Psychological distress longitudinally mediates the effect of vertigo symptoms on vertigo-related handicap
Introduction
Vertigo and dizziness are interconnected body-related symptoms that affect between 20% and 56% of the general population (e.g., [4], [25], [49]). They are among the most common symptoms in primary care (e.g., [17], [23], [45]) and are associated with disabilities/handicap in daily life [20], [52], [57]. However, the severity of vertigo symptoms was only moderately correlated with the degree of vertigo-related handicap in previous studies (e.g., [12], [52], [56]). This implies that not all patients suffering from symptoms develop handicap. In order to prevent patients from being handicapped by the symptoms, it is essential to know the mechanisms underlying the process how symptoms lead to handicap. To explore such mechanisms, mediation analysis appears to be a promising approach, since a mediator is a variable that contributes to the relationship between one variable X and another variable Y. Psychological distress might be a relevant mediator between vertigo symptoms and vertigo-related handicap, because psychological distress related to anxiety, depression, and somatization is frequently associated with symptoms of vertigo as well as with vertigo-related handicap (e.g., [3], [9], [29], [31], [40], [47], [54], [55], [56]).
Psychological distress can result from the experience of vertigo/dizziness symptoms. Staab [46] described a shift in attentional strategies after an acute stage of vertigo including heightened vigilance to environmental factors in order to reduce risks as well as increased checking and monitoring of bodily sensations related to dizziness. Such a distorted awareness of somatic sensory stimuli (somatosensory amplification; [2]) might contribute to the links between vertigo/dizziness and (a) somatoform disorders [3], [31] as well as (b) anxiety disorders [1], [10], [11], [21], [22]. Supporting this line of argumentation, alarming body- and panic-related thoughts after (but not at the acute stage of) vestibular neuritis predicted the subsequent development of panic and somatoform disorders [14]. In related work, Godemann and colleagues reported that anxiety, catastrophic thoughts, and dependent personality traits (but not sub-clinical organic changes) account for the persistence of (chronic) vertigo/dizziness symptoms after vestibular neuritis [13], [15]. Protective psychological factors such as resilience and sense of coherence, however, minimized the chance to suffer from (functional/psychiatric) vertigo/dizziness symptoms 1-year after (structural/metabolic) vestibular diseases [50]. In another 1-year follow-up study, Nakao and Yano [37] showed that dizziness at baseline significantly predicts depressive disorders during the following year. A further study reported that new depressive and anxiety disorders are triggered by neurotologic conditions in 33% of the patients [48]. Although psychological distress has been found to be more prevalent after than before vertigo/dizziness [8], psychological distress can also cause vertigo/dizziness. Kroenke et al. [24] reported that psychiatric disorders are the primary cause of vertigo/dizziness in 16% of the patients. Staab and Ruckenstein [48] found that anxiety (in 33% of the cases), but not depression can cause vertigo/dizziness.
Despite the relevance of anxiety, depression, and somatization in vertigo/dizziness patients, their specific contributions to the process how vertigo symptoms lead to vertigo-related handicap remain unclear. Only a recent 12-month follow-up study found anxiety and pain as mediators between dizziness and falls (one specific vertigo-related handicap) in older people [35]. Therefore, the current study investigated whether psychological distress related to depression, anxiety, and somatization longitudinally mediates the symptom-handicap link by evaluating the follow-ups of a large study with patients of a treatment center specialized in vertigo/dizziness [28], [29]. The hypotheses were that anxiety is a significant mediator because this was the case in the above-mentioned study with elderly patients [35] and also that depression is a significant mediator because this was found in studies in the area of pain [30]. No specific hypothesis was made regarding somatization, because no study was found that investigated somatization as a mediator between symptom severity and handicap.
Section snippets
Study design
Patients with vertigo/dizziness were assessed at three assessment points in this naturalistic study: t0 = baseline, t1 = 6-month follow-up, and t2 = 12-month follow-up. The study was approved by the Ethics Committee of the University of Munich. See Lahmann et al. [28] for a detailed description of the study design. The delivery of a specific treatment was not part of this study, but the patients were allowed to start/stop any treatment during the study period.
Patients
Patients were recruited at a Center for
Results
First, the results of the comparisons between the patients that were included in the present study and the patients that had to be excluded due to incomplete data will be presented. Then, the course of psychological distress during the study and the Pearson correlation coefficients between the measures used in the mediation models (vertigo symptoms at t0, psychological distress at t1, and vertigo-related handicap at t2) will be reported. Finally, the results of the four mediation analyses will
Discussion
Depression, anxiety, and somatization were explored as mediators in the relationship between vertigo symptoms and vertigo-related handicap in this longitudinal study with vertigo/dizziness patients. Vertigo symptoms were measured at baseline (t0), depression, anxiety, and somatization were assessed at 6-month follow-up (t1), and vertigo handicap were evaluated at 12-month follow-up (t2).
Single mediation models revealed that depression, anxiety, as well as somatization mediated the effect
Funding
Parts of this project were supported by funding from the German Federal Ministry of Education and Research (01 EO 0901). The authors bear full responsibility for the content of this publication.
Conflict of interest
The authors declare that there is no conflict of interests.
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