Panic disorder and vestibular disturbance: An overview of empirical findings and clinical implications

doi:10.1016/S0022-3999(97)00132-3

Journal of Psychosomatic Research

Volume 44, Issue 1, January 1998, Pages 107-120

https://doi.org/10.1016/S0022-3999(97)00132-3 Get rights and content

Abstract

The purpose of this article is to provide a general overview of the growing literature on the relationship between panic disorder and vestibular disturbance. This relationship has been examined from two distinct perspectives, including: (a) the assessment of vestibular dysfunction in patients with panic disorder; and (b) the evaluation of panic symptomatology in patients with vestibular disturbance. Consequently, this review focuses primarily on the literature pertaining to vestibular symptoms in patients with panic disorder and panic symptomatology in patients with vestibular complaints. Subsequent to this review we discuss clinical implications suggested by the data, outline recommendations for treatment, and highlight some directions for future investigation.

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Visuo-vestibular contributions to anxiety and fear
2015, Neuroscience and Biobehavioral Reviews
Citation Excerpt :
In fact, panic disorder is one of the best-studied anxiety disorders and the one most often linked to a vestibular/balance dysfunction. A major interaction between vestibular/balance systems and panic disorder is well documented (e.g., Asmundson et al., 1998; Clark et al., 1994; Eagger et al., 1992; Frommberger et al., 1994; Furman and Jacob, 1997; Godemann et al., 2006, 2005; Gordon et al., 1998; Hoffman et al., 1994; Jacob et al., 1996a,b, 1985; Perna et al., 2001; Simon et al., 1998; Sklare et al., 1990; Szirmai et al., 2005; Tecer et al., 2004; Yardley et al., 1995). Furman and Jacob (2001) provide a reasonable framework for understanding psychiatric manifestations more broadly in the context of balance function (see their Fig. 2).
The interactive roles of the visual and vestibular systems allow for postural control within boundaries of perceived safety. In specific circumstances, visual vestibular and postural interactions act as a cue that trigger fear, similarly to what occurs in motion sickness. Unusual patterns of visuo-vestibular interaction that emerge without warning can elicit fear, which can then become associated to a certain stimuli or situation, creating a CS-US association, (i.e., phobia), or can emerge without warning but also without becoming associated to a particular concomitant event (i.e., panic). Depending on the individual sensitivity to visuo-vestibular unusual patterns and its impact in postural control, individuals will be more or less vulnerable to develop these disorders. As such, the mechanism we here propose is also sufficient to explain the lack of certain fears albeit exposure. Following this rationale, a new subcategory of anxiety disorders, named visuo-vestibular fears can be considered. This model brings important implications for developmental and evolutionary psychological science, and invites to place visuo-vestibular fears in a particular subtype or specification within the DSM-5 diagnostic criteria.
Cognitive behavior therapy for chronic subjective dizziness: Longer-term gains and predictors of disability
2013, American Journal of Otolaryngology - Head and Neck Medicine and Surgery
The study sought to evaluate the longer-term effects of a brief cognitive behavior therapy (CBT) intervention for patients with chronic subjective dizziness (CSD). In addition, it sought to identify predictors of longer-term disability in this group.
Forty-four patients with CSD referred by a neuro-otological clinic were followed-up six months after completing a brief treatment program based on the CBT model of panic disorder. Patients completed the following measures: Dizziness Handicap Inventory, Depression, Anxiety and Stress Scales, Dizziness Symptoms Inventory, and the Safety Behaviours Inventory. Measures were completed at pre and post-treatment, as well as at one and six months post-treatment.
Treatment gains observed immediately after treatment were maintained at one and six months post-treatment. High levels of pre-treatment anxiety predicted higher levels of disability at six months post-treatment. Duration and severity of dizziness, and medical or psychiatric comorbidity did not predict disability at six month follow-up.
A brief CBT intervention for patients with CSD produced improvements in physical symptoms, disability, and functional impairment which were sustained at one month and six months post intervention. Patients with high levels of anxiety prior to treatment had higher levels of disability at six months post-treatment. It is possible that more focused interventions that specifically target anxiety might produce further benefits for this cohort.
Validation of the French version of the situational characteristics questionnaire in the measurement of space and motion discomfort
2012, Encephale
L’inconfort spatio-moteur (ISM) est un concept englobant les différents symptômes pouvant survenir dans des situations où les informations visuelles et kinesthésiques ne permettent pas de favoriser une orientation adéquate dans l’espace. Certaines études indiquent qu’il existe des liens stables et prévisibles entre les dysfonctions vestibulaires et les troubles anxieux. Il semble donc utile au plan clinique de développer et de valider des instruments de mesure pouvant évaluer le niveau d’ISM chez des individus avec un trouble panique qui présentent également une dysfonction vestibulaire. La présente recherche porte sur la validation de la version française de l’instrument qui mesure l’ISM, le questionnaire des caractéristiques situationnelles (QCS). Des analyses de la consistance interne indiquent que les échelles ISM-I et ISM-II possèdent une bonne homogénéité. L’échelle agoraphobie démontre en revanche une plus faible consistance interne. Ces résultats sont semblables à ceux de la version originale anglaise. L’échelle ISM-I démontre une faible validité de construit, mais l’échelle ISM-II fournit une mesure adéquate du construit théorique de l’ISM. Les résultats obtenus démontrent donc que les propriétés psychométriques de l’échelle ISM-II de la version française du QCS sont adéquates. Les résultats concordent en général avec ce que la validation de la version originale du questionnaire a révélé.
Space and motion discomfort (SMD) refers to various symptoms that occur in environments with unreliable visual and kinesthetic information that do not permit adequate spatial orientation. Some studies have demonstrated that there is a stable and predictable relationship between vestibular dysfunction and anxiety disorders. Further, vestibular dysfunction can predispose or trigger the development of panic disorder with or without agoraphobia (PD/A) or reinforce phobic avoidance. It therefore seems clinically useful to develop and validate instruments for evaluating SMD in various populations. Measuring SMD could facilitate identification of individuals with PD/A who present comorbid vestibular dysfunction. Jacob et al. developed and validated such a questionnaire: the Situational characteristics questionnaire (SitQ). This questionnaire evaluates the presence of symptoms such as dizziness, vertigo, and instability under specific conditions. The SitQ comprises two subscales that measure SMD and one subscale (agoraphobia) that measures agoraphobic avoidance behaviours. The instrument has two sections. The first section is composed of the SMD-I and agoraphobia subscales, containing 19 and seven items, respectively. Each item consists of two contrasting descriptors of a specific situation or environment. The respondent is required to indicate to what extent the two described situations or environments cause discomfort. Each item includes a “criterion” descriptor for the situation (i.e., a descriptor that is presumed to engender SMD) and an alternative (non-criterion) descriptor. The second section comprises the SMD-II scale; this scale is composed of nine criterion situations, for which non-criterion situations are not supplied. The instrument takes approximately 20 minutes to complete.
The present study focuses on the validation of the French-language version of the SitQ: the questionnaire des caractéristiques situationnelles (QCS).
The sample was composed of French Canadians recruited across Quebec from an anxiety disorders treatment clinic, general psychiatric care clinics, a community organization for individuals with anxiety disorders, advertisements in local newspapers, and ads posted in various public locations. The sample included 141 participants who met the criteria for lifetime PD/A. Participants reported current PD/A (n = 73) or PD/A in remission (n = 68). The control sample was recruited from undergraduate courses in various disciplines. Two hundred and thirty-five (n = 235) students completed the questionnaires. Data from 63 (26.8%) participants were excluded from the analyses due to failure to complete all of the research questionnaires.
Analysis of the global descriptive data and the descriptive data for each dependent variable revealed that the data were independent of sociodemographic variables and respected the assumptions of normal distribution (skewness and kurtosis). Parametric tests were subsequently conducted. Using the combined data from the control and clinical groups, the internal consistency of the scales was analyzed using Cronbach's alpha. The SMD-I and SMD-II scales demonstrated good homogeneity. The results were comparable or superior to those obtained with the English-language version of the questionnaire. The agoraphobia scale demonstrated weaker internal consistency and corresponding weaker homogeneity. This result was consistent with that of the original version of the agoraphobia scale; this scale was eliminated for the subsequent analyses. Construct validity was analyzed via t-tests comparing clinical and control groups. Effect sizes were estimated using percentage of variance explained. The SMD-I scale demonstrated weak construct validity and was also eliminated from subsequent analyses. The SMD-II scale demonstrated good construct validity and provided an adequate measure of the theoretical construct of SMD. This scale permitted discrimination of participants according to the presence or absence of PD/A. It is therefore possible to identify participants with PD/A by their level of SMD. This result is comparable to that of Jacob et al.
The results of the present study are generally consistent with the results of the validation of the original version of the questionnaire. However, the SMD-I and agoraphobia scales in the French-language version of the measure did not achieve a level of significance sufficient to definitively establish validity.
Behavioral models for anxiety and multisensory integration in animals and humans
2011, Progress in Neuro-Psychopharmacology and Biological Psychiatry
Complaints related to dizziness, balance problems and spatial disorientation in psychiatry have seldom been considered as a possible manifestation of a distorted multisensory integrative ability. Several kinds of mismatches among simultaneous sensory information are encountered in everyday life but despite these, the central nervous system usually manages to update the internal representation of the body in the surrounding space. In some cases, a sensory mismatch may elicit an erroneous perception of the body in space, resulting in anxiety, dizziness and balance problems.
As vestibular system dysfunction leads to dizziness and disorientation, it has been hypothesized that a peripheral vestibular abnormality could explain the presence of certain symptoms related to sensory mismatches in anxiety disorders. Several studies tried to find a link between panic disorder with or without agoraphobia and vestibular system dysfunction. Yet, even though some vestibular abnormalities have been demonstrated in these patients, it is difficult to demonstrate a cause-and-effect relationship between panic disorder and vestibular dysfunction. However, this does not rule out a possible influence of anxiety on normal vestibular function. The study of the relation between vestibular system and anxiety has to take into account that the vestibular system has three main functions: to maintain equilibrium through the vestibular spinal reflexes; to stabilize the visualization of the world through the vestibular-ocular reflex; to contribute to perception and orientation in space.
We will review different studies in humans, which have particularly paid attention to the third function and its relation to anxiety. Animal experiments offer possibilities to more precisely analyze the different parameters underlying the behavioral results, as well as possible pharmacological actions on them. Two attempts have been made by our group to model, in mice, the preceding human data on integrated functional sensory relations of the body to space in anxiety disorders: the rotating beam and the rotating tunnel. We summarize here the main results obtained.
Is there a hypersensitive visual alarm system in panic disorder?
2011, Psychiatry Research
Citation Excerpt :
Although these theories do not completely overlap, they share the idea that hypersensitivity in alarm systems triggered by stimuli plays a key role in the pathogenesis of PD and related phobic conditions. Patients with PD and agoraphobia often show a high sensitivity to complex sensorial environments (shopping malls, traffic, crowds) where they experience dizziness and discomfort (Jacob et al., 1993; Asmundson et al., 1998). Most studies showed that these patients do not have specific vestibular diseases but have subclinical abnormalities of the balance system and that their balance control relies mainly on non-vestibular cues, propioceptive or mostly visual (visual dependence) (Jacob et al., 1995, 1997; Asmundson et al., 1998; Perna et al., 2001; Staab, 2006).
Agoraphobia in panic disorder (PD) has been related to abnormal balance system function. Vision influences balance and behavioural adaptations; peripheral vision influences orienting and fast defensive reactions whereas central vision analyzes details of objects. We have hypothesized that the abnormal balance function in PD could be mainly related to peripheral vision as part of a defensive alarm system in the brain. In 25 patients with PD and agoraphobia and 31 healthy controls we assessed, by posturography, balance system reactivity to video-films projected in peripheral and central visual fields (randomized sequence). Length, velocity and surface of body sway were calculated. Patients increased their body sway during peripheral stimulation, whereas controls did not; the two groups showed a similar increase of body sway during central stimulation. Anxiety levels during peripheral stimulation significantly influenced the postural response in the group of patients. These preliminary results suggest that the higher visual sensitivity to peripheral stimulation in patients with PD and agoraphobia may be linked to a more active “visual alarm system” involving visual, vestibular and limbic areas that might influence the development of agoraphobia in situations where environmental stimuli are uncertain.
A Study of the Psychological Characteristics Related to the Degree of Disability in Daily Life Caused by the Subjective Symptom of Dizziness in Various Diseases Associated with Dizziness
2023, Equilibrium Research

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ReviewPanic disorder and vestibular disturbance: An overview of empirical findings and clinical implications

Abstract

Behav Res Ther

Am J Cardiol

Behav Res Ther

Psychosomatics

Behav Res Ther

J Anx Disord

Behav Res Ther

Comp Psychiatry

Lancet

J Psychosom Res

J Psychosom Res

J Anx Disord

Behav Res Ther

J Psychosom Res

Diagnostic and statistical manual of mental disorders

Suicidal ideation and suicide attempts in panic disorder and attacks

New England J Med

Functioning and well-being of patients with panic disorder

Am J Psychiatry

Alcohol use and abuse among diagnosed agoraphobics

Behav Res Ther

Suicidal ideation and suicide attempts in panic disorder and social phobia

Am J Psychiatry

Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey

Arch Gen Psychiatry

Panic disorder in cardiac out-patients

Am J Psychiatry

Prevalence of panic in patients referred for pulmonary function testing at major medical center

Am J Psychiatry

Psychiatric illness in irritable bowel disease

Am J Psychiatry

Vestibular symptoms, panic and phobia: overlap and possible relationships

Ann Clin Psychiatry

On agoraphobia in relation to ear disease

Laryngoscope

Some historical aspects of the concept, phobia

Psychiatry Q

Phenomenology of panic attacks: a descriptive study of panic disorder patients' self-reports

J Clin Psychiatry

Anxiety and its disorders: the nature and treatment of anxiety and panic

The symptom structure of panic attacks in depressed and anxious patients

Can J Psychiatry

Panic attacks in the natural environment

J Nerv Ment Dis

The latent structure of anxiety symptoms in anxiety disorders

Am J Psychiatry

Review
Panic disorder and vestibular disturbance: An overview of empirical findings and clinical implications