Cognitions associated with anxiety in Ménière’s disease

Running head: Anxiety in Ménière’s disease

School of Psychology, University of Southampton, UK

Sarah. E. Kirby, PhD, and Lucy Yardley, PhD

Address correspondence to: Sarah Kirby, School of Psychology, University of

Southampton, Highfield, Southampton SO17 1BJ, UK. Tel: +44 (0)23 8059 2581

Fax: +44 (0)2380 594597. E-mail: Sarah.Kirby@soton.ac.uk

Anxiety in Ménière’s disease 2

Abstract

Objectives: The purpose of this longitudinal study was to identify cognitions

associated with anxiety and maintenance of anxiety in people with Ménière’s disease.

Method: At baseline participants completed the Hospital Anxiety and Depression

Scale (HADS), the Revised Illness Perception Questionnaire, the Dizziness Beliefs

Scale, the Fear Avoidance Beliefs Questionnaire, the Intolerance of Uncertainty Scale,

and measures of demographic and illness characteristics. Participants were then

randomised to no treatment or to receive one of two self-help booklets, and completed

the HADS again at 3 month follow-up. Results: After controlling for symptom

severity, baseline anxiety was associated with intolerance of uncertainty, fear-

avoidance of physical activity, the belief that dizziness would develop into a severe

attack of vertigo, and several illness perception subscales (emotional representations,

consequences, psychological causes, and perceived treatment effectiveness). Anxiety

at follow-up was predicted by higher baseline levels of autonomic/somatic symptoms

and intolerance of uncertainty, and reporting less understanding of the illness. These

longitudinal relationships were found in those who did and did not receive self-help

booklets. Conclusions: Our findings suggest that intolerance of uncertainty is

associated with anxiety in Ménière’s disease. A controlled trial is needed to see

whether anxiety might be reduced in Ménière’s disease by helping patients to tolerate

and cope with uncertainty, but a controlled trial is needed to test this hypothesis.

Keywords: anxiety disorder, vestibular, Ménière’s disease, attitudes, questionnaire

design.

Anxiety in Ménière’s disease 3

Introduction

Ménière’s disease is an incurable chronic disorder of the inner ear, characterised by

recurrent spontaneous attacks of severe vertigo (a strong sense of spinning), which

result in imbalance, sweating, nausea and vomiting. Symptoms also include

progressive hearing loss that becomes permanent in one or both ears, a sense of

fullness or pressure in the ear(s), and intermittent spells of loud tinnitus (a buzzing,

ringing or roaring sound) [1]. There are close neurological links between the

vestibular and autonomic systems, with the consequence that vestibular disturbance

directly provokes autonomic symptoms such as nausea, pallor and sweating (as in

motion sickness). Following an acute attack of vertigo, dizziness gradually

diminishes as the central balance system habituates to the change in vestibular

function. However, residual dizziness can still be provoked by unaccustomed

movements and disorienting situations [2;3]. Autonomic symptoms can also be

induced by anxiety arousal [4-6]. Both illness and anxiety provoked symptoms have

the potential to create a vicious cycle of prolonged symptomatology and distress, as

symptoms can be augmented by anxiety, and in turn fuel further anxiety [6-9].

Indeed, Hhigh levels of anxiety are often reported among those who experience

vertigo [10-12][2-4], and elevated levels of anxiety and distress have been found in

people with Ménière’s disease [13-15][5-7]. It would be helpful to be able to identify

modifiable factors that are associated with anxiety in order to try to limit the

exacerbation of this vicious cycle.

Recent cross-sectional research suggests that whereas handicap in Ménière’s

disease is associated mainly with the severity of symptoms, levels of anxiety are

associated mainly with psychological reactions to illness [8]. Cognitive behavioural

approaches to chronic illness suggest that cognitions about illness and its

Anxiety in Ménière’s disease 4

consequences are important in how people with chronic illness respond emotionally to

their illness [16;17][9,10]. Therefore, if the cognitions that contribute to anxiety in

Ménière’s disease can be identified, this should assist in the identification of the forms

of support and therapy that are most likely to reduce anxiety in people with Ménière’s

disease. This study considers the relevance to Ménière’s disease of three groups of

cognitions found to be related to anxiety among other chronic illnesses: illness

perceptions, dizziness related fears and beliefs, and intolerance of uncertainty.

Anxiety is likely to be related partly to realistic negative cognitions, but in chronic

illness anxiety is also often related to excessive and catastrophic concerns, which

may be amenable to modification.

In other chronic illnesses a group of cognitions called illness perceptions

[18;19][11,12] have been found to play a significant role in relation to a variety of

outcomes, including anxiety [20][13]. Chronically ill people experience more

psychological distress if they have a strong illness identity (i.e. attribute many

symptoms to the illness), a stronger emotional response to illness, feel they do not

understand their illness well, and believe that their illness has serious consequences,

will last a long time and cannot be easily controlled [21-23][14-16].

These negative perceptions of illness may be common in Ménière’s disease.

There are close neurological links between the vestibular and autonomic systems,

with the consequence that vestibular disturbance directly provokes autonomic

symptoms such as nausea, pallor and sweating (as in motion sickness). However,

autonomic symptoms can also be induced by anxiety arousal [17-19]. Following an

acute attack of vertigo, dizziness gradually diminishes as the central balance system

habituates to the change in vestibular function. However, residual dizziness can still

be provoked by unaccustomed movements and disorienting situations [20,21]. A

Anxiety in Ménière’s disease 5

strong illness identity could develop if symptoms of anxiety arousal and residual

dizziness were attributed to active disease. Moreover, some people with the disease

may have to make significant lifestyle changes, including changing or giving up work

or certain social or leisure activities, or becoming unable to drive or travel. Therefore

people may well view the disease as having serious consequences, depending on the

extent to which it has impacted on their family and finances, and social and

occupational areas of life. The disease is incurable and treatment options are limited,

as little is known about what causes the disease. Therefore people with Ménière’s

disease may correctly expect their illness to be long-lasting, and may also believe that

they do not understand their illness very well, and that the symptoms cannot be easily

controlled.

Dizziness related fears and beliefs haveIn addition to illness perceptions,

other specific cognitions may also been found to be relevantcontribute to anxiety. in

people with Ménière’s disease. In Ménière’s disease, as severe vertigo attacks are

experienced which are unpleasant and frightening, and result in a sense of loss of

control and helplessness. As noted above, milder symptoms of residual or movement-

provoked dizziness can also be experienced between attacks. When people with

Ménière’s disease experience any dizziness, they may interpret this catastrophically,

misinterpreting the symptoms as the beginning of a severe attack. Dizziness may also

lead to fear that they will be in physical danger (as attacks carry a risk of injury from

stumbling or falling), or a fear of embarrassment about having an attack in public or

letting people down [24;25][22,23]. Negative beliefs about the consequences of

vertigo have been shown to be more disabling than the symptoms themselves, leading

to high levels of disability and handicap [9;26][24,25]. If people with Ménière’s

disease believe that movement-provoked dizziness may develop into a severe attack,

Anxiety in Ménière’s disease 6

they may also believe that movement is therefore bad for them and should be avoided.

This belief that physical activity may be harmful and subsequent avoidance of

physical activity has also been reported among people with other chronic symptoms

[16;27][9,26].

Thirdly, Another set of cognitions that may cause increased anxiety among

people with Ménière’s disease relate to intolerance of uncertainty has been found to

be relevant to anxiety. Many chronic illnesses result in increased levels of uncertainty

with regard to the occurrence or severity of symptoms, prognosis, or the effectiveness

of treatment. Uncertainty has been well noted anecdotally in Ménière’s disease and

chronic vertigo [13;28;29][5,27,28], as attacks can occur unexpectedly, impacting on

every area of life. Individual differences may occur in how people tolerate these

uncertainties and adapt their lives to accept and incorporate their presence and

consequences. Dugas and colleagues [30][29] describe someone who is

intolerant of uncertainty as having “an excessive tendency to find uncertain

situations stressful and upsetting, to believe that unexpected events

are negative and should be avoided, and to think that being

uncertain about the future is unfair” (p. 58). Intolerance of uncertainty

has been reported to lead to inaccurate appraisals of threat [30;31][29,30] and result in

a greater use of vigilance and avoidance behaviours [32][31]. If people with

Ménière’s disease believe that the unpredictable nature of their illness is stressful,

unfair, and reflects badly on their character (e.g. making them appear to be

disorganised or to under-perform), they may respond anxiously to all uncertain

situations. They may also try to avoid situations in which unexpected attacks may

occur. This may also contribute to anxiety as, due to the nature of the disease, any

situation could potentially be appraised as uncertain.

Anxiety in Ménière’s disease 7

The purpose of this study was firstly to investigate whether illness perceptions,

dizziness related fears and beliefs and intolerance of uncertainty are associated with

clinical levels of anxiety, and secondly, to identify what combination of cognitions

predict the maintenance of anxiety over time. Our multivariate analyses were

designed to examine and control for the effects of symptom severity, in order to

isolate the additional effects of these cognitions.

This study was nested within a randomised controlled trial (RCT) of vestibular

rehabilitation (VR) or symptom control (SC) therapy presented in the form of self-

management booklets for people with Ménière’s disease [33][32]. VR involves

stimulating the balance system using a series of head movements, causing movement-

provoked dizziness. The balance system gradually habituates to these movements,

leading to a gradual reduction in provoked dizziness [2][20]. SC therapy involves the

use of applied relaxation, controlled breathing and stress management strategies; the

rationale is that since arousal and stress may aggravate symptoms of dizziness,

reducing stress can improve adjustment and relieve symptoms [3][21]. By combining

an observational study with this RCT we were able to examine whether the

longitudinal predictors of anxiety differed in those undertaking different self-

management programmes.

It was hypothesised that in line with previous research on illness perceptions,

anxiety would be associated with the belief that the illness has serious consequences,

belief in a chronic timeline, low perceived control, less understanding of the illness

and greater emotional response. Greater levels of anxiety were also hypothesised to

be associated with negative beliefs about dizziness, and a greater intolerance of

uncertainty. Finally, it was hypothesised that these associations would be moderated

by intervention group. As the VR intervention requires the deliberate provocation of

Anxiety in Ménière’s disease 8

unpleasant symptoms, stronger associations were hypothesised to occur within the VR

intervention group than the SC or control groups.

Method

Participants and Procedure

Participants were 358 members of the Ménière’s Society with current dizziness

symptoms but reporting no acute attack in the previous six weeks. They were

randomised to receive a self-management booklet on vestibular rehabilitation (VR) or

symptom control (SC), or were assigned to a waiting list control group [33][32].

Questionnaire measures for this study were sent with the baseline and 3 month follow-

up measures for the RCT.

Measures

Anxiety.

Anxiety was assessed by the anxiety subscale of the Hospital Anxiety and Depression

Scale (HADS) [34][33]. The HADS was chosen because it does not include somatic

symptoms of anxiety that are analogous with secondary symptoms of dizziness.

Anxiety scores at baseline and follow-up were dichotomised for analysis, with

participants being classified as having clinical levels of anxiety if they scored eight or

more [35][34].

Illness perceptions.

Illness perceptions were measured by eight of the nine subscales of the Revised

Illness Perception Questionnaire (IPQ-R) [18][11]. The ‘timeline acute/chronic’

subscale assesses how long the respondent expects the illness to last, and the ‘timeline

Anxiety in Ménière’s disease 9

cyclical’ subscale asks respondents if the illness fluctuates or is unpredictable. The

‘consequences’ subscale measures respondents’ expectations of the effects of the

illness. The ‘personal control’ subscale measures respondents’ belief in personal

control over the illness, whereas the ‘treatment control’ subscale measures belief in

the effectiveness of treatments. The ‘illness coherence’ subscale assesses the extent to

which respondents believe they understand their illness. The ‘emotional

representations’ subscale measures the presence of emotional responses to the illness

(e.g. depression, anger, worry, anxiety and fear). The ‘causal’ dimension asks

respondents what may have caused their illness. Factor analysis (principal component

analysis with varimax rotation) was used to identify any meaningful clusters of

perceived causes that could be used as causal beliefs subscales. Only one clear factor

emerged, which related to the belief that Ménière’s disease was caused by

psychological state (e.g. stress, worry or personality), and corresponded to the

‘psychological attributions’ factor identified by Moss-Morris and colleagues [18][11].

Items loading over 0.5 on this factor were summed to create a subscale with good

internal consistency (Cronbach’s alpha = 0.84).

Beliefs about dizziness.

Three of the four subscales of the Dizziness Beliefs Scale [25][23] were used to

measure the extent to which participants believed that dizziness would result in

negative consequences. The ‘physical danger’ subscale assesses the belief that

dizziness will result in being physically harmed. The ‘social incompetence’ subscale

measures beliefs about the social embarrassment of becoming dizzy in public and

being unable to behave normally. The ‘severe attack’ subscale measures concern that

dizziness will develop into a severe attack of vertigo. The ‘serious illness’ subscale,

which measures the belief that the dizziness is a sign of an underlying disease, was

Anxiety in Ménière’s disease 10

not used in this study because participants knew that Ménière’s disease was the cause

of their dizziness.

The extent to which participants believed that their symptoms could be made

worse by physical activity was measured using the ‘physical activity’ subscale of the

Fear Avoidance Beliefs Questionnaire (FABQ) [27][26]. The FABQ was originally

designed for people with low back pain, and so the ‘physical activity’ subscale was

adapted for the purposes of this study by replacing references to the word ‘pain’ with

the word ‘vertigo’, and removing references to participants’ backs. The internal

reliability for the adapted scale was acceptable (α = .79).

Intolerance of uncertainty.

Intolerance of uncertainty was measured using the Intolerance of Uncertainty Scale

(IUS) [31][30]. The IUS assesses the emotional and behavioural consequences of

uncertainty for respondents, their expectations that future events should be predictable

and attempts to control future events.

Demographic and illness characteristics.

Single items were used to assess length of time (in months) since symptoms began,

gender, and age. Vertigo was assessed using the long version of the Vertigo

Symptom Scale (VSS) [6][19]. The ‘vertigo severity’ subscale measures the

frequency and severity of symptoms of vestibular origin, such as vertigo, dizziness,

and imbalance. The ‘autonomic/somatic symptoms’ subscale measures autonomic

symptoms that are secondary to vestibular dysfunction and symptoms of somatic

anxiety and anxiety arousal. Hearing loss was assessed using five questions from the

Anxiety in Ménière’s disease 11

Hearing Disability Questionnaire [36][35] that assessed subjective severity of hearing

impairment. Tinnitus and fullness in the ear were assessed using the Tinnitus Severity

Index and Aural Pressure Index [37;38][36,37].

Statistical Analyses

Initially, analysis of variance (ANOVA) was used to identify variables related

to anxiety (non-clinical vs. clinical) at baseline. Baseline anxiety was entered into the

analysis as a fixed factor, with each of the baseline variables being entered in turn as

the dependent variable. We then used ANOVA to determine whether the same

baseline variables predicted anxiety at follow-up, and whether intervention group (VR

vs. SC vs. control group) affected this relationship. For these analyses the ANOVAs

were repeated but baseline anxiety was replaced by anxiety at follow-up and treatment

group was added as a second fixed factor. No interactions were found in these

analyses, indicating that intervention group did not influence the relationship between

baseline variables and anxiety at follow-up, and therefore data for the intervention

groups were pooled for our final analyses.

These initial analyses were intended to minimise Type II error (overlooking

variables related to anxiety), and so our focus was principally on the effect sizes of

each variable, rather than their statistical significance. To determine which variables

were associated with anxiety while controlling for Type 1 error (i.e. minimising the

likelihood that relationships were identified as significant by chance), all baseline

variables identified in the ANOVAs (shown in Table 1) as potentially significantly

related to anxiety were entered into two hierarchical logistic regressions with anxiety

at baseline and follow-up as the dependent variables. The logistic regression for

anxiety at follow-up controlled for baseline levels of anxiety by entering baseline

Anxiety in Ménière’s disease 12

anxiety on the first step of the regression, thus allowing us to identify predictors of

change in anxiety from baseline [39][38]. In both regressions, demographic and

illness characteristics were entered together as covariates, to control for the effects of

these variables. The cognitions were lastly entered together on the final step. All

statistical analyses were carried out using the Statistical Package for the Social

Sciences (SPSS), version 14.0 for windows.

Results

Participant Characteristics

Of the 358 participants, 246 were female (68.7%) and 112 were male (31.3%). The

age range was 28-90 years. The length of time since their symptoms began ranged

from 18 to 660 months. Ten participants dropped out before the follow-up assessment

(five from the VR group, four from the SC group and one from the control group),

leaving 114 participants in the VR group, 115 in the SC group, and 119 in the control

group.

Following the clinical cut off points recommended for the HADS [34][33], at

baseline 56.2% of participants had at least mild clinical levels of anxiety , and 27.4%

met the criteria for moderate to severe clinical levels of anxiety. At 3 month follow-

up, 48.1% had at least mild clinical levels of anxiety, and 24.9% had moderate to

severe clinical levels of anxiety.

Bivariate Analyses

Bivariate analyses of the associations between baseline variables and anxiety at

baseline and follow-up are reported in Table 1. None of the baseline variables had

different patterns of association with anxiety at follow-up in the three intervention

Anxiety in Ménière’s disease 13

groups (i.e. there were no significant interactions with intervention group), and so

pooled analyses for the whole sample are presented. In general, a similar pattern of

associations was found with anxiety at baseline and follow-up. Of the illness

characteristics, higher levels of autonomic/somatic symptoms were strongly

associated with clinical levels of anxiety, and anxiety was also higher among those

who reported worse symptoms of vertigo, fullness in the ear and hearing disability.

Among the cognitions, the variables most strongly associated with anxiety

were intolerance of uncertainty and emotional responses to the illness. Participants

who were clinically anxious also had stronger beliefs that dizziness could result in

them losing control and being physically harmed, embarrassed or unable to fulfil

social roles. Having a poor understanding of the illness and believing that it had more

severe consequences were moderately associated with higher levels of anxiety. Small

to moderate associations were found between anxiety and the belief that the illness

was caused by psychological factors and that dizziness would develop into a severe

attack of vertigo. The beliefs that treatment would not be effective in controlling their

illness, and that physical activity could make symptoms worse also had small to

moderate associations with anxiety.

Predictors of Anxiety at Baseline and Follow-up

The results of the logistic regression indicated that 8 of the 14 variables that had been

identified by ANOVA as related to anxiety independently contributed to the

regression equation predicting baseline levels of clinical anxiety (see Table 2).

Clinical levels of baseline anxiety were most strongly associated with reporting

greater autonomic/somatic symptoms; severity of vertigo, fullness in the ear and

hearing disability were no longer related to anxiety after controlling for

Anxiety in Ménière’s disease 14

autonomic/somatic symptoms. However, after controlling for illness severity,

baseline anxiety was strongly related to being more intolerant of uncertainty, and

having a greater emotional response to illness. Clinical levels of anxiety were also

associated with having stronger beliefs that the illness was caused by psychological

factors and that dizziness could be made worse by physical activity and would

develop into a severe attack of vertigo. Higher levels of anxiety were also related to

beliefs that their illness had greater consequences and that treatment would not be

effective in controlling their illness.

After controlling for baseline anxiety, anxiety at follow-up was no longer

related to severity of vertigo, hearing loss or tinnitus, and was also no longer related to

many of the baseline psychological measures that were significant in the bivariate

correlations (i.e. perceived consequences, treatment control, emotional

representations, psychological attributions, fear-avoidance and the belief that

symptoms might herald a severe attack). However, maintenance of anxiety was

predicted by three baseline variables (see Table 2). These were autonomic/somatic

symptoms, a greater intolerance of uncertainty, and reporting less understanding of

their illness.

Discussion

The purpose of this study was to identify cognitions associated with anxiety, while

examining and controlling for the effects of symptom severity, in order to isolate the

additional effects of cognitions. At baseline, anxiety was related to the severity of all

symptoms of Ménière’s disease except for tinnitus, but was most closely related to

autonomic/somatic symptoms. The strength of this correlation is undoubtedly due in

part to the fact that autonomic and somatic symptoms are an intrinsic part of anxiety.

Anxiety in Ménière’s disease 15

However, they can also be provoked by vestibular disorder. It seems likely that in this

study autonomic/somatic symptoms were partly related to the severity of Ménière’s

disease, since the other symptoms of Ménière’s disease were no longer related to

anxiety after controlling for severity of autonomic/somatic symptoms.

After controlling for symptom severity, most of the hypothesised relationships

between anxiety and cognitions were confirmed in the cross-sectional analyses.

Anxiety was associated with the belief that the illness has serious consequences,

negative beliefs about the consequences of dizziness, perceived lack of understanding

of the illness, a stronger emotional response to it and a greater intolerance of

uncertainty. The causal direction of associations cannot be determined from cross-

sectional correlations; consequently, it is not possible to be certain whether high

anxiety levels caused or resulted from these beliefs and attitudes.

After controlling for baseline anxiety, three baseline variables predicted the

maintenance of anxiety at follow-up, a.lthough it should be noted that the size of these

effects was small. Since the variance these variables shared with anxiety at baseline

was partialled out, greater significance can be attached to their potential causal role in

maintaining anxiety. Moreover, these longitudinal relationships were found in all

three intervention groups, and the strength of the relationships was not affected by the

interventions.

After baseline anxiety,The the next strongest predictor of persisting anxiety at

follow-up was autonomic/somatic symptoms. This scale assesses a combination of

illness-provoked and anxiety-provoked symptoms that has the potential to create a

vicious cycle of prolonged symptomatology and distress, as symptoms can be

augmented by anxiety, and in turn fuel further anxiety [19,25,39,40]. Given the

conceptual overlap between autonomic/somatic symptoms and anxiety (as measured

Anxiety in Ménière’s disease 16

by the HADS), it is not surprising that they were strongly associated. Nevertheless, it

was essential to include autonomic/somatic symptoms in order to control for illness

severity when measuring the effects of the psychological variables. Of more interest,

therefore, is the finding that iIntolerance of uncertainty alsopredicted persisting

anxiety after controlling for baseline anxiety and autonomic/somatic symptoms. This,

providesing for the first time an indication that the strong association with anxiety

observed in the cross-sectional analyses at baseline (and in another study [40][8]) may

reflect a causal relationship, whereby the predisposition to react negatively to

uncertainty may contribute to anxiety. In addition, a perceived lack of comprehension

of the illness at baseline predicted persisting anxiety, suggesting that anxiety is

maintained not only by the sense that symptoms are unpredictable but also by the

sense that they are inexplicable.

The findings of this study cannot be generalised to all people with Ménière’s

disease, as the RCT was limited to participants from the Ménière’s Society who had

current dizziness but were not experiencing frequent spontaneous attacks of acute

vertigo. Members of the Ménière’s society may not be representative of the general

medical population of people with Ménière’s disease. For example, members may

have wanted to join the society as a result of higher levels of anxiety than non

members. Therefore, these findings need to be replicated in a sample who have not

joined a self-help group. A further limitation of this study is that we were only able to

analyse and report associations with one aspect of the distress caused by Ménière’s

disease. It is probable that other key aspects of distress, such as depression and

handicap, are related to different patterns of symptoms and cognitions [40][8]. Most

importantly, while longitudinal prediction of changes in anxiety provides stronger

evidence of possible causality than can be inferred from cross-sectional associations,

Anxiety in Ménière’s disease 17

it cannot confirm a causal relationship. In order to do this it would be necessary to

show that the outcome of an intervention that was successful in reducing anxiety was

mediated by a reduction in autonomic/somatic symptoms and intolerance of

uncertainty.

About half of the participants in our RCT had possible clinical levels of

anxiety at baseline. This observation is consistent with the findings of Savastano and

colleagues [41], who identified distressed and non-distressed subgroups, and suggests

that whereas some people with Ménière’s disease are able to successfully adjust to

having the disease, others may need support to achieve this. In the RCT in which this

study was embedded [33][32], vestibular rehabilitation (VR) resulted in a reduction in

symptoms (assessed by a scale that measured both vertigo and autonomic/somatic

symptoms) and a decrease in anxiety (measured by the HADS). Since VR requires

patients to deliberately and repeatedly provoke dizziness (in order to stimulate

neurological adaptation), undertaking VR teaches patients that residual symptoms are

tolerable, and partly predictable and controllable, and that it is not necessary to avoid

activity. It has therefore been suggested that VR can function as a form of cognitive-

behavioural therapy, interrupting the vicious cycle of symptoms and anxiety about

symptoms [3;33;42][21,32,42]. Indeed, in the trial associated with this study, VR also

resulted in a reduction in negative beliefs about dizziness. Nevertheless, benefits

obtained using the self-help booklets were modest, and further research is needed to

identify additional therapy components that might improve outcomes.

The cognitions found to be relevant to anxiety in this study are consistent with

results found among populations with chronic pain [22][15], multiple sclerosis [23]

[16] and dizziness [25;43][23,43], and suggest that there may be a pattern in how

Anxiety in Ménière’s disease 18

people perceive and think about chronic illness that is related to poor adjustment and

increased distress.

Emotions, bodily symptoms, cognitions and behaviours seem to become linked in a

strong and unhelpful way, and it may be necessary for cognitive-behavioural therapy

to address all of these components of the illness experience. However, this study has

identified intolerance of uncertainty as a reaction that may be particularly important to

address in therapy for Ménière’s disease. Action and contingency plans might be

useful coping tools. However, McCracken and Eccleston [44] suggest that

interventions that focus on acceptance rather than coping with chronic illness may be

more beneficial in improving adjustment. As uncertainty cannot be avoided in

Ménière’s disease, support could be focused on helping people with Ménière’s disease

to accept that at times they may not be able to do certain things. A controlled trial is

needed to provide a definitive test whether of the hypothesis that intolerance of

uncertainty contributes to anxiety in Ménière’s disease, and that anxiety can be

reduced by successfully treating intolerance of uncertainty.

Acknowledgments

This study was funded by the Ménière’s Society, UK.

Anxiety in Ménière’s disease 19

Reference List

[1] Committee on Hearing and Equilibrium. Guidelines for the diagnosis and

evaluation of therapy in Meniere's disease. Otolaryngology Head and Neck

Surgery 1995; 113:181-185.

[2] Brandt T. Management of vestibular disorders. Journal of Neurology 2000;

247:491-499.

[3] Yardley L, Redfern MS. Psychological factors influencing recovery from balance

disorders. Anxiety Disorders 2001; 15:107-119.

[4] Balaban CD, Thayer JF. Neurological bases for balance-anxiety links. Journal of

Anxiety Disorders 2001; 15:53-79.

[5] Furman JM, Jacob RG. A clinical taxonomy of dizziness and anxiety in the

otoneurological setting. Journal of Anxiety Disorders 2001; 15:9-26.

[6] Yardley L, Masson E, Verschuur C, Haacke N, Luxon L. Symptoms, anxiety and

handicap in dizzy patients: Development of the vertigo symptoms scale.

Journal of Psychosomatic Research 1992; 36(8):731-741.

[7] Hagnebo C, Melin L, Andersson G. Coping strategies and anxiety sensitivity in

Meniere's disease. Psychology, Health and Medicine 1999; 4(1):17-26.

[8] Furman JM, Jacob RG. A clinical taxonomy of dizziness and anxiety in the

otoneurological setting. Anxiety Disorders 2001; 15(1-2):9-26.

Anxiety in Ménière’s disease 20

[9] Yardley L, Beech S, Weinman J. Influence of beliefs about the consequences of

dizziness on handicap in people with dizziness, and the effect of therapy on

beliefs. Journal of Psychosomatic Research 2001; 50(1):1-6.

[10] Eagger S, Luxon LM, Davies RA, Coelho A, Ron MA. Psychiatric morbidity in

patients with peripheral vestibular disorder: A clinical and neuro-otological

study. Journal of Neurology and Neurosurgery and Psychiatry 1992;

55(5):383-387.

[11] Pollak L, Klein C, Rafael SJ, Vera K, Rabey JM. Anxiety in the first attack of

vertigo. Otolaryngol Head Neck Surg 2003; 128:829-834.

[12] Soderman ACH, Bagger-Sjoback D, Bergenius J, Langius A. Factors influencing

quality of life in patients with Meniere's disease, identified by a

multidimensional approach. Otology & Neurotology 2002; 23(6):941-948.

[13] Crary WG, Wexler M. Meniere's disease: a psychosomatic disorder?

Psychological Reports 1977; 41:603-645.

[14] Kirby S, Yardley L. Understanding psychological distress in Meniere's disease:

A systematic review. Psychology, Health and Medicine 2007.

[15] Van Cruijsen N, Wit H, Albers F. Psychological aspects of Meniere's disease.

Acta-Oto-Laryngologica 2003; 123:340-347.

[16] Moss-Morris R. Symptom perceptions, illness beliefs and coping in chronic

fatigue syndrome. Journal of Mental Health 2005; 14(3):223-235.

Anxiety in Ménière’s disease 21

[17] Vlaeyen JWS, Kole-Snijders AMJ, Boeren RGB, van Eek H. Fear of

movement/(re)injury in chronic low back pain and its relation to behavioural

performance. Pain 1995; 62:363-372.

[18] Moss-Morris R, Weinman J, Petrie K, Horne R, Cameron LD, Buick D. The

revised illness perception questionnaire (IPQ-R). Psychology and Health 2002;

17(1):1-16.

[19] Weinman J, Petrie K, Moss-Morris R, Horne R. The illness perception

questionnaire: A new method for assessing the cognitive representation of

illness. Psychology and Health 1996; 11:431-445.

[20] Reynolds P, Gardner D, Lee R. Tinnitus and psychological morbidity: a cross

sectional study to investigate psychological morbidity in tinnitus patients and

its relationship with severity of symptoms and illness perceptions. Clinical

Otolaryngology 2004; 29:628-634.

[21] Hagger MS, Orbell S. A meta-analytic review of the common-sense model of

illness representations. Psychology and Health 2003; 18(2):141-184.

[22] Hobro N, Weinman J, Hankins M. Using the self-regulatory model to cluster

chronic pain patients: the first step towards identifying relevant treatments?

Pain 2004; 108:276-283.

[23] Jopson NM, Moss-Morris R. The role of illness severity and illness

representations in adjusting to multiple sclerosis. Journal of Psychosomatic

Research 2003; 54:503-511.

Anxiety in Ménière’s disease 22

[24] Yardley L, Todd AM, Lacoudraye-Harter MM, Ingham R. Psychosocial

consequences of recurrent vertigo. Psychology and Health 1992; 6:85-96.

[25] Yardley L. Contribution of symptoms and beliefs to handicap in people with

vertigo: A longitudinal study. British Journal of Clinical Psychology 1994;

33:101-113.

[26] Kinney SE, Sandridge SA, Newman CW. Long-term effects of Meniere's disease

on hearing and quality of life. American Journal of Otology 1997; 18(1):67-

73.

[27] Waddell G, Newton M, Henderson I, Somerville D, Main CJ. A fear-avoidance

beliefs questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic

low back pain and disability. Pain 1993; 52:157-168.

[28] Dowdal OM. Early vestibular rehabilitation in patients with Meniere's disease.

Otolaryngologic Clinics of North America 2002; 35(3):683-690.

[29] Yardley L. Overview of psychologic effects of chronic dizziness and balance

disorders. Otolaryngologic Clinics of North America 2000; 33(3):603-616.

[30] Dugas MJ, Hedayati M, Karavidas A, Buhr K, Francis K, Phillips NA.

Intolerance of uncertainty and information processing: Evidence of biased

recall and interpretations. Cognitive Therapy and Research 2005; 29(1):57-70.

[31] Freeston MH, Rheaume J, Letarte H, Dugas MJ, Ladouceur R. Why do people

worry? Personality and Individual differences 1994; 17(6):791-802.

[32] Mishel MH. The measurement of uncertainty in illness. Nursing Research 1981;

30(5):258-263.

Anxiety in Ménière’s disease 23

[33] Yardley L, Kirby S. Evaluation of Booklet-Based Self-Management of

Symptoms in Ménière Disease: A Randomized Controlled Trial.

Psychosomatic Medicine 2006; 63:762-769.

[34] Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta

Psychiatrica Scandinavica 1983; 67:361-370.

[35] Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the Hospital

Anxiety and Depression Scale. An updated literature review. Journal of

Psychosomatic Research 2002; 52:69-77.

[36] Lutman ME, Brown EJ, Coles RRA. Self-reported disability and handicap in the

population in relation to pure-tone threshold, age, sex and type of hearing loss.

British Journal of Audiology 1987; 21:45-58.

[37] Stahle J, Arenberg IK, Goldman G. Staging Meniere's disease: description of a

vertigo-disability profile. The American Journal of Otology 1981; 2(4):357-

364.

[38] Cass CP. Staging and outcomes for Meniere's disease. In: Harris JP, editor.

Meniere's disease. The Hague, The Netherlands: Kugler Publications, 1999:

311-325.

[39] Bandura A. Self-efficacy: The exercise of control. USA: W.H. Freeman and

Company, 2002.

[40] Kirby SE, Yardley L. The contribution of post-traumatic stress disorder (PTSD),

health anxiety and intolerance of uncertainty to distress in Meniere's disease.

(Submitted) 2007.

Anxiety in Ménière’s disease 24

[41] Savastano M, Maron MB, Mangialaio M, Longhi P, Rizzardo R. Illness

behaviour, personality traits, anxiety, and depression in patients with

Meniere's disease. Journal of Otolaryngology 1996; 25(5):329-333.

[42] Beidel DC, Horak FB. Behavior therapy for vestibular rehabilitation. Journal of

Anxiety Disorders 2001; 15(1-2):121-130.

[43] Yardley L, Beech S. 'I'm not a doctor': Deconstructing accounts of coping, causes

and control of dizziness. Journal of Health Psychology 1998; 3(3):313-327.

[44] McCracken LM, Eccleston C. Coping or acceptance: what to do about chronic

pain. Pain 2003; 105:197-204.