between Stress and Vestibular Compensation – A Review
An open trial of mindfulness-based cognitive therapy program that focused on intensive training in mindfulness meditation and integrated principles of cognitive behavior therapy found to be an acceptable and effective treatment for patients suffering from anxiety disorder Therefore, the primary aim of evaluation of a patient with dizziness versus anxiety is a thorough discussion and explanation of the problem and its clinical appearance.
This should be followed by a careful physical examination in order to assess possible underlying causes; for example, cardiovascular disease e. Management of anxiety or a vestibular disorder has some common components. They both require the patient to undertake an exercise regimen and to take responsibility to ameliorate the symptom or remediate the problem.
Treating dizziness with a management-oriented approach should include non-traditional strategies, such as referral to psychiatry, and vice versa. Cognitive behavioral therapy CBT should also be incorporated into vestibular rehabilitative regimens.
When anxiety treatment succeeds it often results in decreased dizziness and increased activity and socialization. In conclusion, with elderly patients, the family physician may not know the cause of the anxiety or dizziness.
In other words, how do family physicians know that an arbitrary combination of sensory, central, and motor deficits is an adequate explanation for anxiety or for a vestibular disorder.
Many patients have dizziness associated with or attributed to anxiety. Therefore, the family physician must be able to distinguish between psychogenic and vestibular disorders. It is not unusual to make a wrong diagnosis regarding why a person is anxious or dizzy, even after a very thorough evaluation. One should remember that anxiety is sometimes related to a vestibular disorder and vice versa, in a very complex way.
Each may be a cause, as well as a consequence of the other. Conflict of Interest Statement The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Epidemiology of vestibular vertigo.