Influence of beliefs about the consequences of dizziness on handicap in people with dizziness, and the effect of therapy on beliefs

Abstract

Objective: To determine the longitudinal relationship between beliefs about the consequences of dizziness and handicap levels in dizzy patients, and the effect of therapy on beliefs. Methods: Symptoms, beliefs, and handicap were assessed at baseline and 6 months follow up in 76 primary care patients complaining of dizziness or vertigo, of whom 33 were assigned to treatment (i.e., vestibular rehabilitation). Results: At baseline most patients believed that dizziness would have negative consequences such as falling, fainting, or losing control. Handicap levels at follow-up were predicted by baseline beliefs that dizziness would have negative consequences. Significant reduction in negative beliefs at follow-up was observed in the patients who received treatment, whereas there was no reduction in negative beliefs in the untreated patients. Conclusions: Negative beliefs about the consequences of dizziness sustain long-term restriction of activity, and can be modified by therapy.

Introduction

Beliefs about illness (also known as symptom perceptions, cognitions, or attributions) may have an important influence on coping behavior. Qualitative research and clinical experience suggests that beliefs about dizziness (including anticipation of severe symptoms, sinister disease, falling, physical harm, and social embarrassment) may lead to avoidance of a range of physical and social activities [1], [2], [3], [4], [5], [6]. In a questionnaire study, beliefs that dizziness would lead to loss of control were correlated with handicap (i.e., restriction of normal day-to-day activities) after controlling for levels of somatic symptoms [7]. However, owing to the cross-sectional design of this study it was not possible to ascertain whether negative beliefs about dizziness preceded and caused restriction of activity.

If beliefs about dizziness motivate avoidance of physical activity, then recovery may be retarded, and both symptoms and handicap indefinitely prolonged [7]. Exercise therapy for balance disorders that cause dizziness consists of making movements that stimulate the vestibular organs and provoke dizziness, thus providing the balance system with the repeated exposure to movement necessary to achieve neurological adaptation [2], [3], [8], [9]. Although developed as a form of physiotherapy, exercise therapy contains many implicit psychological elements. The requirement to repeatedly make physical movements that initially provoke dizziness resembles the technique of interoceptive exposure to feared sensations that is used to promote psychological habituation to physical symptoms [10]. Cognitive restructuring of beliefs about dizziness is likely to occur as a result of explanations of balance system function, while deliberate self-induction of dizziness by physical movement may act as a behavioral experiment that builds confidence that movement-provoked dizziness is predictable, tolerable, and controllable [8], [9], [11]. If psychological factors make a significant contribution to patient recovery, the benefits of exercise therapy might be enhanced by augmenting these implicit psychological elements. It is therefore important to determine to what extent beliefs about dizziness play a causal role in prolonging handicap in dizzy patients.

The analyses presented here draw on previously unpublished data collected as part of the assessment of a randomized controlled trial of exercise therapy for dizziness in primary care. Details of the outcome and physical assessments are reported elsewhere [12]. There was significant improvement in the treated relative to the untreated group on five outcome measures (physical and psychological symptoms, movement-provoked symptoms, handicap, and objective balance). The aims of the analyses reported below were (a) to determine whether beliefs about dizziness had a longitudinal influence on handicap and (b) to determine whether beliefs were changed by rehabilitation.