Persisterande postural Perceptuell Yrsel 3 PY Mikael Karlberg

Persisterande postural. Perceptuell Yrsel : 3 PY Mikael Karlberg Neuro-otologist “oto-psychiatrist” Dept of Oto-rhino-laryngology Lund University Hospital Lund, Sweden

2 ben = ångest? Visst mått av osäkerhet inbyggt i det tvåbenta ståendet Bottom-up?

Ångest = osäkerhet? Vid ångestsjukdomar påverkas ståendet av osäkerheten (flightfreight? ) Top-down? Psykogen yrsel?

. balance

Emergency department (USA) 100 chronic dizziness patients 50% vestibular 25% “psychogenic” 25% misc. Kroenke et al Dizziness clinic (München) 4214 patients 1989 -2002 BPPV 19% Phobic postural vertigo 16% CNS vestibular 13% Vestibular migraine 9% Vestibular neuritis 8% Meniéres diseaese 7% Strupp & Brandt

SSRI (sertraline -Zoloft- 25 -150 mg/day) Good clinical effect on dizziness +/- vestibular disorder +”minor – major” psychiatric condition Staab JP et al 2002 Good clinical effect in ”chronic subjective dizziness” Staab JP et al 2004 No double-blind placebo controlled studies!

Neuroanatomy dizziness – anxiety after Balaban & co-workers Limbic system (hippocampus) anxiety / conditioning vestibulo-parabrachial nc network coeruleo-vestibular network Raphe nc – vestibular network adrenergic system arousal serotoninergic system? cortex: orientation oculo-motor SSRI discontinuation syndrome postural muscles autonomic reflexes: cardio-vascular/respiratory/gastro-intestinal

50 -years old man, road builder Meniere´s disease sick-leave > 2 years gentamicin treatment at ”St Elsewhere” not better, referred to Lund deaf on treated ear vestibular function almost lost on treated ear many attacks every week What to do? ?

gentamicin injection x 6!!!! ”dead” ear Attacks continue!!! What to do? ?

Careful ”analysis of attacks” = conditioned panic/anxiety attacks! (I had not started using HADS questionnaire) sertraline 25 mg x 1 increased by 25 mg every week

after 1 month 50% work after 2 months full time work After 1 year, sertraline (100 mg/day) everything OK, full time work (As far as I know he continued on sertraline and I have not seen him for many years!) H 81. 0 Meniere F 41. 2 anxiety + depression

32 -years old woman, teacher previously healthy acute vertigo/dizziness in shopping mall chronic dizziness, nausea, fatigue All tests normal 100% sick-leave

3 months later referred Normal: neurotologic examination audiometry, vestibular tests, neuroradiology No anxiety / depression (HADS) What to do?

Vestibular rehabilitation Cognitive behavioural therapy Slowly back to work 50% - 75% (dizzy, tired) Reluctant to try SSRI!

June 2008 (3, 5 years after onset of symptoms) and end of spring semester ”OK! You have talked me into it! Let´s try SSRI!” escitalopram 5 mg x 1 i 2 weeks, then 10 mg x 1

After 2 months: ”I feel 95% better!!!!” ”as comparing a bilateral pneumonia with a slight common cold” Continues on escitalopram and feels worse when she tries to stop or decrease the dose! Diagnosis? F 45. 8 Other specified somatization syndrome?

57 years-old man, travelling mechanic hypertonia, cervical disc hernia: neck pain November 2009: acute vertigo on scaffolding Attacks of vertigo/dizziness, nausea, headache. 0 audiological symptoms GP, ENT, Neurologist, MRI, EEG: normal Long-time sick-leave 100%. (Works at heights: ladders, scaffoldings…). June 2010 referred to our balance clinic

2010 -10 -07: calorics, subjective visual vertical, audiometry: normal HADS: 14 anxiety, 6 depression ”Fully investigated somatically”. Sertraline 50 mg 1/2 x 1 2010 -10 -21 Telephone. Feels better 2010 -11 -18 Telephone. Sertraline 50 mg x 1. Feels fine. Works 100%. GP follow-up. R 42. 9 Dizziness NUD F 41. 2 Anxiety and depression

Of the very few Meniere patients (7 in 15 years!!) who were not cured by gentamicin but had a labyrintectomy 6 of 7 patients needed SSRI in order to return to work!!! (Don´t do anything ”drastic” until your Meniere patient has tried SSRIs in slowly increasing doses for at least 3 months!!)

”Loved child has many names” Psychogenic vertigo = panic syndrome +-agoraphobia Phobic postural vertigo Brandt et al Space and motion dyscomfort/intolerance/phobia Jacobs et al Visual vertigo Bronstein et al Chronic subjective vertigo Staab et al Persistent Postural–Perceptual Dizziness “ 3 PD” International consensus (Persisterande Postural Perceptuell Yrsel 3 PY)

Chronic subjective vertigo Staab JP, 2006 = 3 PD Subjective dizzines/unsteadiness: daily Hypersensitivity to movement: own movement or movement of the surroundings Visual vertigo: symptoms worse in complex visual surroundngs or during visual precision work (computer, reading etc. ) No active neurootologic disorder: history: BPPV, vestibular neuritis? Normal neuroradiology: MRI Vestibular testing: non-diagnostic findings Duration > 3 months

Phobic Postural Vertigo (T Brandt) History / Criteria • Dizziness / unsteadiness while standing / walking (normal balance tests) • Short attacks of vertigo / unsteadiness • Anxiety / vegetative symptoms during or after attacks (not always) • Attacks associated with specific places or situations • Avoidance behaviour / generalisation • ”Obsessive-compulsive” personality / mild depression Onset after a period of illness, usually a vestibular disorder! (vestibular neuritis BPPV PPV)

Easy to diagnose? Diagnosis by exclusion + some specific hints

Posturography!!!! rare differential diagnosis: primary orthostatic tremor

10 15 Power spectral density Patient 3 0 5 10 15 Power spectral density 5 10 15 0 25 Hz 20 Patient 5 0 Power spectral density 20 20 5 10 15 20 Hz Patient 4 Primary orthostatic tremor -unsteady while standing -better walking around or sitting down 025 Hz 5 10 15 20 Hz Patient 6 025 Hz 5 10 15 20 Healthy subject Power spectral density 5 Power spectrum analysis of posturographic recordings Power spectral density 0 Patient 2 Power spectral density Patient 1 0 25 Hz 5 10 15 20 Hz

Easy to treat? Investigation + explanation self-treatment ”exposition in vivo” anti-depressants / physiotherapy 75% long-time improvement Huppert et al 2005

vestibular disorder, ”stress”, personality – “control” unknown distorted proprioception dizziness fear of falling hypervigilance for postural control muscular tension/ fatigue / pain high frequency sway chronic dizziness generalized anxiety chronic pain syndromes mis- interpretation of body sway reduced sway area by muscular co-contraction = “avoidance behaviour”

PPV is harder to treat by CBT as compared to specific phobias and panic disorder Multi-disciplinary assessment and treatment (SSRIs, CBT, physiotherapy) Holmberg J et al

Retrospective review and telephone follow-up to evaluate a physical therapy protocol for treating persistent posturalperceptual dizziness: A pilot study. Thomsen KJ et al. J Vestib Res 2015 26 pat med 3 PD Vestibulär rehab: egenträning Telefonuppföljning efter ca 2 år 14 upplevde positiv effekt 4 av dem besvärsfria 12 upplevde ingen positiv effekt

Clinical characteristics of patients with persistent postural-perceptual dizziness. Bittar RS & Lins EM. Braz J Otorhinolaryngol 2015 81 patienter med 3 PD Kvinnor / Män: 5. 7 / 1 Hyperkolesterolemi: 31% Migrän 26% Diabetes 22% Cervikalt syndrom? 21% Signifikant högre score än friska i: DHI State-Trait Anxiety Inventory Beck Depression Inventory HADS SSRI-behandling: 68% kliniskt förbättrade

Persistent Postural-Perceptual Dizziness: A Matter of Higher, Central Dysfunction? Holle D et al. PLo. S One. 2015 27 patienter med 3 PD Blinkreflex 27 friska matchade kontroller Habituering av reflex: 1: a vs 10: e blocket av reflex x 5

Persistent Postural-Perceptual Dizziness: A Matter of Higher, Central Dysfunction? Holle D et al. PLo. S One. 2015 27 patienter med 3 PD Blinkreflex 27 friska matchade kontroller Habituering av reflex: 1: a vs 10: e blocket av reflexx 5 3 PD signikant lägre reflexhabituering ”Multisensorisk dimension av störd sensorisk processorering hos 3 PD: mer än bara vestibulär / visuell / postural” Liknande fynd hos patienter med migrän eller kroniska smärtsyndrom (Kanske var ”spänningsyrsel” rätt beteckning? )

How do we find these patients? 1. Knowledge! The importance of the ”soul” for balance disorders 2. Measure levels of depression / anxiety! Hospital Anxiety and Depression Scale Zigmond & Snaith, 1983 14 questions with four alternatives: 0 – 3 p / question 7 questions related to anxiety 7 questions related to depression 8 -11 points = mild anxiety/depression (borderline) >11 points = clinical anxiety/depression (case) http: //www. hqlo. com/content/1/1/29

Take home message!!! Long standing (>3 months) unclear dizziness: Thorough investigations incl. MRI and HADS Explain mechanisms behind PPV! Self-treatment: vestibular rehab / CBT Discuss test treatment with SSRI! Or suggest the referring doctor / primary care doctor! (call it serotonin modulating medicine) sertraline 50 mg ½ x 1 citalopram 10 mg ½ x 1 Increase ½ pill every second week Follow-up (telephone) after 1 -2 weeks

Anyone for a double-blind placebo-controlled study of SSRIs for persistant postural perceptive dizziness?

Vestibulär migrän Propranolol and venlafaxine for vestibular migraine prophylaxis: A randomized controlled trial. Salviz M et al. Laryngoscope 2015 64 patienter med definitiv vestibulär migrän 33 propranolol 31 venlafaxin DHI VSS Beck anxiety Beck depression Signifikant positiv effekt på alla variabler! (t ex antal attacker minskade från 12 till 2) Ingen skillnad mellan propranolol / venlafaxin Sign minskad depression med venlafaxin antal attacker

Fixed combination of cinnarizine and dimenhydrinate in the prophylactic therapy of vestibular migraine: an observational study. Teggi R et al. Neurol Sci. 2015 22 patienter med definitiv vestibuär migrän 11 patienter T Arlevert 20 mg x 2 11 patienter livsstilsförändringar vid migrän Antal attacker yrsel / huvudvärk 6 månader före och 6 månader under behandling Arlevert: Yrsel 5. 3 – 2. 1 Livsstil: Yrsel 3. 5 – 2. 2 HV 4. 3 – 1. 7 HV 2. 6 – 2. 0 2/3 av Arlevertpatient erhöll >50% reduktion av attacker