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| ORIGINAL ARTICLE |
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| Year : 2019 | Volume
: 25
| Issue : 2 | Page : 78-80 |
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Illness behavior among patients with medically unexplained dizziness
Geetha Desai1, Jagdish Chaturvedi2, Santosh K Chaturvedi1
1 Department of Psychiatry, NIMHANS, Bengaluru, Karnataka, India
2 Department of ENT, Fortis Hospital, Bengaluru, Karnataka, India
| Date of Web Publication | 16-Aug-2019 |
Correspondence Address:
Prof. Geetha Desai
Department of Psychiatry, NIMHANS, Bengaluru, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/indianjotol.INDIANJOTOL_116_18
Background: Dizziness is a common symptom to which patients seek ENT consultations. It is a symptom for which the cause can be either medical or psychological factors or both. Dizziness can cause significant distress and lead to multiple consultations. This study aimed to assess patterns of illness behaviors among patients with chronic dizziness and understand the underlying patterns. Methodology: Illness behavior was assessed by illness behavior questionnaire (IBQ), somatic symptoms by Scale for Assessment of Somatic Symptoms and diagnosis by the Diagnostic Criteria for Psychosomatic Research (DCPR) and International Classification of Diseases 10. Results: Of the 301 individuals, 24 had dizziness, most of these individuals had another somatic symptom and majority met criteria for health anxiety on DCPR. On the four subscales of IBQ, health concerns scores were higher in patients with dizziness as compared to other somatic symptoms. There was no significant difference between bodily distress, affective distress, and affective inhibition. Conclusions: This study concluded that patients with dizziness can also have other physical symptoms and high health anxiety and hence it may be necessary to screen patients for the same.
Keywords: Dizziness, health anxiety, illness behavior, illness behavior questionnaire
How to cite this article:
Desai G, Chaturvedi J, Chaturvedi SK. Illness behavior among patients with medically unexplained dizziness. Indian J Otol 2019;25:78-80 |
| Introduction | |  |
Patients with medically unexplained somatic symptoms of ENT present with chronic headache, vertigo, giddiness, tinnitus, aphasia, or hearing loss to otolaryngologists. Dizziness is a term, under which many terms have been included such as vertigo, presyncope, disequilibrium, and nonspecific dizziness.[1] Dizziness can present as a result of psychiatric disorders, and psychiatric disorders (anxiety, panic attacks, and depression) may develop dizziness.[2],[3],[4] Further, dizziness as a symptom has been included in some of the scales for somatoform disorders such as Scale for Assessment of Somatic Symptoms (SASS)[5],[6] and Patient Health Questionnaire.[7] Both psychiatric illness and dizziness may coexist, and sometimes, it can be difficult to understand which caused what. It is not uncommon to assume that an organic cause of dizziness which was treated adequately and subsided with treatment may have triggered a psychiatric condition that may have led to continued dizziness because of anxiety. This may lead to a management dilemma causing the patient to shuttle between ENT specialist, psychiatrists, neurologists, and neuro-otologists. This adds to delay, inadequate management and further worsening of both conditions. These frequent help-seeking behaviors with persisting symptoms may contribute abnormal illness behaviors (AIBs).
In ENT practice, when a patient presents with dizziness, the first approach is to identify an obvious ENT cause. This is generally carried out by a quick assessment of clinical history including the relationship of dizziness with the position of the head, hearing loss, association with upper respiratory infection, trauma, medications, or a discharge from the ear. Examination for nystagmus and detailed neurological examination will help in delineating ENT causes. Further investigations such as Dix Halpike's test, magnetic resonance imaging brain/spine, X-ray lateral view of the neck (for cervical issues such as spondylosis), and carotid Doppler studies (to understand blood flow toward the brain), neurovestibular assessments through video or classic electronystagmography or through postural rotatory chairs can aid in further understanding the causes.
However, if the patient continues to complain about nonremission of dizziness, or worsening, despite normal tests and assessments, appears very anxious and worried and excessively requires reassurance and counseling, then a suspicion toward an underlying psychiatric cause or manifestation is made, and the patient is appropriately referred.
More experienced ENT specialists pick up this suspicion early, especially when patients have a long history of numerous doctors having seen them with most test results/scans being normal and most standard treatment provided with poor results. This may also lead to AIBs.
Among ENT disorders, illness behavior has been reported in patients with Meniere's disease. A study was conducted to evaluate illness behavior, personality traits, anxiety and depression in 50 patients with Meniere's disease, using the illness behavior questionnaire (IBQ)[8] and other personality measures. Cluster analysis of the IBQ scores identified a subgroup of Meniere's patients with normal scores and another with severe psychological distress associated with high levels of neuroticism and psychoticism, and an AIB. This study indicated the possibility of distinguishing those patients whose personality traits could facilitate the development of AIB and psychological symptoms in relation to Meniere's disease.[9]
The aim of this current study was to assess illness behavior in patients presenting with medically unexplained dizziness/giddiness to a neuropsychiatry setting.
| Methodology | | |
The study sample was from the individuals attending outpatient services of the Tertiary Neuropsychiatry Hospital. Consecutive patients who satisfied the inclusion criteria were recruited for the study after obtaining written informed consent. Individuals of either gender, between the age of 18–45 years, reporting persistent pain or any somatic symptom (present at least daily or on alternate days), for >6 months for which no organic basis was found, were included. Those with a history of psychosis, mental subnormality, organic brain syndrome, or medical disorders, currently or in the previous 1 year, were excluded. The study was approved by Institutional Ethics Committee.
Sociodemographic and clinical details were noted systematically by a semi-structured pro forma. The clinical diagnosis was ascribed as per 10th edition of the International Classification of Diseases (ICD 10).[10] Illness behavior was assessed using the IBQ[8] which provides an assessment of the patient's attitudes and affects concerning his or her illness as well as the patient's perception of the attitudes of significant others toward himself or herself and their illness and of the social situation. It is 62-item self-reported questionnaire with yes/no responses. The four subscales include health concerns, affective distress, affective inhibition, and bodily distress.[11] The IBQ has been previously translated to Hindi and adapted.[12],[13] The Diagnostic Criteria for Psychosomatic Research (DCPR) was developed to address the need for different conceptual framework to assess psychosocial issues concomitant with medical illness and to detect conditions, which would not be diagnosed in ICD or DSM. The DCPR consists of 12 categories or clusters, which through a semi-structured interview, explore a variety of psychological conditions, and emotional responses to medical illness.[14] SASS was used to assess the somatic symptoms including giddiness and dizziness.[6] This report focuses on medically unexplained giddiness/dizziness in the study group. Other details of the main study are presented elsewhere.[11],[15] Descriptive statistics such as frequency, mean, and standard deviation were used to describe the data and t-test was carried to find the differences on subscales of IBQ in patients with giddiness and the rest of the somatizers.
| Results | | |
In the present study, of the 301 individuals (women 208 and men 93) with chronic non-organic physical symptoms as presenting symptoms, dizziness (moderate-to-severe intensity) was observed and reported in 24 (8%) individuals. Of the 24, 16 (67%) were women; mean age in years was 36.23 + 7.5. The most common psychosomatic diagnosis was health anxiety (17, 71%), disease phobia (6, 25%), and alexithymia (8, 33%) as per DCPR. Some individuals had more than one DCPR diagnosis. According to ICD 10, the psychiatric diagnoses were somatoform disorders (12, 50%), chronic pain disorders (7, 29%), and anxiety and depressive disorders (5, 21%).
Number of other bodily symptoms along with giddiness, were 1 in 9 (37.5%), 2 in 6 (25%), 3 in 4 (16%), and 4 in 2 (8%) individuals. Five patients (21%) with giddiness had no other somatic symptom. The other physical symptoms were headache in 18 (75%), palpitations in 9 (37.5%), pain in limbs in 9 (37.5%), weakness of body in 20 (83%), lack of sleep in all 24 (100%), and poor appetite in 22 (92%).
The mean scores on subscales of IBQ were compared (t-test) between patients with giddiness versus all somatizers is given in [Table 1].
Health concerns scores were significantly higher in patients with giddiness as compared to other somatic symptoms. Other dimensions of illness behavior were comparable in the two groups.
| Discussion | | |
Illness behaviors are considered as the ways in which given symptoms may be differentially perceived, evaluated, and acted (or not acted) on, by the individual.[16] It becomes important when the symptom is medically unexplained, like in the present study.
The findings indicate higher health anxiety and concern in patients with dizziness as compared to those with other bodily or somatic symptoms. This might be due to the fact that dizziness are perceived to be disorders of the brain. No other differences in illness behavior subscales were observed. The findings also indicate that giddiness can occur with other bodily symptoms and needs to be addressed adequately to reduce the health anxiety.
The broad principles of the management of somatoform giddiness includes empathic relationship with the patient, assessment of severity of the symptoms, distress and impairment, experiences related to health care (to elicit illness behaviors), comorbid anxiety and depression, and appropriate use of anxiolytics and antidepressants, if need be; be aware of side effects of psychotropics and psychological and behavioral interventions.
| Conclusions | | |
AIB can present in patients with medically unexplained ENT symptoms like in Meniere's disease[9] and medically unexplained giddiness (the present study). This calls for consultation-liaison between ENT specialists as well mental health professionals for adequate management of persons with medically unexplained giddiness, to deal with the AIB, these patients may exhibit.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Post RE, Dickerson LM. Dizziness: A diagnostic approach. Am Fam Physician 2010;82:361-8, 369.  |
| 2. | Eckhardt-Henn A, Best C, Bense S, Breuer P, Diener G, Tschan R, et al. Psychiatric comorbidity in different organic vertigo syndromes. J Neurol 2008;255:420-8. |
| 3. | Yuan Q, Yu L, Shi D, Ke X, Zhang H. Anxiety and depression among patients with different types of vestibular peripheral vertigo. Medicine (Baltimore) 2015;94:e453. |
| 4. | Kelm Z, Klapchar K, Kieliszak CR, Selinsky C. Psychogenic dizziness: An important but overlooked differential diagnosis in the workup of the Dizzy patient. J Am Osteopath Assoc 2018;118:e22-7. |
| 5. | Chaturvedi SK, Michael A, Sarmukaddam S. Somatizers in psychiatric care. Indian J Psychiatry 1987;29:337-42. [ PUBMED] [Full text] |
| 6. | Desai G, Chaturvedi SK, Dahale A, Marimuthu P. On somatic symptoms measurement: The scale for assessment of somatic symptoms revisited. Indian J Psychol Med 2015;37:17-9. [ PUBMED] [Full text] |
| 7. | Kroenke K, Spitzer RL, Williams JB, Löwe B. The patient health questionnaire somatic, anxiety, and depressive symptom scales: A systematic review. Gen Hosp Psychiatry 2010;32:345-59. |
| 8. | Pilowsky I, Spence ND. Patterns of illness behaviour in patients with intractable pain. J Psychosom Res 1975;19:279-87. |
| 9. | Savastano M, Maron MB, Mangialaio M, Longhi P, Rizzardo R. Illness behaviour, personality traits, anxiety, and depression in patients with Menière's disease. J Otolaryngol 1996;25:329-33. |
| 10. | World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization; 1992. |
| 11. | Desai G, Kandavel T, Chaturvedi SK. Patterns of illness behaviors and its correlates in patients with chronic nonorganic pain. Journal of Neurosciences in Rural Practice 2019;10:60-4. |
| 12. | Varma VK, Malhotra AK, Chaturvedi SK. Illness behaviour questionnaire (IBQ): Translation and adaptation in India. Indian J Psychiatry 1986;28:41-6. [ PUBMED] [Full text] |
| 13. | Chadda RK. Dhat syndrome: Is it a distinct clinical entity? A study of illness behaviour characteristics. Acta Psychiatr Scand 1995;91:136-9. |
| 14. | Fava GA, Freyberger HJ, Bech P, Christodoulou G, Sensky T, Theorell T, et al. Diagnostic criteria for use in psychosomatic research. Psychother Psychosom 1995;63:1-8. |
| 15. | Desai G, Chaturvedi SK. Do diagnostic criteria for psychosomatic research explain diagnosis of medically unexplained somatic symptoms. Psychother Psychosom 2016;85:121-2. |
| 16. | Mechanic D. The concept of illness behavior. J Chronic Dis 1962;15:189-94. |
[Table 1]
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