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Julie A. Honaker, PhDa,, JaneDaniel J. Blum, MDc, Jeffrey Pa Department of Special Education and Commb Division of Audiology, Mayo Clinic, Rochestec Department of Otorhinolaryngology, Mayo Cd Department of Psychiatry and Psychology, M

A R T I C L E I N F O

Article history:Received 15 June 2012

Objective: To demonstrate the excess morbidity caused by vestibular health anxiety and its

Method: Report of a 41-year-old woman with recurrent benign paroxysmal positional

2013 Elsevier Inc. All rights reserved.

A M E R I C A N J O U R N A L O F O T O L A R Y N G O L O G Y H E A D A N D N E C K M E D I C I N E A N D S U R G E R Y 3 4 ( 2 0 1 3 ) 5 9 2 5 9 5

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om1. Introduction

Patients with vestibular and balance complaints are oftendivided into those with clinical signs of active vestibular orneurological disorders and those without. The absence of

may not explain the full extent of their symptoms [13].Psychological factors such as anxiety and depressive disor-ders, which are known to exist in at least one-third of tertiarycare otoneurology patients, may affect clinical presentationsand therapeutic outcomes [2]. There have been numerousvertigo, vestibular migraine, and chronic subjective dizziness, who expressed graveconcerns about her health, repeatedly questioned her otoneurologic diagnoses, and failedphysical therapy and medication treatment until her health anxiety and otoneurologicillnesses were addressed simultaneously.Conclusion: Health anxiety is an empirically validated concept that explains troublesomehealth-related beliefs and behaviors. It is frustrating for patients and health care teams, butcan be treated successfully in otoneurology practice, thereby reducing physical symptoms,emotional distress, functional impairment, and health care overutilization.physical findings at the time of examnecessarily rule out otoneurologic disepatients problems, and the presence of ot

A portion of this paper was presented at Corresponding author. Department of SpecNebraska-Lincoln, Lincoln, NE 68583-0731, U

E-mail address: jhonaker2@unl.edu (J.A. H

0196-0709/$ see front matter 2013 Elsevhttp://dx.doi.org/10.1016/j.amjoto.2013.02.00successful management in a patient with otoneurologic disease.M. Gilbert, AuDb, Neil T. Shepard, PhDb,. Staab, MD, MSd

unication Disorders, University of Nebraska-Lincoln, Lincoln, NE, USAr, MN, USAlinic, Rochester, MN, USAayo Clinic, Rochester, MN, USA

A B S T R A C T

Introduction: Care of patients with vestibular symptoms focuses primarily on physicalotoneurologic disorders; however, psychological factors can sustain symptoms, confoundassessment, and adversely affect treatment. Health anxiety is a particularly perniciousprocess that simultaneously magnifies physical symptoms and inhibits medical care.migraine and chronic subjective dizzinessAdverse effects of health anxiewith benign paroxysmal positi

www.e l sev i e r . cination does notase as a cause ofoneurologic deficits

the annual meeting of thial Education and CommSA. Tel.: +1 402 472 5493;onaker).

ier Inc. All rights reserve2on management of a patientnal vertigo, vestibular

/ l oca te /amjo toinvestigations of anxiety and depression in patients withotoneurologic disorders, [49] but health anxiety has not beenstudied in patients with vestibular complaints. Health anxiety

e American Academy of Audiology, San Diego, CA, April 16, 2010.unication Disorders, 272 Barkley Memorial Center, University offax: +1 402 472 3814.

d.

(disease conviction), and are not easily reassured by the

N Dresults of medical evaluations [1116]. Patients with highlevels of health anxiety overutilize medical care by repeatedlyrequesting evaluations of physical symptoms (reassuranceseeking) [11,12,17]. Paradoxically, they may avoid medicallynecessary appointments because of worries that their diseaseconvictions will be confirmed. Health anxious individualsfunction poorly in social, occupational, and home settingsbecause they avoid activities that they believe could adverselyaffect their health (disease-related avoidance) [18,19]. Healthanxiety may co-exist with other psychiatric disorders such asanxiety or depression, though its psychological features areunique [18,20]. It is not a diagnosis reserved for patients wholack identifiable medical problems as it may occur in in-dividuals with or without active physical illnesses [16,21].Indeed, several features of otoneurologic diseases may beparticularly troublesome for patients prone to health anxiety.These include the appearance of sudden and dramaticphysical symptoms (e.g., acute vertigo attacks) or, conversely,vague and nagging symptoms that are difficult to describe andevaluate (e.g., chronic dizziness). The possibility, howeversmall, that such symptoms could be caused by a life-threatening condition (e.g., stroke) is especially difficult forhealth anxious patients to tolerate. In such situations, theclinicians diagnosis of a benign condition that is easilytreated (e.g., benign paroxysmal positional vertigo, BPPV) canbe strikingly at odds with patients worries about seriousdisease. Patients attempts to avoid physical symptoms maythwart therapeutic interventions, especially those that maytransiently provoke symptoms (e.g., canalith repositioningmaneuvers, CRM). We present here an illustrative case of apatient with severe vestibular health anxiety that seriouslycompromised management of her co-existing recurrent BPPV,vestibular migraine (VM), and chronic subjective dizziness(CSD). A treatment plan that incorporated behavioral in-terventions for health anxiety into otoneurologic therapiessucceeded in having the patient utilize home CRM effectively,tolerate and receive benefit from migraine prophylactic andCSD medications, return to work, and accept discharge fromtertiary care.

2. Case Report

A 41 year old woman presented with a 20 year history ofvestibular symptoms, including intermittent episodes of briefpositional vertigo and recurrent attacks of migrainous head-aches lasting for several hours accompanied by unsteadinessand motion sensitivity. She developed persistent non-vertig-inous dizziness and hypersensitivity to motion that were(aka illness anxiety) is an empirically validated concept that islikely to replace the older notion of hypochondriasis in thepsychiatric nomenclature in 2013 [10]. Health anxiety is acondition in which patients maintain high levels of attentionto physical symptoms (body vigilance), focus on thoughts andimages of disease (disease preoccupation) worry aboutbecoming ill (disease fears), misinterpret bodily sensationsas evidence that they are afflicted with malignant illnesses

A M E R I C A N J O U R N A L O F O T O L A R Y N G O L O G Y H E A D Aexacerbated in environments with complex visual stimuli.She also had a longstanding history of generalized anxietythat was treated with extended release bupropion, but thatmedication may have increased her headaches. Trials ofseveral other anxiolytic antidepressants had been discontin-ued in the past due to unacceptable side effects (e.g., weightgain, low libido). On referral to our center, the patientunderwent a multidisciplinary evaluation, including audio-metric and vestibular laboratory testing, otoneurologic andpsychiatric consultation, and physical therapy assessment.

Audiometric evaluation was unremarkable. Comprehen-sive vestibular and balance function evaluation consisting ofvideonystagmography, rotational chair, cervical vestibularevokedmyogenic potentials (cVEMPs), computerized dynamicposturography and postural evoked responses was entirelynormal. Her history of intermittent brief positional vertigowas consistent with recurrent BPPV, which was not active atthe time of evaluation. Her migrainous headaches withvestibular symptoms were diagnosed as VM and her dailydizziness and motion sensitivity were diagnosed as CSD. Thepatient was given a multimodality treatment plan thatincluded training in the use of home CRM for recurrences ofBPPV, daily home vestibular habituation exercises (headmovements, exposure to visual motion stimuli, and walkingwith head turning exercises) to reduce her sensitivity tomotion stimuli, and gradual introduction of sertraline fortreatment of CSD with a plan to follow that with migraineprophylactic or abortive medications for VM. The patient alsowas advised to obtain cognitive behavior therapy for her co-existing generalized anxiety disorder.

Despite this comprehensive plan, the patient failed toimprove. She continued to have episodic vestibular symptomsindicative of recurrent BPPV and VM and daily symptoms ofCSD. She was impatient with the titration of medications andreported unacceptable side effects for each of three successivemedication trials. She shifted her focus to taking supplementsthat she researched on the Internet. She varied the prescribedvestibular habituation exercises and then discontinued themaltogether due to doubts about the benefit. A neurologyconsultation was arranged for headache management, but thepatient dropped the migraine diet and abandoned the medica-tion recommendations, which she felt were not helpful. She didnot follow-up with her established psychiatrist. During follow-up visits to our center, she repeatedly questioned her diagnosesand requested more testing. She interpreted her continuingsymptomsasevidenceof anundetectedmalignant illness.Overthe course of a year, she contacted our center more than 40times by e-mail or telephone with similar inquiries. This failedto improve her adherence to treatment and did not assuage herincreasing worries about having a serious neurologic disease.We contemplated dismissing her from our practice, but optedinstead to engage her in a structured treatment plan thatsimultaneously limited her health anxious behaviors andestablished a consistent regimen ofmedications and vestibularexercises. Elements of that plan are outlined in Table 1. Thepatient gradually grew accustomed to the plans focus andlimits, which were implemented strictly, but respectfully. Overthe span of a few months, she restarted prescription medica-tions (citalopram and bupropion) and consistently performedher vestibular exercises. She became competent in self-

593N E C K M E D I C I N E A N D S U R G E R Y 3 4 ( 2 0 1 3 ) 5 9 2 5 9 5assessment of symptom flare-ups and successfully usedhome CRM and migraine abortive medications for recurrences

an

ptof di

ease

eisea

N DDisease Preoccupation Recurrent thoughts and images of dis

Disease Fears Fear of having or contracting a diseas Anxiety about possible contact with dTable 1 Features of health anxiety, clinical manifestations,

Features Clinical Manifestations

Body Vigilance Heightened attention to physical sym Repeated checking of body for signs o

594 A M E R I C A N J O U R N A L O F O T O L A R Y N G O L O G Y H E A D Aof BPPV and episodes of VM, respectively. The frequency ofher e-mails and telephone calls decreased dramatically andthe few remaining contacts between scheduled office visitswere for straightforward reasons. She was able to meet all ofher family and work obligations. One year after implemen-tation of this treatment plan she was discharged successfullyfrom tertiary care.

3. Discussion

This patient had three neurotologic diagnoses, BPPV, VM, andCSD, that usually are quite amenable to treatment, evenwhenthey co-exist. From an otoneurologic standpoint, the patientdid not present a diagnostic or therapeutic dilemma. However,her high level of health anxiety caused major morbidity andundermined initial efforts at treatment. We chose not todischarge her from our clinic at the height of her healthanxious behaviors, despite the difficult management prob-

related stimuli (e.g., dirt, blood)

Disease Conviction Belief about having a serious illness

Reassurance Seeking Excessive checking of sources of healthinformation (e.g., Internet) Repeated consultations with medicalprofessionals regarding health status

Disease-Related Avoidance Avoidance of disease-related stimuli (varfrom passive avoidance such as limiting acthat may provoke symptoms or risk diseasexposure to active measures such as use omedically dubious preventative measures)d intervention strategies.

Intervention strategies

mssease

Structured format for symptom reports Implemented a daily symptom log that included a 5-pointseverity rating scale for vertigo, dizziness, and headache. Required that all symptoms be recorded in log, which wasreviewed at each office visit.Using symptom log, taught patient to recognize patterns ofBPPV, VM, and CSD.Structured response to symptom flare-ups Had patient perform home CRM for all episodes of briefvestibular symptoms

Focused on known diagnoses and treatment plan Refocused discussions to treatment plan

se Taught patient to counter disease fears by identifyingpatterns of BPPV, VM, and CSD symptoms in daily log.

N E C K M E D I C I N E A N D S U R G E R Y 3 4 ( 2 0 1 3 ) 5 9 2 5 9 5lems that they presented, because her active otoneurologicconditions warranted treatment. Instead, we incorporatedinterventions for health anxiety into her otoneurologic plan ofcare. The outcome of this case was ultimately favorable, butearlier recognition and treatment of the patients healthanxiety would have been more beneficial.

Interventions for health anxiety are designed to counterhealth-related fears and behaviors and refocus the patient onknown medical diagnoses and clinically indicated treatments.The interventions listed in Table 1 addressed the core featuresof health anxiety. We gave the patient a structured format forrecording her daily symptoms, which focused her bodyvigilance on clinically important symptoms and enabled us toteach her to recognize the patterns of her otoneurologicconditions. This improved her ability to meaningfully reporther response to treatment and successfully use homemanage-ment techniques such as CRM and migraine abortive medica-tions for episodic recurrences. We politely, but consistently,declined to answer reassurance-seeking questions or debate

Quickly countered all queries with firm, but politerestatement of known diagnoses Declined to debate alternative diagnoses

Placed firm limits on reassurance seeking Provided written material on diagnoses and treatmentstrategies, including home CRM, vestibular habituation,medications Discouraged reading of other information Politely, but firmly, refused to review other informationbrought or sent by patient Declined all requests to re-evaluate symptoms caused byknown diagnoses Agreed to evaluate new or significantly differentsymptoms (none developed)

iestivitiesef

Systematically countered avoidance Home-based vestibular habituation exercises (started at2 min twice daily) Motion exposure exercises outside the home (incorporatedinto necessary activities such as shopping and return towork) Refused to discuss use of unproven remedies to preventvertigo and dizziness

alternative diagnoses with her, although we did promise toinvestigate any distinctly new or different symptoms thatmight have developed. Individuals with health anxiety strugglewith uncertainty about their medical diagnoses. Repeatedlyoffering reassurance has the paradoxical effect of reinforcinghealth anxious beliefs because it keeps the focus of interactionson the patients doubts and highlights the fact that no absoluteguarantee of diagnostic accuracy or therapeutic efficacy can be

avoidance of home and work activities.

Health anxiety is an empirically validated diagnosis that is

[2] Staab JP, Ruckenstein MJ. Which comes first? Psychogenicdizziness versus otogenic anxiety. Laryngoscope 2003;113:17148.

[3] Staab JP, RuckensteinMJ. Expanding the differential diagnosisof chronic dizziness. Arch Otolaryngol 2007;133:1706.

[4] Reynolds P, Gardner D, Lee R. Tinnitus and psychologicalmorbidity: a cross-sectional study to investigate psychologicalmorbidity in tinnitus patients and its relationship withseverity of symptoms and illness perceptions. Clin Otolaryngol2004;29:62834.

595A M E R I C A N J O U R N A L O F O T O L A R Y N G O L O G Y H E A D A N D N E C K M E D I C I N E A N D S U R G E R Y 3 4 ( 2 0 1 3 ) 5 9 2 5 9 5replacing the centuries-old concept of hypochondriasis. Leftunrecognized, health anxiety magnifies physical symptoms,inhibits medical care, and interferes with the therapeuticrelationship between patients and their treating clinicians.This case report demonstrates the pernicious effect ofvestibular health anxiety and its successful treatment withinterventions that can be incorporated into routine otoneur-ologic practice. As with many other chronic conditions, apositive outcome was achieved only after a collaborativetreatment plan was developed that cohesively addressed allphysical and psychological aspects of the patients condition.

R E F E R E N C E S

[1] Staab JP. Chronic dizziness: the interface between psychiatryand neuro-otology. Curr Opin Neurol 2006;19:418.The behavioral elements of this plan were designed by thepsychiatrist on our multidisciplinary team, but were carriedout by all clinicians and staff members who interacted withthe patient. This reduced the level of frustration and sense offutility that pervaded our early interactions with her. Forotolaryngologists and other specialists who care for patientswith vestibular symptoms but practice outside a multidisci-plinary clinic, a similar approach could be coordinated with aconsulting psychiatrist or psychologist. The behavioral healthspecialist would not carry out the plan alone because healthanxiety manifests most strongly in medicalsurgical settings.

4. Conclusionmade. Our refusal to respond to the patients health anxiousdoubts reduced the time that she and we had previouslydevoted to unproductive e-mails and phone calls. Finally, weemphasized the benefits of consistent vestibular habituationexercises to improve her physical and psychological tolerancefor motion stimuli, thereby counteracting her disease-related[5] Kirby SE, Yardley L. Understanding psychological distress inMenieres disease: a systematic review. Psychol Health Med2008;13(3):25773.

[6] Nagaratnam N, Ip J, Bou-Haidar P. The vestibular dysfunctionand anxiety disorder interface: a descriptive study withspecial reference to the elderly. Arch Gerontol Geriatr 2005;40:25364.

[7] Hong SM, Kim BG, Lee BC, et al. Analysis of psychologicaldistress after management of dizziness in old patients:multicenter study. Eur Arch Otorhinolaryngol 2011;269(1):3943.

[8] Staab JP. Psychological attributes of Menieres disease. In:Ruckenstein MJ, editor. Menieres disease. 1st ed. San Diego(Calif): Plural Publishing; 2010. p. 13547.

[9] Staab JP. Psychiatric origins of dizziness and vertigo. In:Jacobson GP, Shepard NT, editors. 1st ed. San Diego (Calif):Plural Publishing; 2008. p. 51742.

[10] http://www.dsm5.org.[11] Pilowsky I. Dimensions of hypochondriasis. Br J Psychiatry

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in psychosomatic research. Psychother Psychosom 1995;63:18.

[14] Barsky AJ, Fama JM, Bailey ED, et al. A prospective 4- to 5-yearstudy of DSM-III-R hypochondriasis. Arch Gen Psychiatry1998;55:73744.

[15] Hollifield M, Paine S, Tuttle L, et al. Hypochondriasis,somatization, and perceived health and utilization of healthcare services. Psychomatics 1999;40(5):3806.

[16] Noyes R, Carney CP, Hillis SL, et al. Prevalence and correlatesof illness worry in the general population. Psychosomatics2005;46(6):52939.

[17] Noyes R, Kathol RG, Fisher MM, et al. The validity of DSM-III-Rhypochondriasis. Arch Gen Psychiatry 1993;50:96170.

[18] Barsky AJ, Wyshak G, Klerman GL. Hypochondriasis: anevaluation of the DSM-III criteria inmedical outpatients. ArchGen Psychiatry 1986;43:493500.

[19] Yardley L, Beech S. Im not a doctor: deconstructing accountsof coping, causes and control of dizziness. J Health Psychol1998;3(3):31327.

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[21] Looper KJ, Kirmeyer LJ. Hypochondriacal concerns in acommunity population. Psychol Med 2001;31:57784.

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Adverse effects of health anxiety on management of a patient with benign paroxysmal positional vertigo, vestibular migraine...1. Introduction2. Case Report3. Discussion4. ConclusionReferences