Schaaf H, Holtmann, H., Hesse, G, Rienhoff. N. Kolbe,, U., Brehmer, D. Nelting, M. (2000):

Reactive psychogenic dizziness in Menière's disease

In: Sterkers, O; Ferrary, E.; Daumann, R.; Sauvage, J.P.; Tran Ba Huy, R: (eds): Menière's disease 1999 - update. Proceedings of the 4th international Symposium of Menière's disease Paris, France, April 11-14, 1999. Kugler Publikcations, The Hague. pp. 505-511
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Summary:

Besides recurrent hearing-loss and Tinnitus, attacks of labyrinthine vertigo are the predominant symptom of Menière's disease. Recurrent Menière-attacks, often experienced as life-threatening by patients, can lead to additional dizziness components which mostly cannot be differentiated from the organic event by patients themselves. This - mainly reactive - psychogenic dizziness is partially induced by the labyrinthine events, but can consecutively develop independently.

Efficient therapy and scientific evaluation of therapy require differentiation of organic and psychogenic dizziness components in M. Menière. Therefore, some of the most important aspects of psychogenic influence on Menière's disease will be presented.

These are categorized as follows:

In our neurootological and psychosomatic-oriented hospital we treated 96 in-patients with Menière's disease between March 1994 and August 1997. The average age of the 47 women and 49 men was 53 years, ranging from 26 to 77 years of age. The average medical history was seven years, ranging from six months to 31 years.

According to the classification of Jahnke 1994 (1) we found Menière's disease patients in stage I : 3, stage II: 34, stage III 43, stage IV: 16. Relating to the dizziness component, 41% of our patients were well compensated with sufficient coping abilities. They required treatment mainly for Tinnitus or hearing-loss. 59% predominantly showed insecurity and an unspecific dizziness, which could by classified as a reactive psychogenic dizziness. Psychogenic dizziness coincided with 56% depressive symptoms, 15% anxiety-related disorders, 15% Neurasthenia and 14% other psychological disorders.

In 46% of our Menière's disease patients we observed high psychodynamic tension after existentially threatening event(s) preceding or coinciding with the first vertigo attack.

Usually the psychogenic components of the disease can be treated successfully, if the diagnosis is clear and adequate treatment is applied. A good medical counseling, which helps to increase the patient's self-competence as far as possible, is indispensable for treatment and prevention of the psychogenic component of Menière's disease. This, and - if necessary - psychotherapy, helps restrict attacks of dizziness to "pure organic attacks". Thus, good medical counseling may help patients to cope with their work and improve general life-perspective.

Key-words: Menière's disease - psychogenic dizziness - Reactive psychogenic dizziness - psychotherapy - balance exercises

Introduction

Besides recurrent hearing-loss and Tinnitus, attacks of labyrinthine vertigo are the predominant symptom of Menière's disease. With increasing duration of the disease patients often report some other, but very similarly experienced, form of "permanent dizziness" that cannot be explained sufficiently by organic events.

Patients describe this as follows: They feel dizzy, unsteady, shaky and confused; they have a pounding feeling and often a strong feeling of anxiety. Whole days are now experienced as "Menière's disease days". However, nystagmus, one typical sign for labyrinthine vertigo attacks, is absent.

These states of dizziness are mainly due to additional psychogenic components. Their origin might best be explained by behavioral mechanisms as therapy based upon behavioral principles is often helpful.

Patients and methods

In our neurootological and psychosomatic-oriented hospital we treated 96 Menière's disease in-patients for six to eight weeks between March 1994 and August 1997.

The average age of the 47 women and 49 men was 53 years, ranging from 26 to 77 years of age.

The average medical history was seven years, ranging from six months to 31 years.

32 (33%) patients were affected for the right ear, 59 (61%) for the left ear and five (5%) for both.

According to the classification of Jahnke (1994) we found Stage I : 3, Stage II: 34, Stage III 43, Stage IV: 16.

Stage 1: Fluctuating hearing loss; this may recover to a normacoustic level after the Menière vertigo attack.

Stage 2: Vertigo attacks and fluctuating hearing loss, that may improve spontaneously, but not to a normacoustic level.

Stage 3: Severe hearing loss without fluctuation and persistent vertigo attacks.

Stage 4: The inner ear has lost its function.

Classification of Menière's disease according to Jahnke

We examined all patients neurootologically and psychologically. The neurootological part was based on the medical history, audiometers and vestibular tests; the psychological diagnosis on psychological interviews, including the personal history and psychological tests (FPI-R; SVF and Hamilton depressions scale).

We also carefully proved the possibility of balance in motion, especially when patients were worried about dizziness and signs of nystagmus were absent.

Results

According to the classification of Jahnke 1994 (1) we found reactive psychogenic dizziness in

Stage I : 1 of 3 patients

Stage II: 19 of 34 patients = 56%

Stage III: 33 of 43 patients = 77%

Stage IV: 4 of 16 patients

Reactive psychogenic dizziness coincides with

46% (n= 44) of all patients showed psychological constellations of unreleased high psychodynamic tension before or at the time of the beginning of Menière's disease.

In a post-examination of 21 patients one to five years after treatment we found a statistically significant reduction of dizziness attacks from an average of four attacks per month before treatment, to an average of less than one attack per month, six months after treatment (p<.001).

Discussion:

Menière diseases goes along with vertigo and dizziness; but not every dizziness and vertigo is due to a labyrinthine event.

Literature on psychogenic dizziness-components in Menière's disease is scarce and mainly occupied with presumptions concerning the relevance of psychogenic factors in the origin of Menière's disease's (2,3,4,5,6,7).

Our psychological investigation revealed signs of unreleased high psychodynamic tension before or coinciding with the beginning of Menière's disease for 46% of our patients. Thus, in these patients, the first Menière attack could be interpreted as a maladaptive solution of an explosive release of psychodynamic tension due to a patient's inability to express an existentially threatening event otherwise.

Undoubtedly and often Menière's vertigo attacks themselves had consequences for the psychogenic equilibrium of patients (6,8,9,10,11). Reactive psychogenic dizziness increased with duration of the disease, and the number of Menière's attacks. 59 % of our patients suffered mainly from reactive psychogenic dizziness. It occurred even more frequently when patients had insufficient knowledge of the organic event.

Real labyrinthine events did happen during the observed six to eight weeks. However, they were very seldom. We may conclude, that patients with Menière's disease usually suffer much less from labyrinthine vertigo attacks and more often and for a longer period of time from reactive psychogenic dizziness.

In spite of this, reactive psychogenic dizziness coinciding with Menière's disease is not mentioned in the revisited literature, even though this phenomena can be sufficiently explained and treated by applying behavioral principles.

Pawlow's dog learned to respond to a bell as a food-stimulus (12). During their labyrinthine vertigo attacks Menière's disease patients "learn" to respond to other stimuli through mechanisms of classical conditioning. Frequently observed responses are: insecurity, anxiety, panic and multiple attendant vegetative symptoms .

Table 1: The situation during the classical conditioning

These stimuli may be:

Table 2: The result of classical conditioning and response generalization leading to reactive psychogenic dizziness.

Anxiety, as a reaction on vertigo attacks, may be experienced as a sensation of dizziness. This can easily lead to a viscous circle of anxiety-dizziness and dizziness-anxiety. We often observed psychogenic dizziness accompanied by clinically relevant symptoms of depression and anxiety.

It must be emphasized that these mechanisms operate subconsciously. So psychogenic dizziness can remain or establish itself even if the inner ear has already lost its function. This was true for four of our patients.

Therapy

We treated patients with intensive neurootological counseling, aiming to reach them on a cognitive as well as an emotional level. We offered precise information for the distressed patients within their individual capacities.

In cases of reactive psychogenic dizziness we treated every subconsciously learned connection inducing dizziness similar to the labyrinthine event psychotherapeutically, mainly by cognitive behavioral therapy.

To stabilize body-experiences we used "easy to follow" practical exercises, reducing psychological or organic effects by allowing new balance experiences. Here the exercises of Cawthorne (13) and Cooksey (14) have proved useful since about 50 years.

We also worked psychotherapeutically to improve coping abilities and reduce symptoms of depression and anxiety.

This therapeutical approach often reduces dizziness to the unavoidable dizziness of purely organic attacks. We observed the frequency of attacks and complaints lessening after six to eight weeks of psychosomatic in-patient treatment. In a post-examination of 21 patients one to five years after treatment we found a statistically significant reduction of dizziness according to the classification of the American Committee on Hearing and Equilibrium.

Summary

Psychogenic dizziness is an additional component in Menière's disease. It may be partially determined by labyrinthine events, but then can develop independently.

In many cases it can be treated successfully if the diagnosis is clear and adequate treatment is applied. Essential for therapy and prevention is good medical counseling. This should include helping patients to develop or enhance self-competence. Psychological treatment is necessary if psychogenic dizziness is the main reason for patients' suffering from Menière's disease.

For research purposes, differentiation between psychogenic dizziness and labyrinthine vertigo is important, e.g. to enable therapy evaluation.

References:

1. Jahnke K: Stadiengerechte Therapie der Menièreschen Krankheit. Deutsches Ärzteblatt 91 A: 428-434, 1994

2. Fowler jr. EP, Zeckel A: Psychosomatic aspects of Menière's disease. JAMA; 148:1265-71, 1952

3. Groen, J.J: Psychosomatic Aspects of Menière's Disease. Acta Otolaryngol 95: 407-416, 1983

4. Hinchcliffe R: Emotions as a precipitating factor in Menière's disease. J Laryngol Otol; 81:471-5, 1967

5. Basecqz G : Aspects psychodynamiques de la maladie Menière. Laval medical; 40: 838-43, 1969

6. Lamparter, U: Schwindel. In: Ahrens S (ed.): Psychosomatik in der Neurologie. Pp 122-151. Stuttgart/New York: Schattauer 1995

7. Modestin J: Schwindel als psychosomatisches Phänomen. Psychother med Psychol 33: 77-86, 1983

8. Schaaf, H: M. Menière, Berlin/Heidelberg/New York: Springer 1998

9. Schaaf, H., Holtmann, H., Hesse, G: Schwindel im Wechselspiel zwischen Körper und Seele bei M. Menière. Psychomed 10: 88-92, 1998

10. Schaaf, H: Klinik und psychosomatische Behandlungsansätze bei der Menièreschen Krankheit. In: Goebel G (ed.) Ohrgeräusche - Psychosomatische Aspekte des komplexen chronischen Tinnitus. pp 278-201. München MMW 1999

11. Schaaf, H., Holtmann, H., Hesse, G. Kolbe, U. Brehmer, D.: Der (reaktive) psychogene Schwindel - eine wichtige Teilkomponente bei wiederholten M. Menière-Anfällen. HNO. (1999) in preperation, will be concret placed until to authors revison

12. Pawlow, I.P: Conditioned reflexes. London, Claredon 1927

13. Cawthorne, T: The physiological basis for head exercises. Journal of Chartered Society of Physiotherapy, 106 - 107, 1944

14. Cooksey, F.S.: Rehabilitation in vestibular injuries. Proceedings of the Royal Society Medicine, 39, 273 - 278, 1946

Annex:

Treatment for reactive psychogenic dizziness in Menière's disease

A good medical counseling that reaches the patient on a cognitive as well as on an emotional level, is the basis of any treatment and also the best prevention of psychogenic dizziness.

Such counseling requires precise information of the patient in his need and within his individual possibilities.

So it's essential to point out that:

1. Menière's disease is a serious illness, but not a life threatening diagnosis.

2. Attacks might occur suddenly and with unexpected intensity, frequency or duration, but medical intervention is possible and will lessen the symptoms.

3. In case of hearing-loss, hearing-aids will significantly improve hearing.

Nevertheless, Menière's disease goes along with a high portion of organic and psychogenic insecurity.

To establish a feeling of security, it is useful to help patients prepare for coping with their attacks:

So

1. Menière's disease patients should always carry "an antiemetic suppository" to suppress the symptoms of an attack until medical aid arrives.

2. They should carry a "Help-Card", in case of an attack, so they can ask for help and are not considered - for example - to be drunken. This "Help cards" can usually be received from self-support groups (e.g. in England: Menière Society, 98 Maybury Road, Woking, Surrey,

GU 21 5HX.. Tel.: (0483) 740597) (1)

3. They should carry technical devices such as mobile phones, so they can call for help at any time.

If psychogenic dizziness is already manifest, comprehensible and sympathetic information on the behavioral principles of a psychogenic dizziness-process may have a strong anxiety reducing effect.

Psychotherapy

The symptom-oriented approach of behavioral therapy seems to be the prime method for reactive psychogenic dizziness. Besides learning new, more stable behavior, it should also involve cognitive processing.

But if there are signs of unreleased tension as a important factor of initiating vertigo, a psychoanalytical approach and focus on unprocessed conflicts e.g. aggression - or conscious conflicts may reduce the overall emotional tension and, as a consequence, the frequency of attacks.

For any treatment it is of course crucial not to class every attack as psychogenic!

Psychopharmaca

If anxiety-related disorders or depressive episodes occur along with Menière's disease, it can make sense to use antidepressants or neuroleptics. Sometimes this might even be necessary to enable first therapeutical steps. However, medication should not be prescribed to treat labyrinthine vertigo as a long-term therapy! Here ENT-doctors and psychotherapists should cooperate closely to ensure appropriate and adequate treatment.

Differentiation between psychogenic dizziness and labyrinthine vertigo

Because any form of dizziness can be misunderstood as an Menière attack as duration of illness increases, it is important to differentiate between psychogenic dizziness and labyrinthine vertigo as well as other forms of organically induced dizziness.

In absence of ataxia or impairment of brain-nerves permanent dizziness is most likely psychogenic, especially the more complex the reported dizziness is experienced and expressed, even though the patient may experience it as a vertigo-attack. The only condition being, that even with nystagmus glasses, there is no evidence of nystagmus.

But it is quite important to know that the absence of an organic component alone does not prove psychological dizziness. Therefore it is necessary to outline a psychogenic model of possible circumstances and conditions which make the event understandable.

One simple technique all patients can learn easily is to look for fixed points in the environment when the actual vertigo attack starts. That way the patient can find out if the world is starting to move around him - as it would do in case of labyrinthine vertigo.

If he can fix whatever he is looking at with his eyes without this sensation, the attack is probably psychogenic.

Another method is getting up and stamping or trying to walk. If this leads to a more steady and stable feeling - and not to falling down - psychogenic dizziness is likely.

We take Menière's disease patients for neurootological and psychosomatic treatment in our hospital if other possibilities of treatment have failed and/or if significant psychogenic elements, depressive symptoms etc. become predominant.

The main advantage of in-patient treatment is the institutionalized teamwork of different doctors and therapists, which is particularly desirable when dealing with a disease as complex as Menière's disease.

References

1. Myall J, Sheppard T (eds): Menière's disease - The real story, Woking, Menière's Society 1992


 Text zuletzt geändert am 23.6.2000

Dr.Helmut Schaaf,
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