Journal of Psychosomatic Research 76 (2014) 80–83

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Journal of Psychosomatic Research

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Anxious, introverted personality traits in patients with chronic subjective dizziness Jeffrey P. Staab a,⁎, Daniel E. Rohe a, Scott D.Z. Eggers b, Neil T. Shepard c a b c

Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA Department of Neurology, Mayo Clinic, Rochester, MN, USA Vestibular Laboratory, Division of Audiology, Mayo Clinic, Rochester, MN, USA

a r t i c l e

i n f o

Article history: Received 18 May 2013 Received in revised form 8 November 2013 Accepted 9 November 2013 Keywords: Anxiety Chronic dizziness Introversion Neuroticism Risk factor Temperament

a b s t r a c t Objectives: 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. Methods: 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. Results: There were no differences between groups in demographics, mean DHI or HADS-anxiety scores, or DSMIV 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 b 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. Conclusion: An anxious, introverted temperament is strongly associated with CSD and may be a risk factor for developing this syndrome. © 2013 Elsevier Inc. All rights reserved.

Introduction Chronic subjective dizziness (CSD) is a neurotologic disorder of persistent non-vertiginous dizziness or unsteadiness that is present throughout the day for 3 months or more [1]. Symptoms may be exacerbated by upright posture, patients' own movements, exposure to full field visual stimuli (e.g., shopping malls), or performance of precision visual tasks (e.g., reading). CSD is usually triggered by neurotologic or other events that cause acute attacks of vertigo, unsteadiness, or dizziness, such as vestibular neuritis, presyncope, or panic attacks [2]. Retrospective [3] and prospective [4,5] studies found that CSD symptoms developed in about 25% of patients afflicted by these events. CSD also may occur in patients with episodic neurotologic illnesses, such as Meniere's disease. It may persist for years [1]. The pathophysiologic processes underlying CSD are unknown, but may relate to patients'

⁎ Corresponding author at: Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN, USA. Tel.: +1 507 284 2649; fax: +1 507 284 4158. E-mail address: [email protected] (J.P. Staab). 0022-3999/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpsychores.2013.11.008

failure to return to normal postural control after adapting to the demands of acute vestibular crises [1]. CSD is not a rare or new condition. It is the second most common cause of dizziness in tertiary neurotology centers that track it [1]. Physical symptoms of CSD are similar to those of phobic postural vertigo (PPV), which was described in Germany 27 years ago [6]. However, the definition of PPV included mild anxiety and depressive symptoms and obsessive compulsive personality traits [6] that were not retained in the definition of CSD. This conceptual refinement parallels changes in constructs of irritable bowel syndrome (IBS) from early psychosomatic formulations that included anxiety and depressive symptoms, personality traits, and stress [7], through identification of core gastrointestinal symptoms [8] to widely accepted Rome III diagnostic criteria [9]. Fibromyalgia evolved similarly. CSD, like IBS and fibromyalgia, frequently co-exists with anxiety and depressive disorders [8,10–12], but may occur independently of psychiatric morbidity [2,13]. Personality traits have been investigated in patients with IBS, fibromyalgia, and non-cardiac chest pain (NCCP). Patients with these conditions had higher levels of neuroticism than normal controls [10,14–17]. Those with IBS also were more introverted than normal controls

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[10,14,16]. Patients with IBS or NCCP who had Type D (distressed) personality reported more physical symptoms and poorer health-related quality of life than others [15,18,19]. In patients with IBS, the severity of neuroticism correlated inversely with physical and psychological responses to treatment with mianserin [20]. Several studies investigated psychological factors in patients with CSD. Pre-existing anxiety disorders predicted development of CSD symptoms after acute neurotologic illnesses [3,5], and premorbid anxiety diatheses were associated with poorer treatment response to selective serotonin reuptake inhibitors, the primary medications for CSD [21]. In contrast, patients with greater resilience, life satisfaction, and sense of coherence were less likely to develop CSD-type symptoms after acute neurotologic illnesses than individuals with lower scores on these positive characteristics [22]. This investigation was part of a larger project to validate the definition of CSD, including the presence or absence of psychological symptoms and personality traits that may differentiate it from other neurotologic disorders. This study focused on personality traits. Attention was given to obsessive compulsive traits, which were included in the definition of PPV [6], but not CSD, and to neuroticism and introversion, which have been associated with IBS, fibromyalgia, and NCCP [7,10,14–17]. To identify personality traits that might be associated specifically with CSD, a comparison group of patients with similar levels of vestibular and psychological symptoms was chosen, lest symptom burden alone or neuroticism associated with co-existing psychiatric disorders confound the results. Personality traits measured by the NEO Personality Inventory — Revised (NEO-PI-R) [23] were compared between 24 patients with CSD and 16 patients who had chronic neurotologic conditions plus comorbid anxiety disorders. Method Study design This retrospective review included 40 patients with either CSD or coexisting chronic neurotologic and anxiety disorders. Patients provided

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written informed consent for research record review. Our Institutional Review Board approved this study. Subject selection and evaluation Subjects were drawn from the Mayo Clinic Vestibular Syndrome Validation Project (MC-VSVP, N = 600), a study investigating characteristic symptoms of CSD and vestibular migraine, plus features that differentiate these conditions from other neurotologic disorders. Subjects in the MC-VSVP completed multidisciplinary clinical evaluations including neurotologic examination, vestibular laboratory testing, head imaging, if indicated, and self-reports of impairment on the Dizziness Handicap Inventory (DHI) [24]. Per clinical protocol, subjects underwent behavioral medicine consultations if their vestibular symptoms or functional impairment were not fully explained by physical neurotologic findings alone or they recorded positive scores on the Hospital Anxiety and Depression Scale (HADS) [25]. Behavioral medicine assessment including the Mini International Neuropsychiatric Inventory [26], standardized psychosocial interview, clinical examination by a psychosomatic medicine psychiatrist and/or clinical health psychologist, and assessment with the NEO-PI-R [23], if indicated. Subjects who completed the NEO-PI-R were selected for this study if they were diagnosed with CSD alone (N = 24) or had other neurotologic conditions and levels of persistent vestibular and psychiatric symptoms roughly comparable to those in the CSD group (N = 16). Measures Patient demographics, DHI and HADS scores, neurotologic diagnoses, DSM-IV psychiatric diagnoses, and NEO-PI-R results were abstracted from the medical record. The DHI is a 25-item, self-report of physical symptoms, functional impairment, and emotion distress due to dizziness with total score from 0 to 100 [24]. The HADS is a validated selfreport with seven questions each for anxiety and depression, rated 0–3 [25]. The HADS may be used continuously or categorically with scores ≥ 8 for anxiety or depression or total scores ≥ 12 indicating

Table 1 Characteristics of CSD and comparison subjects

Age (years) Sex Race DHI-total HADS—anxiety HADS—depression DSM-IV anxiety disorders

DSM-IV depressive disorders

Primary neurotologic diagnoses

Mean ± standard deviation Range Male Female % Caucasian Mean ± standard deviation Mean ± standard deviation % positive (≥8) Mean ± standard deviation % positive (≥8) Majorb Minorc None Majord Minore None Chronic subjective dizziness Central vestibular deficit Peripheral vestibular deficit Vestibular migraine Autonomic disorder

CSD group (N = 24)

Comparison group (N = 16)

Between group differencesa

43.5 ± 18.5 16–89 9 15 91.7% 54.8 ± 19.3 10.9 ± 3.8 89.5% 8.1 ± 4.4 47.4% 14 7 3 6 1 17 24

48.6 ± 21.1 18–81 8 8 87.5% 52.7 ± 29.2 8.5 ± 4.2 72.7% 5.2 ± 3.8 27.3% 8 4 4 3 2 11

n.s.

6 5 3 2

DHI = Dizziness Handicap Inventory. HADS = Hospital Anxiety and Depression Scale. a Student's t-test for continuous data. Chi-square test for categorical data. n.s. = not significant. b Panic disorder with or without agoraphobia, generalized anxiety disorder, posttraumatic stress disorder, and obsessive compulsive disorder. c Specific phobia (of dizziness), anxiety disorder not otherwise specified. d Major depressive disorder, single episode or recurrent, any severity. e Depressive disorder, not otherwise specified.

n.s. n.s. n.s. n.s. n.s. p b 0.05 n.s. n.s.

n.s.

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J.P. Staab et al. / Journal of Psychosomatic Research 76 (2014) 80–83 Mean scores for the CSD group fell within population norms for the conscientiousness factor and all six of its facets. Conscientiousness is a necessary component of obsessive compulsive personality as defined in the Five Factor Model [27]. This argues against obsessive compulsive personality playing a role in CSD. The inclusion of obsessive compulsive traits in the definition of PPV was based on clinical observations in the mid-1980s [6]. Just as in cardiology, where investigations of Type A personality as a risk factor for heart disease in the late-1950s [28] gave way to narrower constructs (e.g., Type D personality) following detailed reassessments in later years [18,19], these initial observations were not so much erroneous as too broad. Anxious and introverted traits were associated with CSD in this study. Conscientious traits (e.g., orderliness, dutifulness, achievement striving) were not. The finding that an anxious, introverted temperament was associated specifically with CSD and not more generally with co-existing vestibular and anxiety disorders may provide a clue to its pathophysiologic mechanisms. In electrophysiologic studies [29,30], the interaction of neuroticism and introversion affected arousal, attention, and stimulus detection thresholds. Highly neurotic introverts detected electrocutaneous stimuli at lower thresholds than others [29]. Perhaps trait-determined hypersensitivity to motion stimuli exists in patients with CSD [1].

clinically meaningful symptoms. The NEO-PI-R is a validated 240-item measure of Five Factor Model personality (neuroticism, extraversion, openness, agreeableness, conscientiousness). Each factor has six facets. Factor and facet scales are population-normed at 50; scores N55 are high, b45 are low [23]. Statistical analysis Differences between groups in demographics, dizziness, anxiety, depression, and psychiatric diagnoses were examined using Student's t-tests or Chi-square tests to check comparability of the two groups on these potential confounds. Mean NEO-PI-R factor and facet scores, and numbers of subjects with high, normal, or low NEO-PI-R scores were compared between groups using Student's t-tests or Chi-square tests. Factors and facets that were significantly different between groups (p b 0.05) and those with mean scores outside of population norms for either group were identified. It was not expected that any single factor or facet would discriminate strongly between groups, so composite temperaments were constructed from all possible logical (AND/OR) combinations of facets identified in these bivariate analyses. The composite temperament with the highest odds ratio (i.e., best fit model) for differentiating CSD and comparison groups was identified using simple binary logistic regression with group membership as the dependent variable, presence or absence of each composite temperament tested individually as the independent variable, and HADS-depression, which differed between groups, as a covariate. Power calculations showed that N = 40 was sufficient for this simple logistic regression analysis.

Competing interest statement Dr. Staab is Chair of the Behavioral Subcommittee of the International Committee for Classification of Vestibular Disorders of the Barany Society, which is charged with drafting diagnostic criteria for behavioral neurotologic conditions, including potential updates to definitions of CSD, PPV, and related syndromes. Drs. Rohe, Eggers, and Shepard have no competing interests to report. References [1] Staab JP. Chronic subjective dizziness. Continuum (Minneap Minn) Oct 2012;18:1118–41. [2] Staab JP, Ruckenstein MJ. Expanding the differential diagnosis of dizziness. Arch Otolaryngol Head Neck Surg 2007;13:170–6. [3] Staab JP, Ruckenstein MJ. Which comes first? Psychogenic dizziness versus otogenic anxiety. Laryngoscope 2003;113:1714–8. [4] Godemann F, Siefert K, Hantschke-Bruggemann M, Neu P, Seidl R, Strohle A. What accounts for vertigo one year after neuritis vestibularis — anxiety or a dysfunctional vestibular organ? J Psychiatr Res 2005;39:529–34. [5] Best C, Eckhardt-Henn A, Tschan R, Dieterich M. Psychiatric morbidity and comorbidity in different vestibular vertigo syndromes: results of a prospective longitudinal study over one year. J Neurol 2009;256:58–65. [6] Brandt T, Dieterich M. Phobischer Attacken-Schwank-schwindel, ein neues Syndrom? Munch Med Wochenschr 1986;28:247–50. [7] Creed F, Guthrie E. Psychological factors in the irritable bowel syndrome. Gut 1987;28:1307–18. [8] Manning AP, Thompson WG, Heaton KW, Morris AF. Towards positive diagnosis of the irritable bowel. Br Med J 1978;2:653–4. [9] Drossman DA. The functional gastrointestinal disorders and the Rome III process. Gastroenterology 2006;130:1377–90.

Results and discussion Groups were well matched on demographics, dizziness handicap, and psychological symptoms. The only significant difference was a mean HADS depression score just barely into the clinically meaningful range for patients with CSD (Table 1). Patients with CSD were more introverted and had higher trait anxiety, lower trust, and less openness to feelings than patients in the comparison group (Table 2). Composite temperaments were constructed from facets in Table 2. A temperament consisting of high trait anxiety and low excitement seeking or low positive emotion was most discriminative (Table 2), controlling for HADS-depression. Thus, patients with CSD were more likely to have a combination of neurotic and introverted personality traits than individuals with similar physical and psychological symptom burden. These traits are the converse of resilience, life satisfaction, and sense of coherence that were previously associated with a low incidence of CSD symptoms [22]. This suggests that an anxious-introverted temperament may be a risk factor for developing CSD, as appears to be the case for IBS, fibromyalgia, and NCCP [10,14–16]. In many ways, CSD is the neurotologic counterpart of these functional syndromes. Table 2 Significant NEO-PI-R factors and facets; most discriminating temperament Factors

Facets

Standardized scores (T-scores)

Between group differencesa

CSD group

Comparison group

Trait anxiety (N1)

61.1 ± 8.8b

53.9 ± 13.4

p b 0.05

Warmth (E1) Excitement seeking (E5) Positive emotion (E6)

45.3 48.2 42.7 45.7

50.8 54.1 46.3 51.7

p b 0.05 p b 0.05 n.s. p b 0.05

Openness to feelings (O3)

47.4 ± 12.6

54.6 ± 9.7

p b 0.05

Trust (A1)

48.7 ÷ 12.9

56.1 ± 11,5b

p b 0.05

High N1 plus Low E5 or E6

16 of 24 (67%) subjects

4 of 16 (25%) subjects

OR = 6.0 (95% CI = 1.5–24.7) p b 0.01

Neuroticism (N)

Extraversion (E)

± ± ± ±

8.9 8.3 8.6c 13.2

± ± ± ±

9.3 11.5 7.6 10.3

Openness (O)

Agreeableness (A)

Composite Temperament

OR = odds ratio for composite temperament. a Student's t-test for individual factors and facets. n.s. = not significant. b Above population norm (N55). c Below population norm (b45).

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