Original article
Dizziness: Anxiety, health care utilization and health behavior—: Results from a representative German community survey

https://doi.org/10.1016/j.jpsychores.2008.09.012Get rights and content

Abstract

Background

Due to the lack of epidemiological data on the relation of dizziness and anxiety, we investigated the prevalence of dizziness and anxiety in a representative sample of the German population. We explored the consequences of comorbid anxiety for emotional distress, functional impairment, health care utilization, and health behavior in dizziness.

Methods

By the end of 2006, we surveyed a total of 1287 persons between 14 and 90 years of age in their homes by trained interviewers with standardized self-rating questionnaires on anxiety (Patient Health Questionnaire, Generalized Anxiety Disorder Scale, Mini-Social Phobia Inventory) and dizziness (Vertigo Symptom Scale). The sample was representative for the German population in terms of age, sex, and education.

Results

Symptoms of dizziness were reported by 15.8% of the participants. Of the participants with dizziness, 28.3% reported symptoms of at least one anxiety disorder (generalized anxiety, social phobia, panic). Persons with dizziness reported more somatic problems such as hypertension, migraine, diabetes, etc. Comorbid anxiety was associated with increased health care use and impairment.

Conclusion

Dizziness is a highly prevalent symptom in the general population. A subgroup with comorbid anxiety is characterized by an increased subjective impairment and health care utilization due to their dizziness. Because treatment options for distinct neurotologic disorders are also known to reduce psychological symptoms, and in order to avoid unnecessary medical treatment, early neurologic and psychiatric/psychotherapeutic referral may be indicated.

Introduction

Dizziness is one of the most common complaints in medicine, affecting about 20% up to 30% of the general population [1], [2], [3], [4]. Classified as a coexisting symptom, dizziness can be observed in a large group of medical, especially neurologic and psychosomatic syndromes [5], [6]. Interestingly, extremely high rates of comorbid psychiatric disorders (30–50%) have been reported in patients presenting with vertigo and balance disorders [7], [8], [9], [10]. Investigations of the interaction of psychiatric and vestibular disorders have identified three pathogenic patterns: the otogenic (somatopsychic) hypothesis postulates that primary neurotologic conditions trigger secondary anxiety disorders. Psychogenic dizziness means that the underlying psychiatric disorder (e.g., anxiety) itself causes dizziness. The interactive hypothesis assumes that as neurotologic conditions exacerbate preexisting anxiety [5], [7], [8], [11], [12], [13]. Staab et al. [11], [14] endorsed the somatopsychic concept of phobic postural vertigo assuming that chronic (subjective) dizziness results from an anxious appraisal of neurotologic vertigo syndromes. Recent studies postulated a causal linkage between the vestibular and emotion processing system: (a) the monoaminergic inputs to the vestibular system mediate the effects of anxiety on vestibular function, (b) the parabrachial nucleus network mediates emotional responses related to vestibular dysfunction, and (c) the noradrenergic outflow from the locus coeruleus mediates the responsiveness of these symptoms to novel stimuli [15], [16], [17]. Additionally, (d) links between the vestibular, autonomic, and respiratory system are hypothesized [16].

Indeed, the coincidence of anxiety and phobic disorders in patients with primarily somatoform dizziness is reported as up to 45%. Similarly, 41% of patients with different neurotologic vertigo syndromes were reported to suffer from comorbid anxiety disorders [9], [10], [12], [13], [18]. Anxiety accompanies dizziness attacks, and dizziness is a concomitant phenomenon of fear arousal and panic attacks [13], [15], [19], [20], [21].

As most previous studies have been selectively based on patients in primary care or specialized dizziness units, epidemiological data are needed on the relation of dizziness and anxiety [5], [7]. To our knowledge, the UK primary care study [4] is the only study addressing the prevalence of dizziness and anxiety in a community sample. Yardley et al. [4] found a prevalence of dizziness of 23.3%. Nearly half of the participants experienced some handicap. Of those reporting dizziness, 46% also reported anxiety and/or avoidance. Only 13.3% of those without dizziness reported anxiety. Our study investigated the prevalence of dizziness in a representative sample of the German general population, its somatic and psychosomatic comorbidities, and their impact on health behavior and health care utilization. Considering the high comorbidity of dizziness and psychiatric disorders in the literature, we surveyed the prevalence of the different anxiety subgroups (e.g. panic disorders, social phobia and generalized anxiety disorders) and their co-occurrence with dizziness. Consistent with previous findings from the United Kingdom and the United States, we expected a high overall frequency of dizziness and a large comorbidity with anxiety and somatic complaints. We further expected dizziness to be associated with higher emotional distress, functional impairment, a higher degree of health care utilization, and dysfunctional health behavior, particularly when accompanied by comorbid anxiety disorders.

Section snippets

Questionnaires

In addition to sociodemographic data, participants filled out standardized self-report inventories. To assess anxiety, we used items of the German version of the Patient Health Questionnaire (PHQ) [22]. Generalized anxiety was assessed with the two screening items of the short form of the Generalized Anxiety Disorder 7 scale [23], [24]: “Feeling nervous, anxious or on edge” and “Not being able to stop or control worrying.” Subjects can answer these items with 0=“not at all,” 1=“several days,”

Prevalence of dizziness in the German population

A total of 201 participants (15.8 percent) reported symptoms of dizziness in the past 4 weeks. Because of incomplete data regarding comorbid anxiety we excluded n=3 from further analyses. The following results refer to the remaining 198 subjects.

Comorbidity of dizziness with generalized anxiety, social phobia, and panic

Based on the aforementioned cutoff scores of the self-rating instruments on anxiety, 56 (28.3%) of the participants with dizziness reported symptoms of at least one anxiety disorder (generalized anxiety, social phobia, or panic), compared to only 5.1%

Conclusions

In our representative sample, we found a considerable 4-week prevalence for dizziness of 15.8%; 28.3% of the dizzy persons were additionally suffering from anxiety.

Former studies described panic disorders as the most frequent psychosomatic disease underlying the development of somatoform dizziness [9], [13], [29]. The combination of unpredictable vertigo attacks and accompanying severe vegetative reactions was considered as a causative factor for anticipatory anxiety, phobic fear and social

Acknowledgment

The study was conducted without any form of external financial support.

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