Cognitive-behavioral treatment of a patient with vertigo
and unusual sensitivity to smells: A case report
Joshua Fogel, PhD1-3
Rolf G. Jacob, M.D.4-5
Departments of Mental Health1, Biostatistics2,
Psychiatry and Behavioral Sciences3, Johns Hopkins University,
Baltimore, MD 21205; Departments of Psychiatry4 Otolaryngology5,
University of Pittsburgh Medical Center, Pittsburgh, PA 15213
Fogel J., Jacob R. (2002 Cognitive-behavioral treatment of a patient with vertigo and unusual
sensitivity to smells: A case report. International Journal of Psychosocial Rehabilitation. 7, 119-126.
Acknowledgement: This case treatment occurred while Joshua Fogel was a psychology extern at the Northport VA M Medical Center in Northport, NY, USA. His supervision by Janet Eschen, Ph.D., is gratefully acknowledged.
Correspondence:Joshua Fogel, Ph.D.Johns Hopkins UniversityBloomberg School of Public Health624 North Broadway, Suite 861, Baltimore, MD 21205; Phone: (410) 502-9840 Fax: (410) 955-9088. Email: firstname.lastname@example.org
Meniere’s disease is characterized by hearing loss, tinnitus, vertigo, and aural pressure. We describe the cognitive-behavioral treatment of a patient who carried a diagnosis of Meniere’s disease, with additional symptoms of somatoform disorders. In 16 sessions over six months, cognitive-behavioral interventions reduced his symptoms and improved his quality of life. Implications for the role of cognitive-behavioral interventions in rehabilitation and primary care settings for somatizing patients with vestibular disorders are discussed. We advocate an increased interdisciplinary focus toward helping patients with vestibular disorders.
Key words: Meniere’s disease, vestibular disorders, cognitive-behavioral therapy, rehabilitation, disability
Meniere’s disease is a disease affecting the vestibular (balance) and auditory parts of the inner ear. It is characterized by hearing loss, vertigo (i.e., dizziness and/or imbalance), tinnitus (i.e., sensation of ringing in the ears), and feelings of fullness or pressure in the ear. The patients often have demonstrable abnormalities on clinical tests of vestibular and audiological function. Prevalence rates reported in various studies are, for Japan: 4, US: 15, Sweden: 46, and for the UK: 15, 100, and 160 per 10001.
In general, vestibular disorders have high rates of psychiatric comorbidity, particularly anxiety2-3. One study showed 20% of consecutive patients evaluated in a dizziness clinic had panic disorder4. Conversely, psychiatric patients with certain anxiety disorders, particularly agoraphobia, have an elevated rate of balance dysfunction5-8. These vestibular-psychiatric interactions can occur in several ways5. The dizziness may be a symptom of a psychiatric disorder ("psychiatric dizziness", e.g. the dizziness during a panic attack). More complex interactions include central nervous system linkage, somatopsychic effects, or psychosomatic effects in which "stress" activates the previously compensated vestibular lesions. There is also the probability that some patients may be especially vulnerable to developing psychiatric symptoms (e.g., those who have somatizing tendencies, are anxiety prone, or have personality disorders or traits)9. Finally, the psychiatric–vestibular relationship can be complicated by factors in the patient’s health-care and social environment. For example, the patient may react with anger and frustration to the clinician’s dismissive behaviors that typically follow lack of treatment success. In the family environment, lack of understanding of the patient’s symptoms shown by significant others can lead to feelings of loneliness and depression.
We present the case of a patient with dizziness and other symptoms suggestive of Meniere’s disease and somatoform disorder whose symptoms did not respond to the efforts of multiple physicians. The patient’s symptoms included an unusual sensitivity to certain smells. After psychological treatment for six months with a cognitive-behavioral approach, the patient’s condition improved. We discuss the role of the importance of a cognitive-behavioral treatment approach for patients with Meniere’s disease or other vestibular disorders complicated by somatization.
The patient is a 55-year old single man with an associate-degree education who currently was living with his parents. Prior to his hearing disability and related difficulties (both financial and medical), he was independent and lived in his own apartment. He had worked for over 20 years in a sales/marketing position at a large medical supply firm, from which he was fired one year after the onset of symptoms. His peak salary in this position was $100,000 per year. The official reason for dismissal from this position was alleged "fiscal irresponsibility," but he believed it to be due to his disability, as his supervisor had expressed concerns about his hearing loss. Following that job, he worked for a recruiting firm. At this new position, he noticed that his symptoms would increase when he was exposed to perfume odors used by women in his office. Previously he never had any reactions to perfume. Because of these symptoms, he left that job after six months.
At the time of his initial evaluation, he had been unemployed for six years. His past psychiatric history includes an emergency room visit for panic attacks 15 years ago. He had no history of psychiatric hospitalizations. He never had problems with alcohol or drug abuse. Besides his vestibular disorder, his medical history is significant for Type II diabetes mellitus and asthma.
At the initial interview, his medications were fexofenadine (Allegra®, 60 mg, b.i.d.); Methotrexate (2.5 mg, q.d.); diazepam (Valium®, 2.5 mg, b.i.d.); meclizine hydrochloride (Antivert®, 25 mg, t.i.d.); famotidine (Mylanta®, 20 mg, b.i.d.); Prednisone, (30 mg, q.d.); and Glyburide, (2.5 mg, q.d.). These medications suggest that he was receiving treatment for his vestibular disorder (apparently thought to have an autoimmune basis), anxiety, diabetes, dyspepsia, and asthma.
He described symptoms of dizziness, tinnitus, and hearing loss for the past 7.5 years. The dizziness came in attacks that occurred several times per week. During these attacks, he would feel lightheaded and imbalanced, and during many of them he would actually fall. He wore hearing aids on both ears and described progressive hearing loss over the past few years. In addition, he complained of numbness in his arms and legs, severe pain inside his head, and intolerance of certain smells — not only to the smell of perfume already described, but also to cigarette smoke and warm bread. His diabetes was under control; he did not have diabetic neuropathy. His psychiatric symptoms (which he minimized) included depression and anxiety symptoms, including panic attacks.
He was referred for psychological treatment because several physicians had not been able to find a treatment for him. Over the past year, he had a CT, MRI, EEG, and neuropsychological testing; a review of these indicated no specific pathology. A month before seeing the first author, his otolaryngologist had prescribed diazepam, a drug that has both anxiolytic and vestibular suppressant effects. His otolaryngologist had also referred him to an allergist, internist, rheumatologist, podiatrist, and psychiatrist.
For the first few sessions while receiving his cognitive-behavioral treatment, he was seeing all of the above health-care professionals except the psychiatrist who had referred him on. During most of the cognitive-behavioral treatment sessions he was not receiving any concurrent treatment other than diazepam at the dose specified above.
The patient came for treatment after sequential referrals from one mental health care provider to another. These mental health care providers assessed him and did not provide any psychotherapy treatment. The psychiatrist to whom he had been referred by the otolaryngologist referred him on to a psychologist who specialized in insight-oriented psychoanalytic psychotherapy, and who referred him on to the first author, a psychologist-in-training with two years of experience from working in other medical settings using cognitive-behavioral interventions.
The patient described how he was almost constantly preoccupied with seeking a cure for his symptoms. None of his earlier health-care providers had a solution. Although he did not believe that his condition could be affected by psychological factors, he stated that he was willing to try "anything" that would allow him to feel better.
The initial interview established a DSM-IV diagnosis of panic disorder with agoraphobia and of adjustment disorder with depressed mood. Due to his complex case presentation, the psychological testing consultation service was consulted for psychological evaluation.
The test report indicated that the test battery included the Millon Clinical Multiaxial Inventory-Second Edition (MCMI-II), Minnesota Multiphasic Personality Inventory-Second Edition (MMPI-2), and a Meniere’s Disease-Vertigo Questionnaire10. The test results were interpreted as signifying that the patient chose to interpret his symptoms as medical rather than psychological. On the Hägnebo et al. vertigo questionnaire, he consistently and strongly endorsed items comprising factors of somatic and situational origin whereas he did not endorse any psychological correlates with the vertigo attacks. Unlike his psychiatric evaluation, his multiple test scores indicated minimal if any depression or anxiety, but he may have answered test questions defensively.
The first few treatment sessions focused on providing the patient a rationale for the cognitive-behavioral treatment approach. He was assigned to self-monitor his symptoms and instructed to record antecedents, behaviors, and consequences on a simple monitoring sheet. His recordings would be subject to discussion during the subsequent treatment sessions. Although he superficially complied with these cognitive-behavioral interventions, he remained preoccupied with his various medical appointments, expressing a conviction that one of these might result in a definite diagnosis and specific cure.
After the first few sessions, the patient had completed the concomitant medical specialist evaluations, the results of which again had been disappointing. Furthermore, his psychological test results were shown to him. At this time, the patient became more cooperative with the cognitive-behavioral approach.
His self-monitoring suggested that a majority of his symptoms were associated with stress or situational factors. For example, the patient described vertigo symptoms while reading computer software at an office supplies store (i.e., visual vertigo11). Curiously, a significant proportion of his symptom-triggering stimulus profile was of the olfactory modality. His response to these stimuli could be respiratory in nature. For example, he developed extreme difficulty breathing while visiting his brother because one person at his brother’s house was smoking cigarettes. Additional provocative olfactory stimuli included waiting for his medical appointment, smelling perfume from others, and smelling freshly baked bagels at a bagel shop while eating breakfast with a friend.
His treatment included cognitive restructuring and behavioral techniques. The cognitive restructuring component of his treatment included questions and dialogue about possible ramifications about his feared events, all aimed at helping him re-evaluate his phobic belief structure. The behavioral interventions included diaphragmatic breathing and self-paced graduated in vivo exposure to eliciting stimuli related to his problematic olfactory sensitivity. Olfactory sensations were focused upon, as he mentioned that previously he used to socialize with friends at a bagel store while now he was unable to do so. As he was unemployed and not performing any regular activities, the idea was double pronged; he could obtain social support from his friends and also benefit by reducing his anxiety to olfactory stimuli. After this exercise with graded time exposure to the anxiety producing smell of warm bagels, he often frequented the bagel store and had breakfast with his friends. Also, he was instructed to practice diaphragmatic breathing in his natural environment whenever he felt a vertigo attack and to wait out the symptoms for their duration. The diaphragmatic technique was taught with his eyes open, as clinical practice suggests that relaxing with the eyes closed during an episode of vertigo can increase its severity. As his confidence was boosted by the graded exposure to the bagel store, he was repeatedly encouraged to little-by-little try to participate in various activities that he was afraid of, because they had previously been associated with vertigo attacks.
He reported that his vertigo attacks occurred less often and were often reduced in intensity with relaxation/diaphragmatic breathing. He also reported gradual decrements of tinnitus, numbness, pain, allergic symptoms, gastrointestinal distress, depression, and anxiety. The patient began to show an increased awareness of the interplay of psychological factors and his symptoms. He began to react less catastrophically to the symptoms of vertigo. The patient indicated that he no longer feared these symptoms and developed a more accepting attitude towards future vertigo attacks. He became able to discriminate between dizziness related to his vestibular disorder and that related to anxiety. These anxiety-associated dizziness attacks became quite infrequent. Likewise, his non-anxiety attacks decreased in frequency.
The patient came to accept that his Meniere’s disease was chronic but would not have to be disabling. He was able to modify and eliminate many of the psychological aspects of his symptoms, such as catastrophizing cognitions, and his fears of olfactory stimuli. He no longer had asthmatic reactions to olfactory stimuli of bagels. He continued to experience slight discomfort to perfume and cigarette smoke, but did not have as severe a breathing difficulty. He also no longer focused exclusively on his symptoms and even began to consider various career options. He considered re-training in computer programming and was looking forward to a life less troubled by his symptoms of the past few years. Over the last three months of treatment, he only had two attacks (one anxiety and one vestibular), whereas before treatment, he had multiple attacks each week.
Follow-up evaluations at one and three months after treatment indicated that he maintained the improvement in his psychiatric and somatic symptoms. His vertigo attacks were less frequent, and after falling spells, he was able simply to pick himself up from the floor and continue with his activities.
Five attacks per week
Once a month
Did not recognize "anxiety" as a contributor
Able to identify anxiety-related dizziness
Cognitions concerning dizziness
Task focused (career)
DiscussionLimitations Inherent In Case Reports
As is true for all individual case reports, we cannot rule out that the improvement noted in the patient may have been due to factors other than the cognitive-behavioral treatment. One possible confounding factor was the concomitant treatment with diazepam. However, the dose of diazepam was not changed during his cognitive behavioral treatment, and the patient did not experience reduction in symptoms until two months after beginning diazepam. Therefore, most of the improvements described below are more likely to be related to the cognitive-behavioral treatment than the benzodiazepine treatment. Also, there is the possibility of observer bias from the therapist and patient as symptoms can be expressed subjectively and were not monitored or confirmed with objective physiological monitoring.
Psychiatric Disorder, Vestibular Dysfunction, and Cognitive-Behavioral Interventions The treatment of the unusual, "somatizing" symptoms of this patient with suspected Meniere’s disease was challenging. Many of the ancillary symptoms of the patient discussed here, have not been described as psychiatric consequences of vestibular dysfunction (e.g., of numbness in his arms and legs, severe pain inside his head, and the "allergic reactions" to the smell of perfume and warm bread) and may be suggestive of an additional diagnosis of undifferentiated somatoform disorder.
Part of the key to success with this patient may have been a careful individuation of treatment focus to those symptoms that were of the greatest concern for the patient. Rather than the dismissive behaviors that the patient described experiencing with most of his health-care providers, the therapist showed interest in the patient’s symptoms and accepted them at face value. Of interest is that self-monitoring suggested that some aspects of his symptoms were situational or stress-related. This impression would be consistent with a study of Meniere’s disease patients that showed a concurrent association of stress with their symptoms; however, the direction of causality in that study is unclear, since these symptoms were not associated with stress on preceding days12.
Thus, the cognitive-behavioral interventions of self-monitoring, diaphragmatic breathing, and cognitive-restructuring helped this patient from some of the distressing aspects of his symptoms. Although at post-treatment he still would experience intermittent falling on the floor, he now continued with his activities to the best of his ability. The patient’s regard for this treatment approach shifted from being hesitant to that of a faithful adherent; over the duration of 16 treatment sessions, the patient only re-scheduled two sessions. He learned to identify and accept anxiety-related dizziness as contributing to his symptoms. After treatment, he chose to no longer primarily focus on his symptoms but to focus on possible career options.
Interdisciplinary Treatment Approach
Psychologists in rehabilitation settings may find themselves collaborating with physical therapists that treat chronic vestibular disorders such as Meniere’s disease and their psychiatric consequences. Vestibular rehabilitation involves exercises that maximize central nervous system compensation for the vestibular pathology and is administered by physical therapists. Beidel and Horak13 discuss the similarities between vestibular rehabilitation as practiced by physical therapists and cognitive-behavioral therapy as practiced by psychologists. Both perform multidimensional assessments on their patients, including at the degree of functional impairment and coping strategies. Their treatment interventions both include exposure to dizziness or anxiety evoking stimuli and techniques of arousal reduction such as relaxation. However, they differ in that physical therapists aim for central nervous system compensation while psychologists aim for elimination of panic attacks and other psychological distress.
Integration of the two approaches can benefit patients with anxiety disorders complicated by vestibular dysfunction. One study of patients with both agoraphobia and vestibular dysfunction had participants complete a four-week self-directed behavioral-exposure program followed by a 8-12 week program of vestibular rehabilitation. Although the behavioral treatment improvement occurred in some parameters, there were no significant changes in anxiety or phobic avoidance. After the vestibular rehabilitation program, there were further improvements in clinical global impressions of severity, anxiety, and phobic avoidance14.
Besides rehabilitation settings, primary care settings can quite often benefit from the psychological approach toward treating those with vestibular disorders. There is increased collaboration of mental health professionals with physicians in primary care settings15-16. This case study was instrumental in helping to increase the collaborative relationship between psychology professionals and internists and otolaryngologists at this particular hospital. Although quite well read and practicing in their field for many years these medical professionals had not thought of the possibilities that psychological interventions could offer to patients experiencing vertigo and other somatizing symptoms related to Meniere’s disease. Following this successful outcome, the psychology staff received numerous referrals from the primary care physicians and also increased questions about the possibilities regarding if psychological treatment approaches could benefit their patients.
The Specific Role of the Psychologist
The psychologist may have a role beyond that of the physical therapist especially in those cases where physical rehabilitation proves problematic or ineffective. In addition, psychologists can offer specialized assessment for psychiatric disorders and psychological difficulties.
Each of the main symptom categories of Meniere’s disease, (i.e, tinnitus and vertigo) can lead to psychological difficulties. Especially, chronic tinnitus can cause disrupted sleep and there may be an inability to concentrate. Psychological difficulties associated with chronic tinnitus include anxiety, depression, feelings of hopelessness, irritability, and even suicide17-18. Furthermore, as already discussed, vertigo or dizziness symptoms can result in adjustment issues depending on the severity and frequency of the attacks. Psychological difficulties associated with vertigo include panic attacks, fear leading to activity restriction, and if an individual’s gait becomes unstable, embarrassment and ridicule leading to social avoidance.
More generally, there is a need to develop interdisciplinary programs for vestibular patients, similar to what has been done with chronic pain patients. However, such a program would need to be adapted, taking into account the physiology of the vestibular system as it relates to symptom formation and the possible situational triggers. Furthermore, in the future, more attention should be focused on the psychological screening of patients with vestibular disorders so that appropriate cognitive-behavioral interventions can improve their recovery and quality of life.
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