慢性头晕与精神心理障碍的认识历史

20世纪80年代后已知慢性头晕与各种精神心理障碍有关,并提出"恐惧性姿势性眩晕"、"空间运动不适"、"视觉性眩晕"、"慢性主观性头晕"和"慢性特发性头晕"等概念和诊断术语,而最新诊断术语——"持续性姿势感知性头晕"涵盖上述术语的共同临床特征。关于慢性头晕与精神心理障碍关联性的机制假说包括慢性头晕与精神障碍和人格障碍的关联,认为适应不良是功能性头晕的中枢机制。     

持续性姿势性知觉性头晕研究现状

德国神经学家Brandt和Dieterich (1986)在临床上发现了一组以非眩晕性的头晕为主要表现,且不能被已知的神经前庭性病变所解释的病例,基于对这些病例的研究,提出了恐惧性姿势性眩晕(PPV)的概念。美国学者Staab和Ruckenstein (2007)确定了这一组综合征的核心症状与概念,将其称为慢性主观性头晕(CSD)。之后国际Barang协会经过长达4年的讨论,通过综合关于PPV、CSD的相关研究结果,将其正式重新命名为持续性姿势性知觉性头晕(PPPD),并为其制定了详实的诊断标准。本研究检索了关于PPPD的研究的相关文献,阐述关于PPPD的研究现状。     

持续性姿势-感知性头晕生物标记物研究进展

<正>持续性姿势-感知性头晕(persistent postural-perceptual dizziness, PPPD)是一种慢性前庭综合征，以持续性非旋转性头晕和/或不稳感为主要表现，持续时间>3个月，不能用现有的临床证据解释症状持续存在的一种功能性疾病^[1]。PPPD是恐惧性姿势性眩晕(phobic postural vertigo, PPV)、空间运动不适综合征(space motion discomfort, SMD)、     

持续性姿势-感知性头晕研究进展

持续性姿势-感知性头晕(PPPD)是一种新定义的慢性前庭功能障碍性疾病,其统一了恐惧性姿势性眩晕、空间运动不适综合征、视觉性眩晕和慢性主观性眩晕的核心特征。PPPD人群发病率无准确数据,最新研究表明该病在眩晕门诊中占有重要比例。但由于该病病名新颖,故目前临床医生知晓率低,诊断率低。本文回顾了PPPD的历史演变,简述其诊断标准及流行病学,重点探讨了病理机制及治疗手段,推广治疗经验,希望提高该病的临床识别及诊疗率。     

慢性主观性头晕

慢性主观性头晕（chronic subjective dizziness,CSD）指一种慢性非旋转性头晕或主观不稳感,患者对运动刺激高度敏感,对复杂视觉刺激或精细视觉任务耐受性差,不伴有活动性前庭功能障碍。CSD的概念由Staab和Ruckenstein在2004-2005年首次提出,反映了精神因素与神经科-耳科疾病之间的紧密联系,可分为神经-耳源性、心因性、交互性三种类型。CSD的治疗包括药物、心理治疗、前庭康复训练和认知行为治疗。本文将就CSD的病因、发病机制、临床表现、诊断与治疗进行全面阐述。     

未引起重视的头晕的临床研究进展

头晕是神经科常见的临床症状,临床诊断的常见病因包括良性发作性位置性眩晕、前庭神经元炎、梅尼埃氏病、椎-基底动脉供血不足等。而其他一些头晕或眩晕的病因,包括慢性主观性头晕、周围前庭阵发症、特发性双侧前庭功能减退症、偏头痛性眩晕、及雌激素相关性头晕等,由于临床重视不够或相对少见,因此较少诊断。     

脑部病变与眩晕和非眩晕性头晕关系初步观察

目的研究脑部病变与眩晕和非眩晕性头晕的关系。方法收集2010年1月-2011年8月在我院就诊的患者136例资料。病例收集标准:①有头晕症状,包括眩晕和非眩晕性头晕;②有中枢性病变;③良性阵发性位置性眩晕和梅尼埃病被排除。观察眩晕和非眩晕性头晕所占比例,观察各脑叶病变与眩晕和非眩晕性头晕的关系,观察疾病种类与眩晕和非眩晕性头晕的关系。结果 136例患者中,眩晕病例占23%,非眩晕性头晕病例占77%。幕上幕下病变均伴有眩晕和非眩晕性头晕症状,其中幕下病变伴随的眩晕症状多于幕上病变,小脑病变伴随的眩晕症状多于桥脑,小脑中线病变伴随的眩晕症状多于小脑半球。病种与眩晕及非眩晕性头晕之间未发现明确的规律。结论中枢神经系统病变出现的非眩晕性头晕多于眩晕,幕上病变也可能出现眩晕,幕下病变引起的眩晕可能多于幕上病变,小脑中线病变引起眩晕可能多于小脑半球。非眩晕性头晕可能是中枢神经系统对损伤的非特异反应。     

临床医师头晕/眩晕规范化培训的现状调查

目的 了解头晕/眩晕诊疗的诊疗现状。 方法 对2015年9月-2016年1月全国眩晕巡讲培训的临床医师进行微信形式的问卷调查,收集数据 进行统计分析。 结果 共625例临床医生参与调查。住院医师和主治医师组对头晕/眩晕的相关知识掌握程度低于 副主任医师和主任医师组（P <0.001）。在规范化培训内容方面,仅有22.4%的医师认为自己熟练掌握 眩晕相关体格检查,60%的医生关注眩晕相关查体,57.92%的医生关注眩晕相关疾病鉴别诊断。 结论 应加强低年资住院医师和主治医师在头晕/眩晕相关知识方面的培训。     

盐酸舍曲林联合心理干预及视觉脱敏训练治疗持续性姿势知觉性头晕疗效观察

目的观察在传统口服药物盐酸舍曲林+心理干预治疗基础上加用视觉脱敏训练的治疗方案对于持续性姿势知觉性头晕的疗效。方法符合入组标准的门诊患者随机进入试验组或对照组,试验组和对照组均给予治疗前的心理干预+盐酸舍曲林片口服作为基础治疗,试验组在基础治疗基础上加视觉脱敏训练治疗。在治疗基线及第1、3、6个月末行HADS、DHI评分判定治疗效果。结果试验组HADS、DHI评分下降显著,于对照组比较差异有统计学意义(P<0.05),试验组药物不良反应少于对照组(P<0.05),试验结束半年后随访提示试验组复发率也明显低于对照组(P<0.01)。结论口服药物+心理干预治疗+视觉脱敏训练的PPPD治疗模式能更有效缓解患者头晕、焦虑等临床症状,不良反应少,复发率低。     

脑血管疾病与眩晕或头晕

脑血管疾病能够导致多种多样的中枢或外周性前庭综合征,以眩晕和头晕为主要表现。其 中仅表现为孤立性眩晕/头晕或神经功能缺损轻微的脑血管病容易被漏诊,可能造成严重后果。鉴 别血管源性孤立性头晕和其他内耳疾病所导致的眩晕/头晕十分重要。本文就脑血管病与眩晕/头晕 的相互关系、临床表现、发病特点、诊断和鉴别诊断进行阐述,以期早期识别眩晕的外周性病因和 血管性病因,对卒中危险因素进行早期干预。     

Neuroimaging studies in persistent postural–perceptual dizziness and related disease: a systematic review

Journal of Neurology - Persistent Postural–Perceptual Dizziness (PPPD) is one of the most common types of chronic dizziness. The pathogenesis remains unclear. This study aimed to...     

Treatment of phobic postural vertigo

In balance clinic practice, phobic postural vertigo is a term used to define a population with dizziness and avoidance behavior often as a consequence of a vestibular disorder. It has been described as the most common form of dizziness in middle aged patients in dizziness units. Anxiety disorders are common among patients with vestibular disorders. Cognitive–behavioral therapy is an effective treatment for anxiety disorders, and vestibular rehabilitation exercises are effective for vestibular disorders. This study compared the effect of additional cognitive–behavioral therapy for a population with phobic postural vertigo with the effect of self–administered vestibular rehabilitation exercises. 39 patients were recruited from a population referred for otoneurological investigation. Treatment effects were evaluated with the Dizziness Handicap Inventory, Vertigo Symptom Scale, Vertigo Handicap Questionnaire, and Hospital Anxiety and Depression Scale. All patients had a self treatment intervention based on education about the condition and recommendation of self exposure by vestibular rehabilitation exercises. Every second patient included was offered additional cognitive behavioral therapy. Fifteen patients with self treatment and 16 patients with cognitive– behavioral treatment completed the study. There was significantly larger effect in the group who received cognitive behavioral therapy than in the self treatment group in Vertigo Handicap Questionnaire and the Hospital Anxiety and Depression scale and its subscales. Cognitive–behavioral therapy has an additional effect as treatment for a population with phobic postural vertigo.A multidisciplinary approach including medical treatment, cognitive–behavioral therapy and physiotherapy is suggested.     

One-year follow-up of cognitive behavioral therapy for phobic postural vertigo

BACKGROUND: Phobic postural vertigo is characterized by dizziness in standing and walking despite normal clinical balance tests. Patients sometimes exhibit anxiety reactions and avoidance behavior to specific stimuli. Different treatments are possible for PPV, including vestibular rehabilitation exercises, pharmacological treatment, and cognitive behavioral therapy. We recently reported significant benefits of cognitive behavioural therapy for patients with phobic postural vertigo. This study presents the results of a one-year follow-up of these patients. METHODS: Swedish translations of the following questionnaires were administered: (Dizziness Handicap Inventory, Vertigo Symptom Scale, Vertigo Handicap Questionnaire, and Hospital Anxiety and Depression Scale) were administered to 20 patients (9 men and 11 women; mean age 43 years, range 23-59 years) one year after completion of cognitive behavioral therapy. RESULTS: Test results were similar to those obtained before treatment, showing that no significant treatment effects remained. CONCLUSION: Cognitive behavioral therapy has a limited long-term effect on phobic postural vertigo. This condition is more difficult to treat than panic disorder with agoraphobia. Vestibular rehabilitation exercises and pharmacological treatment might be the necessary components of treatment.     

重归因-认知-药物模式治疗精神性眩晕的疗效

目的探讨重归因-认知-药物模式（RCPM）在治疗精神性眩晕中的临床效果。方法96例精神性眩晕患者随机分为两组,分别接受单独帕罗西汀治疗（A组）和RCPM联合帕罗西汀治疗（B组）,在治疗第4,12周进行疗效评定和药物依从性研究。结果B组在第4,12周的有效率分别为77．08％,93．75％,均优于A组的68．75％,81．25％,差异均有统计学意义（Χ^2=4．17,5．35;P〈0．05）。B组12周停药人数（3例）明显少于A组（10例）,差异有统计学意义（Χ^2=4．36,P〈0．05）。结论RCPM能有效改善精神性眩晕症状,比单用帕罗西汀效果更明显,RCPM能明显提高精神性眩晕患者对抗抑郁药物的依从性。     

Validation of the German version of the Vertigo Symptom Scale (VSS) in patients with organic or somatoform dizziness and healthy controls

Objective   The objective of this study was to validate the German version of the Vertigo Symptom Scale (VSS) and to determine its ability to differentiate the type, frequency, and severity of balance disorders. The scale (34 items) was designed by Yardley and coworkers and has been already validated in its English and Spanish versions. Methods   98 patients with organic vertigo syndromes, 90 patients with somatoform (psychogenic) dizziness and 56 healthy controls were evaluated with the VSS and additional standardized questionnaires regarding distress (SCL-90R), quality of life (SF-36), anxiety and depression (HADS). In order to differentiate organic from somatoform dizziness all patients underwent detailed clinical neurological and vestibular neurophysiological testing. Results   The two identified subscales ‘vertigo and related symptoms’ (VER) and ‘somatic anxiety and autonomic arousal’ (AA) had good internal consistencies (Cronbach’s alpha: VER 0.79; AA 0.89). Test-retest correlations were r = 0.75 for VER and r = 0.75 for AA. VER could discriminate well between dizziness patients and healthy controls. AA discriminated moderately between somatoform and organic dizziness. We found close relations between the AA scale and different measures of emotional distress. Correlations between VER and measures of emotional distress were weaker. Conclusion   The German version of the VSS has good reliability and validity in the detection of different vertigo syndromes. Measurement of anxiety symptoms can be helpful to identify patients with somatoform dizziness.     

Chronic dizziness: the interface between psychiatry and neuro-otology

PURPOSE OF REVIEW: This paper reviews the often-enigmatic relationships between dizziness and psychiatric symptoms. Psychiatric causes of dizziness, neuro-otologic causes of anxiety, underrecognized co-morbid conditions, and medical illnesses that masquerade as 'psychogenic' dizziness are examined. Key clinical features and data from recent treatment trials are presented with potential pathophysiologic mechanisms. RECENT FINDINGS: Investigations at the interface between psychiatry and neuro-otology have identified the distinguishing features of several clinical conditions that present with non-vertiginous dizziness, subjective imbalance, and psychiatric symptoms. The most common condition is chronic subjective dizziness; a refinement of earlier concepts of psychogenic dizziness, phobic postural vertigo, and space-motion phobia. Chronic subjective dizziness is consistent with advancing research on anxiety and somatoform disorders and offers greater insights into the relationships between neuro-otologic illnesses and anxiety. Migraine, post-concussional syndrome, and dysautonomias also cause persistent dizziness and may be misdiagnosed or malingering or psychogenic dizziness because they often present with comorbid psychiatric symptoms in the absence of identifiable vestibular deficits. SUMMARY: Recent research has defined the key features of several medical-psychiatric conditions that cause chronic dizziness, permitting greater diagnostic precision and insight into underlying pathophysiologic processes. Treatment studies have identified potentially effective interventions, which must be evaluated in controlled clinical trials.     

Anxious,introverted personality traits in patients with chronic subjective dizziness

Objectives

Chronic subjective dizziness (CSD) is a neurotologic disorder of persistent non-vertiginous dizziness, unsteadiness, and hypersensitivity to one's own motion or exposure to complex visual stimuli. CSD usually follows acute attacks of vertigo or dizziness and is thought to arise from patients' failure to re-establish normal locomotor control strategies after resolution of acute vestibular symptoms. Pre-existing anxiety or anxiety diathesis may be risk factors for CSD. This study tested the hypothesis that patients with CSD are more likely than individuals with other chronic neurotologic illnesses to possess anxious, introverted personality traits.

Methods

Data were abstracted retrospectively from medical records of 40 patients who underwent multidisciplinary neurotology evaluations for chronic dizziness. Twenty-four subjects had CSD. Sixteen had chronic medical conditions other than CSD plus co-existing anxiety disorders. Group differences in demographics, Dizziness Handicap Inventory (DHI) scores, Hospital Anxiety and Depression Scale (HADS) scores, DSM-IV diagnoses, personality traits measured with the NEO Personality Inventory — Revised (NEO-PI-R), and temperaments composed of NEO-PI-R facets were examined.

Results

There were no differences between groups in demographics, mean DHI or HADS-anxiety scores, or DSM-IV diagnoses. The CSD group had higher mean HADS-depression and NEO-PI-R trait anxiety, but lower NEO-PI-R extraversion, warmth, positive emotions, openness to feelings, and trust (all p < 0.05). CSD subjects were significantly more likely than comparison subjects to have a composite temperament of high trait anxiety plus low warmth or excitement seeking.

Conclusion

An anxious, introverted temperament is strongly associated with CSD and may be a risk factor for developing this syndrome.     

Persistent postural-perceptual dizziness: Clinical and neurophysiological study

The aim of this study was to evaluate clinical and neurophysiological characteristics of Persistent postural-perceptual dizziness (PPPD) in a tertiary vertigo clinic. This was a cross-sectional study that included consecutive patients examined in the Vertigo clinic of the University Hospital Center Zagreb, Croatia. The following data were extracted from the electronic hospital records: age, sex, the duration of symptoms, initial trigger event, results of the caloric testing, video head impulse test (vHIT) for all six semicircular canals and ocular and cervical vestibular evoked myogenic potentials (oVEMP and cVEMP). During the study period 147 consecutive patients with dizziness were examined and 28 (19%) were diagnosed with PPPD, 68% of them were women and the mean age was 59.5 ± 15 years. The median duration of symptoms was 23 months. The most common initial event was vestibular neuritis in 39.3% of patients, followed by benign paroxysmal positional vertigo in 10.7% of patients. Caloric testing was performed in 25 patients. It revealed six cases of unilateral canal paresis. vHIT was performed in 24 patients. There were 13 pathological responses with three cases of lateral canal dysfunction, two cases of posterior, one case of anterior and seven cases of multiple canals affection. VEMP was performed in 23 patients. There were five isolated oVEMP pathologies, one isolated cVEMP pathology and 11 findings of a combined oVEMP and cVEMP pathology. This study provides clinical and neurophysiological data on PPPD and indicates the utility of complete neurophysiological assessment of vestibular function in this group of patients.