Why Does Vertigo Become Chronic After Neuropathia Vestibularis

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Why Does Vertigo Become Chronic After Neuropathia Vestibularis

FRANK GODEMANN, MD, CHRISTIANE KOFFROTH, MD, PETER NEU, MD, AND ISABELLA HEUSER, MD
Objective: Vertigo is one of the most frequent complaints in general medical practice and is often linked to psychiatric disorders.
A longitudinal study of 67 patients with an acute vestibular disorder was undertaken to clarify if, after experiencing acute vestibular
vertigo, certain patients have a higher likelihood of developing chronic, debilitating dizziness despite no evidence of a damaged
peripheral vestibular system. Method: The severity of dizziness was determined in 67 patients with vestibular neuronitis, 6 months
after their release from hospital, using the Vertigo Symptom Scale from Yardley et al. The intensity of anxiety directly after vertigo
was experienced, body-related cognitions, illness coping, personality structure, and the recovery of the organ of equilibrium were
recorded in order to explain the severity of vertigo that occurred after 6 months. The function of the organ of equilibrium was
assessed by using a caloric test. Results: Over a period of 6 months, 13 of the 67 patients (19.4%) reported continuing dizziness
after neuropathia vestibularis. Eleven of the 13 patients showed high scores on a scale for measuring vertigo-related symptoms,
which can be interpreted as being equivalent to anxiety. The variables of gender, catastrophic thoughts and a dependent personality
accounted for 35% of why vertigo became chronic. Conclusion: Neuropathia vestibularis represents a risk factor for the
development of chronic vertigo. Chronic vertigo after neuropathia vestibularis appears to be equivalent to anxiety and is partly
conditional on catastrophic thoughts at the beginning. Key words: neuropathia vestibularis, chronic vertigo, psychogenic vertigo,
risk factors.
DIPS Diagnostic Interview of Psychiatric Diagnoses; VSS
Vertigo Severity Scale; SA somatic anxiety; VS vertigo severity;
STAI State Trait Anxiety Inventory; ACQ Agoraphobic
Cognitions Questionnaire; BSQ Body Sensations Questionnaire;
PSSI Personality Disorder and Type Inventory; FKV Freiburg
Coping Illness Questionnaire; MSP mean slow phases; OE
organs of equilibrium.
INTRODUCTION
Vertigo is a common symptom in general medical practice
(1). Neurological, ENT-related, cardiologic, and psychiatric
disorders are the most frequent differential diagnoses (1,2).
Results so far indicate that vertigo, independent of its etiology,
has a tendency to become chronic. In more than 80% of all
patients seeking consultation for vertigo, the vertigo symptoms
did indeed improve within half a year, but only a third
reached a full recovery (3). This leads to the question of
whether these findings would also be prevalent among a
homogeneous group of patients experiencing vertigo for the
first time, and, if so, how many patients would subsequently
develop chronic vertigo?
In order to better understand why vertigo becomes chronic,
we prospectively studied a group of patients with neuropathia
vestibularis. Although neuropathia vestibularis is considered
to be a benign illness where usually most or all symptoms
disappear within 2 to 3 weeks, almost 50% of patients report
the continuation of vertigo symptoms (4 –7). However, the
quality of vertigo with neuropathia vestibularis changes over
the course of an indefinite period of time: at the beginning,
rotary vertigo with nausea and vomiting is experienced, later
a feeling of insecurity and numbness (7).
Two alternative models to explain why vertigo becomes
chronic are likely: 1) Persistent vertigo reflects an acquired
mild vestibular dysfunction. It is hypothesized that these types
of mild subthreshold vestibular dysfunctions become symptomatic
if the individual experiences anxiety or hyperventilation,
because the autonomous arousal overrides the central
compensation mechanism (8). 2) At the onset, vertigo is
accompanied by a strong feeling of anxiety (9). Later on,
vertigo could also be understood as being equivalent to anxiety,
without the person necessarily being consciously aware
of their anxiety (10). In this experience, vertigo serves as a
“model” for the subsequent development of anxiety as a
symptom (11).
Yardley et al. describes the various means of explanation as
follows: “Transient, weak vestibular symptoms may hence be
a common experience, but become a contributory factor for
psychiatric disturbance only in those who are predisposed to
react adversely to disorientation” (9).
The relationship between the experience of anxiety and
chronic vertigo is yet to be understood. Neuropathia vestibularis
provides us with a suitable basis for shedding light on this
relationship. We therefore included patients who had suffered
an acute vestibular disorder in the study, monitoring the development
of anxiety and vertigo over a period of 6 months.
METHOD
Eighty patients, who had been diagnosed as suffering from neuropathia
vestibularis directly after their admission into hospital, were recruited over a
period of 1.5 years from one neurological and seven ENT departments in
Berlin.1 The criteria for inclusion in the study were an acute onset, rotary
vertigo and nausea or vomiting. Additional requirements for inclusion were an
abnormal caloric test result in the first 4 days after admission to hospital
and/or spontaneous nystagmus. Only first-time sufferers were included. Patients
with reduced hearing ability or tinnitus, the presence of a central
vestibular condition, a head injury, or a previous anxiety disorder were
excluded. A random sample (102 people) was recruited via the Berlin Residents’
Registration Office as a control group. The test participants received
compensation of €50 for taking part in the study. With this random sample,
From the Department of Psychiatry, Free University of Berlin, Berlin,
Germany.
Address correspondence and reprint requests to Frank Godemann, MD,
Department of Psychiatry and Psychotherapy, Charite´ Hospital, Humboldt
University at Berlin, Schumannstrasse 20/21, 10117 Berlin, Germany. E-mail:
f.godemann@alexius.de
Supported by grant no. DFG Go 923/1–1.
Received for publication December 11, 2002; revision received May 17,
2004.
DOI: 10.1097/01.psy.0000140004.06247.c9
1Departments of Otolaryngology of the Free University of Berlin, n 26;
St. Gertrauden Hospital, n 16; St. Hedwig Hospital, n 2; “Im Friedrichshain”
Hospital, n 11; “Prenzlauer Berg” Hospital, n 8; “Neuko¨lln”
Hospital, n 8; Accident Hospital Berlin, n 6; and the Department of
Neurology of the Charite´, n 3.
783 Psychosomatic Medicine 66:783–787 (2004)
0033-3174/04/6605-0783
Copyright © 2004 by the American Psychosomatic Society

we were able to calculate Cronbach’s alpha and the correlation of Vertigo
Symptom Scale (VSS) subscales, and to compare our caloric test results with
a healthy control group.
The VSS was selected as an independent variable for recording the
severity of vertigo after 6 months. Patients indicate on a 5-point Likert scale
(0 “the symptom never occurred” to 4 “the symptom occurred on
average more than once a week”) the frequency of 22 vertigo symptoms over
the past 6 months. The VSS consists of two subscales. Vertigo severity (VS)
describes vertigo symptoms such as rotary vertigo, and somatic anxiety (SA)
describes the autonomous accompanying symptoms of vertigo like sweating
and sensations such as heart tremors or discomfort. With both subscales,
Cronbach’s alpha is above 0.80 (VS 0.88; SA 0.83); the test-retest
correlation is around 0.95. Both subscales correlate only moderately with each
other (0.33–0.46) and differentiate between vertigo patients and healthy
controls. A stable correlation between the two subscales and the diagnosis of
anxiety disorder is found in the literature (p .05). In our patients with acute
vestibular disorder, an improvement in the vertigo symptoms was to be
expected within a few weeks. We therefore considered vertigo lasting over a
number of months to have become chronic. We consider VS and SA scores as
pathologic if they are higher than the mean value for outpatients of a special
vertigo clinic (10).
Panic disorder, agoraphobia, post-traumatic stress disorder, obsessivecompulsive
disorder, and generalized anxiety disorder were diagnosed using
the Diagnostic Interview for Psychiatric Disorders (12). Patients diagnosed as
permanently suffering from these anxiety disorders were excluded from the
evaluation, since chronic vertigo is often a symptom of these disorders
(1,2,13–15).
The influence of a wide range of variables on the development of chronic
vertigo was investigated with the assistance of the following scales: STAI
State and Trait, Freiburg Coping Illness Questionnaire, Agoraphobic Cognitions
and Body Sensations Questionnaire, and Personality Type and Disorder
Inventory. We selected these scales to test our main hypothesis that following
acute vestibular disorder a number of patients are prone to develop psychogenic
vertigo. These scales seemed to us to be particularly suited to identifying
possible psychological risk factors.
The State-Trait Anxiety Inventory (16) records both state anxiety and
anxiety as a permanent personality trait. The questionnaire on body-related
anxieties and cognitions (17) is a German translation of the Body Sensation
Questionnaire (BSQ) and the Agoraphobic Cognitions Questionnaire (ACQ)
(18). On a 5-point Likert scale in the BSQ, physical symptoms are assessed
which, in confrontation with anxiety-producing stimuli, are experienced by
patients as being particularly stressful. The ACQ records catastrophic
thoughts in relation to body sensations, with the assistance of 14 items. The
scale ranges from “the thought never occurs” (1) to “the thought always
occurs” (5). The 14 items on the ACQ result in two total scores, describing
anxiety before a control loss and the experience of a physical crisis in one’s
own body. The Freiburg Coping Illness Questionnaire (FKV) from Muthny
records five different coping styles (depressive coping, active problem-oriented
coping, distraction and building self-esteem, religiousness and soul
searching, as well as trivializing and wishful thinking) (19). The PSSI is a
personality inventory developed by Kuhl and Kaze´n depicting personality
types and is oriented to ICD 10 within the framework of a dimensional
understanding of personality (20). Three of 13 types are mentioned here
(Table 1): careful-compulsive, schizo-typical, and loyal-dependent.2 Immediately
after admission into hospital, patients assess their vertigo using a
visual analogue scale (1 no vertigo; 10 heavy vertigo).
The caloric test was carried out with the “Humid Air Caloric HAC 3” 6
weeks after discharge from hospital. Initially, a warm water douche (44°C)
was flushed into the healthy side for about 40 seconds. After a pause of 20
seconds, nystagmus was recorded for 90 seconds. The affected ear was then
examined in the same way. Finally, cold flushing (30°C) of both the affected
and healthy ear concluded the test. The function of the peripheral vestibular
organs was calculated using Scherer’s formula. The mean slow phases (MSP)
reflect the sensitivity of the organs of equilibrium (OE) in both the affected
and healthy ear (21).
Statistical Methods
Statistical evaluation of the data was carried out with SPSS for Windows,
version 10.07. The Mann Whitney U-Test for independent random samples
was used for rank comparison of scores with nonstandard distribution. Associations
between two variables were determined using Pearson’s correlation
coefficient. Partial correlation was calculated for the determination of apparent
correlations. Testing of the independence of two variables was calculated
with Pearson’s 2 test. Step-by-step linear regression analyses were used to
determine the relevance of different variables. The data are presented in mean
values and SD from the mean values. A p value of less than 0.05 was
considered significant.
RESULTS
Eighty patients were screened for the study. Six were
excluded because anxiety disorder was diagnosed as having
been present before the incidence of vertigo (panic disorder,
n 3; agoraphobia, n 3). Data for 7 patients were incomplete,
either because they had moved to an unknown address
or because they had declined to take part in the caloric test. Of
the 102 controls, 13 were excluded from the study due to an
anxiety disorder (panic disorder, n 2; agoraphobia, n 3;
agoraphobia with panic disorder, n 3; generalized anxiety
disorder, n 5). The average age in the patient group was 52
(14.3), and in the control group 51 (11.5) years. There was
therefore no significant age difference (t 0.31, p .76)
between the two groups. The patient group consisted of 38
women and 29 men, the control group of 35 women and 47
2 Careful-compulsive: This style is characterized by thoroughness and
exactness in the completion of the person’s own activities. The corresponding
personality disorder is marked by perfectionism and rigidity.
Schizo-typical: People with a particular sensibility for foreseeing events
and actions which neither logical thought or intuitive experience could bring
about.
Loyal-dependent: There is a high readiness to defer one’s own desires, if
they collide with the interests of an important reference person. In the
extreme, this style can sometimes lead to dependent or submissive behavior.
TABLE 1. Characteristics of 67 Patients With Neuropathia
Vestibularis
Characteristic Value
Gender
Male 29 (43.3%)
Female 38 (56.7%)
Age (years) 52 14.3
Vertigo Severity Scale*
Somatic anxiety (SA)
SA 1.32 56 (83.6%)
SA 1.33 11 (16.4%)
Vertigo severity (VS)
VS 1.11 64 (95.5%)
VS 1.12 3 (4.5%)
Vestibular side difference in caloric testing Low SA 1.33
20% 5 (10%)
20% 46 (90%)
High SA 1.33
4 (37%)
7 (63%)
*Vertigo Severity Scale subscales: VS vertigo severity, SA somatic
anxiety; SA 1.33 and VS 1.12 pathological scores.
F. GODEMANN et al.
784 Psychosomatic Medicine 66:783–787 (2004)

men. There was no significant difference between the two
groups with regard to gender distribution (2 2.91, p .09).
Of the 67 patients for whom data were evaluated, three had
pathological scores on the vertigo severity scale (1.37–1.74;
mean, 1.49 0.21) and 11 on the somatic anxiety scale
(1.33–3.18; mean, 2.13 0.61). Only one female patient rated
as pathological on both scales. The average score on the
somatic anxiety scale was 0.73 (0.76) and on the vertigo
severity scale 0.28 (0.37) (Table 2). Immediately after admission,
patients tend to suffer from severe vertigo (visual
analogue scale: 7.9 2.1). We found no correlation between
the intensity of vertigo at the beginning and the values in the
vertigo severity (p 0.24) or somatic anxiety scales (p
0,14) during the follow-up period.
Correlations between the sensitivity of the organs of equilibrium
6 weeks after an acute one-sided vestibular dysfunction
and vertigo severity after 6 months (0.13)/somatic anxiety
(0.05) were not significant. Of the 11 patients with pathological
scores on the somatic anxiety scale, seven (63%) indicated
side differences of 20%, and of the patients without persistent
vertigo as many as 90% (46 of 51) had side differences of
more than 20% (Table 2). Similar findings for side differences
are found in the literature (21–23) and were also present in our
healthy control group. The female gender seems to represent
a risk factor in the development of chronic vertigo. All patients
with high somatic anxiety scores were female (Pearson
11.8, p .001, df 1).
The absolute scores for the severity of somatic anxiety
were higher in the patient group than in our control group
(0.73 vs. 0.53); however, this difference was not significant.
The differences to the 11 patients with pathological vertigo
scores were significantly higher than in the control group
(2.13 vs. 0.53, U 24, p .001). All 11 vertigo scores were
above the mean values for the Yardley and Hallam patient
group who were attending a vertigo consultation (24).
In comparison to patients whose symptoms had remitted,
those with chronic vertigo after acute vestibular disorders
were significantly more anxious after they had experienced
the acute dysfunction of the organs of equilibrium. They had
a stronger impression of losing control over their bodies (r
0.41, p .01) and experienced the dysfunction as a serious
crisis (r 0.35, p .01). Physical symptoms such as dizziness
significantly increased their anxiety (r 0.44, p .001)
(Table 1).
The evaluation of personality found “loyal-dependent”
(p .001), “compulsive” (p .05) and “schizo-typical”
(p .05) personality types to be significantly more prevalent
among patients with chronic vertigo. In all the other
personality types, we found no significant difference. The
average STAI trait for all patients was 36.01 (10.51). This
corresponds to the scores obtained in a German random
sample (34.45 8.83). Anxiety as a personality trait was
found to be significantly higher in patients whose vertigo
had become chronic (r 0.28, p .05). The FKV indicated
that only the coping strategy of “depressive coping”
and vertigo after 6 months could be correlated (r 0.30,
p .05). The other coping strategies were not in any way
linked to the continuation of vertigo (Table 1). The Bonferroni
correction procedure was subsequently carried out
on 20 correlations in a post-study analysis. Following this
correction procedure, with its significance level of p
.0025, the BSQ, ACQ total value, and dependent personality
structure all remained significant.
In a linear regression analysis, the predominant factors
contributing to chronic vertigo were: the female gender, a
dependent personality structure, and the tendency to evaluate
body sensations fearfully (ACQ). Combined, these factors
offer an explanation for 35% of the variance in vertigoassociated
symptoms.
TABLE 2. The Significance of Personality Traits, Coping Strategies, and Anxieties on Vertigo Becoming Chronic
Somatic
Anxiety
1.32
Somatic
Anxiety
1.33
U R
Sensitivity of organs of equilibrium 79.41 (81.32) 65.70 (41.00) 235.50 0.70 (n.s.)
ACQ
Total 1.31 (0.32) 1.90 (0.91) 164.00* 0.46***†
Physical crises 1.35 (0.50) 1.89 (1.05) 165.00* 0.35**†
Loss of control 1.34 (0.42) 1.97 (1.04) 199.00 0.41**†
BSQ
Total 1.92 (0.70) 2.69 (0.67) 128.5* 0.44**†
PSSI
Careful-compulsive 63.96 (26.17) 84.16 (18.41) 156.50* 0.31*
Schizo-typical 28.05 (24.79) 45.23 (30.72) 182.50* 0.28*
Loyal-dependent 37.53 (27.48) 61.15 (30.11) 182.00* 0.42***†
STAI trait 34.34 (8.73) 44.55 (14.64) 183.50* 0.28*
FKV
Depressive coping 1.80 (0.72) 2.24 (0.63) 179.00* 0.30*
ACQ Agoraphobic Cognitions Questionnaire; BSQ Body Sensation Questionnaire; PSSI Personality Disorder and Type Inventory; STAI State Trait
Anxiety Inventory; FKV Freiburg Coping Illness Questionnaire.
Mann Whitney’s U-Test and Pearson’s correlation coefficient (r), *p .05, **p .01, ***p .001; †Significant after Bonferroni correction procedure.
CHRONIC VERTIGO AFTER NEUROPATHIA VESTIBULARIS
785 Psychosomatic Medicine 66:783–787 (2004)

DISCUSSION
In our study, a proportion (20%) of patients suffered
chronic symptoms following an acute vestibular disorder. The
prognosis for patients experiencing vertigo for the first time is
considerably better than that for patients already attending a
vertigo clinic, who have a 66% chance of developing chronic
vertigo (25).
The results of our study suggest that chronic vertigo in our
sample is a symptom of acquired anxiety because there is no
correlation between vertigo complaints and the sensitivity of
the organs of equilibrium. In addition, only a small number of
patients (3 of 67) report typical vestibular symptoms like
rotary vertigo and there is practically no overlap of reported
vestibular symptoms with somatic anxiety in the VSS. We
therefore show a shift from a vestibular to a somatoform
vertigo. This contradicts the results obtained by Jacob et al.
(23) and Yardley et al. (24), who state that in patients with
vertigo within the scope of anxiety disorders (in particular
agoraphobias) it is mostly a dysfunction of the peripheral
organs of equilibrium that is diagnosed. In contrast, it could be
that we found no correlation to caloric testing because, in
nearly all patients, typical vestibular symptoms disappeared.
Development of chronic vertigo depends in part on the
female gender, dysfunctional coping with vertigo and a dependent
personality type.
Yardley et al. also found dysfunctional coping in a sevenmonth
longitudinal study of 101 patients attending a vertigo
consultation clinic. In their study, 45% of the patients described
their handicap as the fear of losing control. It is likely
that patients who develop chronic vertigo shift their focus of
attention to the threat posed by their vertigo experience and
thus induce, beyond the anxiety itself, further dizziness (25).
In turn, this results in the avoidance of situations which could
lead to the feared loss of control, resulting in the patients
imposing further restrictions on their social activities and
therefore feeling increasingly disabled by their vertigo (26). In
our study, we have shown that this altered focus of attention
is an important factor in the etiology of somatoform anxiety.
It turned out that the STAI trait score for those patients who
showed significant somatoform vertigo after 6 months was at
the beginning on average 10 points higher than the mean of
the patients without vertigo (U 183.50, p .05). This
supports the thesis that people with increased negative emotionality
tend to observe their body a lot and to evaluate the
symptoms observed negatively (27).
Of the FKV only “depressive” coping showed a significant
correlation with increased anxiety scores 6 months later (p
.05). A negative correlation, as would be expected for example
with active problem-oriented coping, did not occur. Yardley
also investigated vertigo patients in respect of the influence of
illness coping on impediment caused by vertigo (“handicap”)
and anxiety caused by vertigo (“distress”) after 7 months. She
found that the conviction of having influence on the course of
the illness correlated negatively with the impediment caused
by vertigo 7 months later (p .05) (28).
Brandt and Dieterich describes a “phobic swaying vertigo”
as being the second most common cause of chronic vertigo
syndromes (29). The personality of these patients was found to
be the obsessive-compulsive type. In our study, a rigid-compulsive
personality type, but also a dependent personality
structure, seemed to be more prevalent among chronic vertigo
patients. Lilienfeld and Penna were able to show that anxiety
sensitivity is linked to a dependent personality type (30). An
association between anxiety disorders and dependent personality
disorders has also been described (31,32). If we view
vertigo as psychogenic in our study, our results are in line with
these findings. As in our study, a dependent personality disorder
has been found particularly in women (33).
There are some limitations to our study. First, because we
only have data starting from 6 weeks after the onset of
vestibular dysfunction and, second, because caloric testing is
a problematic method of examining neuropathia vestibularis,
due to its low specificity. Thus, Yardley et al. were not able to
establish a difference of any significance between 36 panic
patients and 20 control participants in respect of audiology
and caloric testing. Posturography, however, led to the destabilization
of more than 60% of panic and agoraphobic patients,
whereas this was only the case in 10% of the control
group (22). The study gives no answer to the question of
whether those suffering from any of the anxiety disorders are
prone to somatic reactions like vertigo. We had to exclude
these patients because our study design did not allow us to
differentiate between the vertigo of an original anxiety disorder
and the newly developed somatic symptoms. The study
was able to show that about 20% of all patients suffer from
persistent vertigo after an acute vestibular disorder. We suggest
that this chronic vertigo is in reality a kind of fear. It
would make sense to clarify whether in other functional studies
of the balance function, such as posturography, indicators
cannot also be found, that this experience of vertigo is not an
expression of a persistent vestibular neuropathia or at least
that functional deficits do not occur more frequently than in
the group without vertigo. This is surely a limitation of the
study. In addition, it would be interesting to discover whether
this persistent experience of vertigo is a threshold symptom of,
or an integral part of, a psychiatric disorder.
TABLE 3. Prediction of Severity of Vertigo 6 Months After an
Acute Vestibular Disorder in 67 Patients
Corrected R² F
ACQ total mean value 0.196 16.87*
Sex 0.302 15.03*
PSSI: loyal-dependent 0.344 12.37*
Excluded variables
FKV: depressive coping
PSSI: careful-compulsive NS NS
STAI trait
BSQ total mean value
PSSI: nervous-schizo-typical
NS not significant.
*p .001 (linear regression analysis).
F. GODEMANN et al.
786 Psychosomatic Medicine 66:783–787 (2004)

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