Anxiety Disorders: Ruckenstein MJ

Ruckenstein MJ, Staab JP. · Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Health System, 3400 Spruce Street, 5 Silverstein, Philadelphia, PA 19104, USA. · Otolaryngol Clin North Am. · Pubmed #19134491 No free full text.

Abstract: This article reviews the authors' work, which expands on previous studies to confirm that anxiety-related processes cause or maintain symptoms of dizziness. Discussed are interventions directed at patients' underlying psychologic disorders, including current methods of pharmacotherapy and psychotherapy. Patients with chronic complaints of nonspecific dizziness can present frustrating diagnostic and therapeutic challenges, but can be offered definitive and palliative care. The authors emphasize the importance of eliciting a precise description of the dizziness sensation from the patient as the critical factor in delineating the specific diagnosis and guiding treatment.

Staab JP, Ruckenstein MJ, Amsterdam JD. · Department of Psychiatry, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA. · Laryngoscope. · Pubmed #15475796 No free full text.

Abstract: 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, Ruckenstein MJ. · Department of Psychiatry, University of Pennsylvania Health System, Philadelphia, Pennsylvania 19104, USA. · Otol Neurotol. · Pubmed #17514065 No free full text.

Abstract: OBJECTIVE: The goals of this study were to validate the clinical diagnosis of autonomic dizziness as a cause of chronic nonvertiginous dizziness that may be exacerbated by physical exertion or orthostatic challenges, estimate its prevalence in a tertiary referral population, and investigate the usefulness of three autonomic challenges as objective tests for this condition. STUDY DESIGN: Laboratory investigation of autonomic activity. SETTING: Tertiary care balance center. PATIENTS: Fifteen men and women with symptoms indicative of autonomic dizziness. Subjects with other causes of dizziness, histories of syncope, or psychiatric disorders were excluded. INTERVENTIONS: Autonomic tests included 45 minutes of head upright tilt (HUT), 20 minutes of 5% CO2 inhalation and then HUT, and 2 minutes of voluntary hyperventilation and then HUT. MAIN OUTCOME MEASURES: Patterns of cardiovascular and respiratory responses and subjective ratings of dizziness, autonomic symptoms, and anxiety during autonomic challenges. RESULTS: Twelve subjects had evidence of autonomic dysfunction, including 10 with abnormal heart rate, blood pressure, or respiratory responses to HUT. Two other subjects had prolonged hypocarbia after voluntary hyperventilation. Many of these abnormalities would have been missed by current autonomic testing paradigms. In one subject, CO2 inhalation revealed latent anxiety. In two subjects, the presence of high symptom ratings without objective autonomic dysfunction prompted a successful search for other diagnoses. CONCLUSION: Study results validated the clinical syndrome of autonomic dizziness. Autonomic testing protocols may have to be updated to detect clinically relevant abnormalities in patients with dizziness.

Staab JP, Ruckenstein MJ. · Department of Psychiatry, The Balance Center, University of Pennsylvania Health System, Philadelphia, PA, USA. · Arch Otolaryngol Head Neck Surg. · Pubmed #17309987 links to  free full text

Abstract: OBJECTIVE: 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. DESIGN: Prospective cohort study from 1998 to 2004. SETTING: Tertiary care balance center. PATIENTS: 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. INTERVENTIONS: Patients were systematically directed through multiple specialty examinations until definitive diagnoses were made. MAIN OUTCOME MEASURE: Final diagnoses associated with dizziness. RESULTS: 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. CONCLUSIONS: 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.

Staab JP, Ruckenstein MJ. · Department of Psychiatry, The Balance Center, University of Pennsylvania, Philadelphia, USA. · Arch Otolaryngol Head Neck Surg. · Pubmed #16103297 links to  free full text

Abstract: OBJECTIVE: To investigate the hypothesis that the efficacy of selective serotonin reuptake inhibitors (SSRIs) for chronic subjective dizziness (CSD) and anxiety depends on the longitudinal pattern of the patients' symptoms. DESIGN: Prospective cohort study. SETTING: Tertiary care, multidisciplinary, balance center. PATIENTS: Eighty-eight consecutive patients treated with an SSRI for CSD and anxiety between 1998 and 2003. All patients were referred for evaluation of unremitting dizziness. They entered SSRI treatment after comprehensive neurotologic and psychiatric evaluations revealed a syndrome of CSD with accompanying anxiety. Patients were separated into 3 groups according to their longitudinal patterns of illness: (1) otogenic, defined as primary neurotologic conditions triggering secondary anxiety disorders; (2) psychogenic, defined as anxiety disorders alone causing dizziness; and (3) interactive, defined neurotologic conditions exacerbating preexisting anxiety. INTERVENTIONS: Patients with CSD were treated with an SSRI according to an established protocol for at least 8 weeks or until they proved intolerant to medication. MAIN OUTCOME MEASURES: Changes in dizziness and anxiety as measured by the Clinical Global Impressions-Improvement scale. RESULTS: Patients with the otogenic and psychogenic patterns of illness had a more complete response to SSRI treatment than did patients in the interactive group (P<.01). Rates of SSRI intolerance were similar for all 3 groups. CONCLUSIONS: Selective serotonin reuptake inhibitors are effective for patients with CSD and anxiety. However, patients with clinically significant anxiety predating neurotologic illness may require more intensive interventions.

Staab JP, Ruckenstein MJ. · Department of Psychiatry, Hospital of the University of Pennsylvania, Founders Pavilion F11.015, 3400 Spruce Street, Philadelphia, PA 19104, USA. · Laryngoscope. · Pubmed #14520095 No free full text.

Abstract: SUMMARY: OBJECTIVE To investigate the hypotheses that physical neurotologic conditions may trigger anxiety disorders (otogenic pattern of illness), that psychiatric disorders may produce dizziness (psychogenic pattern), and that risk factors for these syndromes may be identified.STUDY DESIGN Retrospective review of all patients (N = 132) treated at a tertiary care balance center from 1998 to 2002 for psychogenic dizziness with or without physical neurotologic illnesses.METHODS All patients underwent comprehensive neurotologic and psychiatric evaluations with attention to the longitudinal course of symptoms and risk factors for psychopathology. Patients were grouped according to the condition first causing dizziness. Risk factors were compared across groups.RESULTS Three equally prevalent patterns of illness were found: anxiety disorders as the sole cause of dizziness (33% of cases), neurotologic conditions exacerbating preexisting psychiatric disorders (34%), and neurotologic conditions triggering new anxiety or depressive disorders (33%). Panic disorder and agoraphobia were significantly more prevalent than less severe phobias in the first two groups, whereas the opposite pattern existed in the third group (P <.0001). More patients in the first two groups had risk factors for anxiety disorders (P <.05). Depression was not a primary cause of dizziness in any patient. Vestibular neuronitis, benign paroxysmal positional vertigo, and migraine were the most common neurotologic conditions.CONCLUSIONS These data support the hypothesis that physical neurotologic conditions may trigger psychopathology as often as primary anxiety disorders cause dizziness. A third pattern appears to be equally common wherein physical neurotologic conditions exacerbate preexisting psychiatric illnesses. Individuals at risk for anxiety disorders may be more likely to have primary psychopathology.

Staab JP, Ruckenstein MJ, Solomon D, Shepard NT. · Department of Psychiatry and The Balance Center, University of Pennsylvania Health System, Philadelphia, Pennsylvania 19104, USA. · Laryngoscope. · Pubmed #12172243 No free full text.

Abstract: OBJECTIVES: To define the clinical characteristics and treatment of dizziness induced by physical exertion and to investigate autonomic nervous system function in exertional dizziness. STUDY DESIGN: Retrospective case series from a review of 1400 patients evaluated for dizziness at a neurotology referral center, identifying those with predominantly exertional symptoms. METHODS: Records of patients with exertional dizziness were screened to eliminate those with known vestibular deficits, cardiopulmonary illnesses, and psychiatric disorders. The clinical characteristics, evaluation results, and treatment of nine patients with purely exertional dizziness were described. RESULTS: The cohort included 4 male and 5 female patients (age range, 13-53 y) with symptoms for 1 to 8 years. Only one patient had a history of autonomic symptoms: phlebotomy-induced syncope in childhood. No patient was taking medications that caused dizziness or orthostasis. All patients experienced "spacey" or "foggy" head sensations without vertigo during exertion. Provocative activities ranged from standing upright for extended periods to running and swimming. On examination, voluntary hyperventilation provoked moderate symptoms in all patients (without nystagmus or anxiety), although no patient had spontaneously occurring, hyperventilation-related complaints. Seven patients underwent autonomic testing. Tilt table tests (n = 5) produced severe symptoms in one patient and mild symptoms in two patients. Sodium lactate infusions (n = 6) provoked marked symptoms in four patients and moderate symptoms in one patient. All were treated for autonomic dysregulation. Seven patients improved substantially and resumed all of their premorbid activities. Two improved slightly. CONCLUSIONS: In nine patients with exertional dizziness, autonomic challenges were provocative, and medications for autonomic dysregulation were effective. Exertional dizziness may be a clinical manifestation of autonomic nervous system dysregulation.

Staab JP, Ruckenstein MJ, Solomon D, Shepard NT. · Department of Psychiatry, Hospital of the University of Pennsylvania, Founders Pavilion, F11.015, 3400 Spruce St, Philadelphia, PA 19104, USA. · Arch Otolaryngol Head Neck Surg. · Pubmed #12003587 links to  free full text

Abstract: OBJECTIVE: 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. DESIGN: 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. SETTING: Tertiary care, multidisciplinary referral center. PATIENTS: 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. INTERVENTIONS: Open-label treatment with an SSRI titrated to 1 of 3 end points: optimal clinical benefit, intolerable adverse effects, or no therapeutic response. MAIN OUTCOME MEASURE: Change in dizziness and psychiatric symptoms measured by the 7-point, clinician-rated, Clinical Global Impressions-Improvement Scale. RESULTS: 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. CONCLUSIONS: 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.