Equilibrium September 2016 l 1

Whirled Foundation Quarterly Newsletter

Sept 2016 • $5Equilibrium

Labyrinthitis Learn about the symptoms and treatment… See page 6

Feature StoryClinical Psychologist Anthony Bevan liaises with other health care professionals to help sufferers of Vestibular Disorders... See below

President’s Report President John Cook summarises Whirled Foundation’s recent activities and how we build for the future…See page 2

Meniere’s Disease Professor William Gibson introduces us to the Meniere’s Treatment Ladder… See page 8

Anthony Bevan, MSc, BDS, BSc (Hons), M Psych (Clin), MAPS MCCLP is the Director of All Senses Health Care based in Adelaide, South Australia. As a Clinical Psychologist, Anthony focuses on the Clinical-Health Psychology assessment and treatment of people suffering from disorders or dysfunction of any of the sensory systems, especially hearing, balance, and head or neck pain. He liaises with other health care providers in a multidisciplinary team approach.

Anthony is a pioneer in the relatively new field of psycho-neuro-otology that deals with the interconnections between the mind, the brain, and the hearing and balance systems. Anthony’s professional interest in this field spans more than 25 years with his Churchill Fellowship in 1988 including investigation of the application of relaxation procedures to the treatment of distressing tinnitus. Recently he has become the first psychologist member of the Neuro-Otology Society of Australia.

The referral of patients with vestibular disorders or symptoms of dizziness,

imbalance or tinnitus for psychological assessment and treatment often raises many questions in patients’ minds. These questions include: Why would I need to see a psychologist for my “physical symptoms”? Does this mean that my physical symptoms are not real? Sometimes patients will even wonder if this means that they are “crazy”. By the time patients come to see me many of them have consulted a multitude of healthcare providers and have been left feeling very confused as to why no one seems to know what is wrong with them or can help them. The majority of these patients have never consulted a psychologist or psychiatrist before.

Other questions that are commonly troubling patients when they first consult me include: Why am I still suffering from dizziness or imbalance after all this time (many months and sometimes even many years) and why aren’t I getting better? Do I need to get another specialist medical

opinion? If there isn’t any cure for my tinnitus or imbalance, how can I “learn to live with it”?

My aim in this article is to at least begin to answer these puzzling questions from a psychological perspective. In doing so I also hope to help in reducing the stigma that still commonly surrounds mental illness. As a psychologist working in this multidisciplinary field, my main goal therefore is to contribute to alleviation of the suffering experienced by so many people with vestibular disorders or dysfunction. This suffering is often made much worse by the contribution or overlay of mental illness (‘double trouble’).

What Mental Health Problems Are Associated with Vestibular Disorders or Dysfunction?

As for the general population, the most common mental health problems associated with vestibular (continued page 3)

Double Trouble? Mental Health and Vestibular Disorders

2 l Equilibrium September 2016

From The EditorIn this Spring edition of Equilibrium we extend our coverage of vestibular disorders by describing the symptoms and treatment of Labyrinthitis, a commonly occurring and treatable vestibular condition which can sometimes be confused with more deep-seated and longer –lasting conditions.

We also open discussion on the crucial, but vexed, issue of the relationship between Psychological health and physical/ “medical” health by publishing an important and authoritative article by Adelaide Psychologist Anthony Bevan. Anthony tackles complex issues of cause and

effect when describing the crucial importance of the psychological component of Meniere’s disease, vestibular migraine and many other chronic conditions. Whilst there may be room for debate about some of Anthony’s conclusions, no sufferer of a chronic vestibular disorder will ever deny the reality of the significant psychological impact of their disorder on their wellbeing and will gain great benefit from Anthony’s review of psychological conditions and their treatments.

Professor Bill Gibson continues his outstanding input to Whirled Foundation’s Equilibrium with the first instalment of his explanation of the Treatment Ladder for Meniere’s

disease. We look forward to the concluding instalment in our next edition.

Finally, the Editorial team would like to express wholehearted thanks to all those who so generously responded to our recent appeal for donations at a time of financial stress for our organisation. We continue to be totally committed to providing help and advice to all sufferers of chronic vestibular disorders. As a result of the success of the appeal we can continue to do so for some time longer. Many thanks for your ongoing support.

Editor

President’s Report June 2016It was very pleasing to tally up the results of our 2016 End of Tax Year Appeal. We raised an additional $44,000 over what is normally received in June from donations and this is a great result! A key donation was a $20,000 gift from the Clem Jones Foundation in Brisbane. The appeal was also very well supported by Whirled Foundation members, demonstrating the value they see in their membership. Thank You.

The recent online petition initiated by Beatrice Tarnawski calling for medications used to treat Meniere’s disease to be PBS subsidized, gained almost 4000 signatures. This illustrates how widespread Meniere’s and other Vestibular disorders are in the community. However much more needs to be done to raise community awareness and to achieve better diagnosis and treatment.

This is the role of Whirled Foundation and we need to ensure it continues. It would be remiss of me not to report that it is a struggle maintaining and delivering services.

First, we need to increase our regular income to better cover annual staffing costs. We urgently need to find new sources of Trust income and grant income. Legacies and Bequests also build for the future.

Second, too much depends on too few Committee Members. To build for the future we need more suitably qualified people on the Committee. There are many ways you might be able to help, including assisting with our Communications to members, enhancing the services we

offer, helping to influence our profile with Government, finding new avenues for raising funds, and further developing our relationship with the medical community.

Committee Meetings are held 3- 4 times a year by teleconference. If you are interested in joining the Committee please contact Micky on 03 9783 9233 or email micky@whirledfoundation.org

John Cook

President.

Equilibrium September 2016 l 3

disorders are anxiety and depression [1,2]. Significant adjustment issues and grief may occur following onset or diagnosis of a vestibular disorder. If, as occurs with head injury, there is a history of trauma at the onset of the vestibular disorder, then the patient also may be suffering from Posttraumatic Stress Disorder (PTSD). In cases where the physical symptoms cannot be fully explained by a medical condition, the person may be suffering from a Somatic Symptom Disorder.

The anxiety disorders most commonly associated with vestibular symptoms are Panic Disorder and phobias, including agoraphobia, positional or postural phobia, and falling or space phobia. Generalized Anxiety Disorder is commonly associated with persistent, non-medical dizziness or imbalance.

The characteristic features of Panic Disorder are recurrent unexpected panic attacks along with: (a) persistent worry or concern about having additional attacks or their consequences such as having a vertigo attack; and/or (b) behaviours designed to avoid having panic attacks; for example, avoiding certain head movements [3]. Agoraphobia often occurs with Panic Disorder.

Agoraphobia is an anxiety disorder in which marked fear or anxiety and behavioural avoidance are experienced about being in places and situations from which either: (a) escape might be difficult; or (b) help may not be available in the event of having panic-like symptoms or other embarrassing or incapacitating symptoms, for example a Meniere’s or dizziness attack in public [3].

Generalized Anxiety Disorder (GAD) is characterized by proneness to excessive and uncontrollable worry [3]. High levels of health anxiety are often experienced by people with pre-

existing GAD who develop vestibular dysfunction.

Although not everyone with a vestibular disorder will suffer from depression, depression is commonly found in vestibular patients [4]. Depression associated with vestibular disorders or dysfunction can manifest as Major Depressive Disorder (often referred to as clinical depression) or depressed mood. The depression may have existed prior to the onset of the vestibular dysfunction (primary depression) or, more commonly, it arises as a consequence of changes in behaviour caused by the vestibular disorder (secondary depression). Secondary depression typically results from the reduced engagement in social, recreational and work activities that normally provide pleasure and a sense of achievement. Secondary depression is often associated with secondary agoraphobia caused by the vestibular disorder. Depression is a significant predictor of fear of falling in dizzy elderly patients [5]. In some people with vestibular disorders pre-existing depression is exacerbated (‘double’ depression).

Significant adjustment issues and/or grief can arise from the diagnosis of any medical condition. Sudden, profound hearing loss, as for example arising from acute labyrinthitis, typically causes severe social and emotional adjustment issues. Distressing anxiety, anger, and/or depression commonly occur. The communication and relationship difficulties stemming from hearing impairment often create additional suffering.

Somatic Symptom Disorders are a group of psychological disorders characterized by physical symptoms, for example tinnitus or imbalance, that cause significant distress and impairment of everyday functioning. In Somatic Symptom Disorders the physical symptoms are associated

with abnormal thoughts, feelings, and behaviours [3]. Significant health anxiety is a common feature. While the physical symptoms in Somatic Symptom Disorders cannot be fully explained by a medical condition, it is important to note that a Somatic Symptom Disorder may occur along with a vestibular disorder or some other medical condition. Persistent Postural-Perceptual Dizziness (previously called Chronic Subjective Dizziness) can be viewed as a subtype of Somatic Symptom Disorder in which dizziness and/or imbalance are the troublesome physical symptoms.

How Do Mental Health Issues Affect People with Vestibular Disorders or Dysfunction?

Just as mental health issues can affect anyone, mental health problems can occur in anyone with vestibular dysfunction. As there are strong connections between regions of the brain that regulate our negative emotions and both the auditory [6] and balance systems [7], there is often substantial crossover between dizziness, vertigo, or tinnitus and psychological or psychiatric symptoms. Hence mental health problems are very common in people with vestibular dysfunction and it can be difficult to determine what is causing or maintaining the distressing bodily symptoms. For example, patients with Panic Disorder often have abnormal vestibular test results [8] and patients with dizziness often meet Panic Disorder criteria [9]. Some vestibular symptoms are triggered in situations involving long visual distances or misleading cues for motion or balance such as brightly lit supermarket aisles with high gloss floors. This can lead to avoidance behaviours similar to those found in agoraphobia and height phobia [10].

Psychosocial factors appear to contribute to dizziness and imbalance

Double Trouble? Mental Health and Vestibular Disorders (from page 1)

4 l Equilibrium September 2016

in up to 70% of outpatient visits [11] and the majority of patients presenting with chronic tinnitus at audiology clinics have mental disorders [12]. Tinnitus distress is commonly associated with heightened anxiety, depression, and general arousal. Severe tinnitus is linked with a major depression [13]. Troublesome tinnitus is more frequent among patients with Somatic Symptom Disorders [14] and often contributes to insomnia [15]. Some patients abuse alcohol or other drugs in attempt to cope with their tinnitus distress.

Many patients with dizziness have a pattern of symptoms that does not match a clearly defined vestibular syndrome and therefore their symptoms cannot be fully explained by a medical condition [16]. Often their psychological condition(s) are the explanation for some of their symptoms. A greater incidence of vestibular abnormalities is found in patients with higher anxiety levels [17]. Even in people who do not have any vestibular dysfunction, increased levels of anxiety are associated with poorer balance [18] and the vestibular-eye reflex is impaired in patients with anxiety disorders [19]. Therefore, the high prevalence of mental disorders in dizzy patients of up to 46% [20] increases the likelihood of dizziness and imbalance.

Anxiety and depressive disorders have been found in 57% of patients with Meniere’s disease and 65% of patients with vestibular migraine, levels three times higher than in patients who had either vestibular neuritis or BPPV and people with no vestibular dysfunction [21]. The prevalence of Panic Disorder in vestibular and neurology clinics is up to 3 times higher than in mental health outpatient clinics where the prevalence is 10% [22].

The Overlap between Vestibular Disorders and Mental Disorders

The crossover between mental disorders and vestibular disorders often leads to confusion for both patients and their health care providers. The difficulty with distinguishing anxiety disorders from vestibular disorders stems from them sharing some of the same symptoms. For example, dizziness is a very common symptom of a panic attack and spatial disorientation can occur with heightened levels of anxiety. Situations that worsen vestibular dysfunction are often the same as those that trigger anxiety attacks; for example, supermarket shopping or certain head movements. Both people with anxiety disorders and people with a history of vestibular disorders typically experience avoidance behaviours designed to prevent or reduce their troublesome or distressing symptoms. For example, avoiding going to supermarkets or avoiding lying flat on their back. Even when anxiety levels are low, postural instability is often associated with agoraphobic avoidance [23]. ‘Safety behaviours’ also commonly occur in both people with anxiety disorders and people with a history of vestibular dysfunction; for example, the habit of always carrying a walking stick to prevent falling.

The bio-medical model originating in the mid-19th century is based on complete separation of mind and body. With the dawn of behavioural medicine in the 1970s and research stemming from advances in brain imaging methods over the past 20 years, the interconnections between mind, brain and body have become well-established. The extent of these interconnections has been highlighted by MRI studies that have found not only functional but structural changes in the brains of people who have completed an eight week course of

Mindfulness-Based Stress Reduction [24]. It is of special interest to us that the increases in brain cells in these studies occur not only in regions of the brain involved in regulation of negative emotions but also in regions of the brain with major roles in balance and spatial memory.

A very high proportion of dizzy patients complain of fatigue and difficulty concentrating. Fatigue and difficulty concentrating are common features of depression. As spatial orientation and postural control are significantly demanding upon attention and the brain’s capacity to process information, the resulting state of “cognitive overload” may contribute to depression [25].

Stress and Vestibular Dysfunction

Events that damage the vestibular system also activate the primitive stress (threat) response in the brain. Episodes of vertigo are typically distressing and may cause a lot of anxiety. An optimal stress response is necessary to bring about vestibular compensation, especially in the early (acute) stage of a vestibular disorder [26].

If the threat system remains activated beyond the acute stage, vicious cycles of heightened threat arousal and increased vestibular symptoms confirm the patient’s belief that something is seriously wrong. This hyper-vigilance around any changes in bodily symptoms results in more attention

Double Trouble? Mental Health and Vestibular Disorders (from page 3)

Episodes of Vertigo can cause stress

Equilibrium September 2016 l 5

being given to physical symptoms such as dizziness, imbalance, or tinnitus, thereby undermining recovery (compensation or habituation). These changes in attention are associated with heightened levels of health anxiety and may result in the patient becoming fixed in their belief that they are still suffering from the same medical condition that first caused their symptoms [27], even though full vestibular compensation has occurred. Some people are prone to being fearful of any arousal-related body sensations because of their belief that such sensations are dangerous or harmful. These people have what is called “anxiety sensitivity”. Higher levels of anxiety sensitivity are significantly associated with greater tinnitus distress [28, 29]. Furthermore, researchers have found that higher levels of anxiety sensitivity are significantly associated with more emotional handicap from dizziness and reported discomfort from Meniere’s disease [30].

Unpredictability or lack of control over vertigo episodes, as occurs in Meniere’s disease or vestibular migraine, increases distress and thereby interferes with compensation or habituation. Chronic stress from persistent or recurrent physical symptoms can lead to persistent vestibular dysfunction; therefore, stress can be both a cause and an effect of vestibular symptoms. Chronic or repeated episodes of dizziness, vertigo or imbalance lead to higher rates of secondary anxiety or depressive disorders [21].

How Do Psychological Factors Influence the Onset or Course of Vestibular Dysfunction or Disorders?

Psychological factors are the strongest predictors of progression from acute (short-term) dizziness or tinnitus distress to persistent or chronic (long-term) illness. The main psychological factors involved in dizziness or troublesome tinnitus becoming chronic

are: catastrophic thinking (for example, thinking that the tinnitus or dizziness will never get better), cumulative stress, health anxiety, anxiety sensitivity and obsessive-compulsive personality features [31, 32, 33].

Another possible contribution to the maintenance of chronic dizziness is over-breathing or hyperventilation syndrome which commonly arises with chronic stress and anxiety. Over breathing or hyperventilation indirectly (via increased blood acidity) reduces the amount of oxygen that can reach the brain cells [34]. As the brain is extremely sensitive to even small deficits in oxygen supply, many untoward physical symptoms arise with hyperventilation, including lightheadedness or dizziness. Panic attacks are associated with acute hyperventilation and dizziness, lightheadedness, or unsteadiness are common symptoms of panic attacks [3].

The process by which psychological stress or emotional conflict is unconsciously expressed as physical symptoms is known as ‘somatization’. We have all experienced somatization in one form or another, as for example butterflies in the stomach when giving a speech. Somatization can be a major cause of dizziness or other bodily symptoms leading to treatment seeking, in which case a diagnosis of a Somatic Symptom Disorder may be given.

How Are Comorbid Mental and Vestibular Disorders Best Diagnosed and Treated?

Clinical Psychologists are highly trained in the assessment and treatment of mental disorders. Health psychology is the branch of psychology that deals with the relationships between medical conditions and psychological factors. Therefore, psychologists with a background in both clinical and health psychology are best qualified to

provide psychological assessment and treatment to people with vestibular dysfunction and/or associated troublesome physical symptoms.

There have been three generations of evidence-based psychotherapies: (1) behavioural therapies, (2) cognitive behavioural therapies (CBT), and (3) mindfulness-based therapies. All of these psychotherapies can have an important role in the treatment of both mental disorders and vestibular dysfunction. Some components of Vestibular Rehabilitation Therapy are based on principles of behaviour therapy. Over the past 20 years a very large body of research evidence has accumulated showing the effectiveness of CBT in the treatment of distressing tinnitus [35, 36, 37]. Furthermore, there is growing evidence for the effectiveness of CBT in the treatment of vestibular dysfunction [38] and chronic, non-medical dizziness [39, 40]. One study found breath retraining to be effective in reducing dizziness distress in patients with chronic vestibular disease [41]. It seems very likely that further research into the application of mindfulness- and acceptance-based therapies to the treatment of distressing tinnitus and persistent dizziness or imbalance will establish them as recommended treatments [42, 43, 44, 45].

(References for this article can be found on page 11)

If the information contained in this article has raised any immediate mental health concerns for you, then you can obtain telephone support from either:

Lifeline Australia on 13 11 14 or Beyondblue on 1300 22 4636.

For non-urgent mental health issues, you can consult your General Medical Practitioner regarding referral to a suitable Clinical Psychologist.

6 l Equilibrium September 2016

Vest

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Labyrinthitis is an inner ear infection. It causes a delicate structure deep inside your ear called the labyrinth to become inflamed, affecting your hearing and balance.

The labyrinth is the innermost part of the ear. It contains two important parts:

• thecochlea–thissmall,spiral-shapedcavityrelayssounds to the brain and is responsible for hearing

• thevestibularsystem–acomplexsetoffluid-filledchannels that contributes to your sense of balance. The vestibular fluid moves when you move your head, telling your brain how far, fast and in what direction your head is moving. This allows your body to balance properly.

Inflammation of the labyrinth can disrupt both your hearing and sense of balance, triggering the symptoms of labyrinthitis.

The labyrinth usually becomes inflamed either because of:

• aviralinfection,suchasacoldorflu

• abacterialinfection,whichismuchlesscommon

The most common symptoms of labyrinthitis are dizziness, hearing loss and vertigo – the sensation that you, or the environment around you, is moving.

These symptoms can range from mild to severe, with some people feeling that they are unable to remain upright.

The vestibular system works in a similar way to a stereo, with your left and right ears sending separate signals to your brain. If one ear becomes infected, these signals become out of sync, which confuses your brain and triggers symptoms such as dizziness and loss of balance.

Certain things can make the dizziness worse, including:

• coldsorillness

• thedark

• beingincrowdedareasorsmallrooms

• tiredness

• menstruation

• walking

Other symptoms can include:

• afeelingofpressureinsideyourear(s)

• ringingorhumminginyourear(s)(tinnitus)

• fluidorpusleakingoutofyourear(s)

• earpain

• feelingsick(nausea)orbeingsick

• ahightemperature(fever)of38C(100.4F)orabove

• changesinvision,suchasblurredvisionordoublevision

• mildheadaches

WHO GETS LABYRINTHITIS?

Most cases of viral labyrinthitis occur in adults aged 30 to 60 years old.

Viral labyrinthitis is relatively common in adults. Bacterial labyrinthitis is much less common. Younger children under two years old are more vulnerable to developing bacterial labyrinthitis.

Bacterial labyrinthitis carries a higher risk of causing permanent hearing loss, particularly in children who have developed it as a complication of meningitis.

CAUSES OF LABYRINTHITIS

Viral labyrinthitis

Around half of all cases of viral labyrinthitis are thought to be caused when a viral infection of the chest, nose, mouth and airways – such as the common cold or flu – spreads to the inner ear.

Infections that affect the rest of the body, such as measles, mumps or glandular fever, are a less common cause of viral labyrinthitis.

Bacterial labyrinthitis

Bacteria can enter the labyrinth if the thin layers of tissue that separate your middle ear from your inner ear are broken. This can happen if you have a middle ear infection or an infection of the brain lining (meningitis). Bacteria can also get into your inner ear if you have had a head injury.

Immune system problems

Labyrinthitis often develops in people who have an

Labyrinthitis

Equilibrium September 2016 l 7

underlying autoimmune condition (where the immune system mistakenly attacks healthy tissue rather than fighting off infections).

DIAGNOSING LABYRINTHITIS

Many conditions can cause dizziness and vertigo. Your GP will usually diagnose labyrinthitis based on your symptoms, your medical history and a physical examination.

Your GP may carry out the following tests:

• aphysicalexamination–youmaybeaskedtomoveyour head or body and your ears will be checked for signs of inflammation and infection

• hearingtests–labyrinthitisismorelikelyifyouhavehearing loss

Your GP will also check your eyes. If they are flickering uncontrollably, it is usually a sign that your vestibular system is not working properly.

Further testing

Further testing is usually only required if you have additional symptoms that suggest you may have a more serious condition, such as meningitis or a stroke. Symptoms can include:

• severeheadache

• mentalconfusion

• slurredspeech

• weaknessorparalysisononesideofyourbody

These tests can include:

• alumbarpuncture–afluidsampleistakenfromthebase of your spine and checked for infection

• computerisedtomography(CT)scan–togiveathree-dimensional picture of your brain

• magneticresonanceimaging(MRI)scan–togiveadetailed image of your brain

• bloodtests

TREATING LABYRINTHITIS

In most cases, the symptoms pass within a few weeks. Treatment involves a combination of bed rest and medication to help you cope better with the symptoms. You may need additional medication to fight the underlying infection, although antibiotics are not often required as the cause is most commonly due to a virus.

A small number of people have persistent symptoms that last for several months, or possibly years. This requires a more intensive type of treatment called vestibular rehabilitation therapy (VRT).

VRT is an effective treatment for people with chronic labyrinthitis. VRT trains your brain to use the information from your eyes, joints and muscles to compensate for the confusing information coming from your inner ear.

Not all physiotherapists have training in VRT, so you need to make it clear you require this type of treatment before making an appointment and make sure the therapist you choose is not only a member of a recognised body, such as the Australian Physiotherapy Association (APA), but has relevant experience in VRT.

Self-help

Drink plenty of liquid, little and often, particularly water, to avoid becoming dehydrated.

In its early stages, you may feel constantly dizzy and it can give you severe vertigo. You should rest in bed to avoid falling and injuring yourself. After a few days, the worst of these symptoms should have passed and you should no longer feel dizzy all the time.

You can do several things to minimise any remaining feelings of dizziness and vertigo. For example:

• duringanattack,liestillinacomfortableposition(onyour side is often best)

• avoidalcohol

• avoidbrightlights

• trytocutoutnoiseandanythingthatcausesstressfrom your surroundings

Medication

If your dizziness, vertigo and loss of balance are particularly severe, your GP may prescribe a short course of medication such as benzodiazepine or antiemetics (vestibular sedatives).

Benzodiazepine

Benzodiazepines reduce activity inside your central nervous system. This means your brain is less likely to be affected by the abnormal signals coming from your vestibular system.

However, long-term use of benzodiazepines is not recommended because they can be highly addictive if used for long periods.

Antiemetics

A prescription medication known as an antiemetic may be prescribed if you’re experiencing nausea and vomiting.

Prochlorperazine 5mg tablets are an antiemetic used to treat the symptoms of vertigo and dizziness. It may be considered as an alternative treatment to benzodiazepines.

(Cont’d page 12)

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Men

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After a diagnosis of Meniere’s Disease has been established, the family doctor or the specialist will consider the most appropriate treatment. The ‘treatment ladder’ shows steps that are usually taken in Australia from the most benign therapies to the most radical surgery. I will be writing brief explanations about each group of steps along the treatment ladder.

The medical treatments, introduction

After suffering fearsome attacks of vertigo preventing a normal family and working life, the newly diagnosed sufferer may demand surgical treatments but it should be remembered that the final outcome may be better if surgery is avoided. Meniere’s disease sufferers must remember that the condition will eventually ‘burn out’ leaving some hearing and balance in the affected ear. There is always ‘a light at the end of the tunnel’ although the problem is how long is the tunnel.

‘Burn out’ is the most usual end point of the disease. At this stage the balance organ has lost its fire power and has become so weak that it cannot cause severe attacks. The hearing no longer fluctuates and there is a severe hearing loss in the affected ear. The tinnitus remains and can bother some people much more than others especially if they are unable to ignore it. Tinnitus is rather like a noisy refrigerator – some people completely forget it is there while others find it intolerable. The feeling of blockage in the ear usually fades away at burn

out. Modern hearing aids are usually effective in restoring some useable hearing and in lessening any tinnitus.

Although sufferers welcome ‘burn out’, it is not a cure just the end point of the disease. The problem is that ‘burn out’ may take many years to occur especially if there are prolonged periods of remission.

Medical treatment can be the alleviation of symptoms during an attack or treatments which aim at preventing further attacks occurring. Alleviation during attacks is usually achieved using antiemetics / antinauseants. In Australia, Stemetil™ (prochlorperazine) is usually given either by an injection in the hospital, or by using a suppository (25mg), or by using tablets (each is 5mg). To get an effective oral dose of Stemetil™ at least 4 tablets are required and these may have to be chewed or they can be vomited out too easily. Stemetil™ should be used cautiously as long term therapy because it will cause Parkinsonian-like symptoms. A better oral medication is Zofran™ (ondansetron) which is effective in stopping the nausea and vomiting but does not stop the attack. It is placed under the tongue to dissolve avoiding any tendency to vomit it away. To stop

the nausea and vomiting during a Meniere’s attack, 8mg is the minimum dose.

The treatment ladder concerns the measures taken to prevent further attacks occurring.

STEP ONE - Reassurance

When the first attack occurs, the sufferer is usually rushed to hospital fearing they have suffered a cerebral event or heart attack. Reassurance that there is not a terminal illness is needed.

Once the diagnosis has been reached, reassurance can help prevent further attacks. Stress and anxiety are believed to precipitate attacks both of Meniere’s disease and migraine, although the evidence is only anecdotal. Reassurance should be given that Meniere’s disease will not continue to cause attacks for the rest of the person’s life. In the early stages, prolonged remissions are common and indeed some fortunate people will never have a flare up of the disease again. In the less fortunate sufferers the attacks will continue often in clusters at intervals, but the attacks will get weaker and weaker until the attacks are barely noticeable. There

THE MENIERE’S TREAMENT LADDEREmeritus Professor William P R Gibson MD FRACS FRCS The University of Sydney

Equilibrium September 2016 l 9

are treatments available to lessen the frequency and severity of the attacks until a natural ‘burn out’ occurs. It is very reassuring for the sufferer to know these facts and by lessening the stress and anxiety, a positive start is made.

STEP TWO - A salt reduced diet

It is widely believed that salt (sodium chloride) increases endolymphatic hydrops and can precipitate attacks of vertigo. The concept was introduced in 1932 by Mygind and Dedering[1]. Dedering suffered from Meniere’s herself and documented how increased dietary salt caused her attacks. Over the years many sufferers have given anecdotal evidence that salt exacerbates their condition. Scientific evidence is not possible as the sufferer would easily know if they were being given salt or not. However Harrison and Naftalin[2] did undertake a study when they gave a 5G supplement of salt to the diet of Meniere’s sufferers. They showed that this often was followed by an attack of vertigo and there was an increase in the urinary sodium output at the time of the attack. The study had to be concluded as it distressed many of the participants and nowadays I doubt if ethical approval would be given again.

The author is convinced that controlling dietary salt is important and very effective especially in sufferers who had a high salt intake prior to the onset of the condition. Similarly, scientific evidence for reducing sugar, caffeine and nicotine is lacking but many sufferers have found these extra steps to be helpful.

STEP THREE - Diuretics and Urea

Diuretics are medicines that reduce the amount of water in the body. Most diuretics also reduce sodium levels. Diuretics are commonly used to treat high blood pressure and oedema. Klockhoff and Lindblom in 1967[3] reported success using hydrochlorothiazide. Subsequent studies also reported success but were criticised for poor design and control. The best designed study using Diazide (hydrochlorothiazide and triamterene)[4] showed a statistically favourable effect on the vertigo but did not halt the progression of hearing loss or affect tinnitus.

There are significant side effects caused by diuretics. The commonest side effect is postural hypotension, or on standing the blood pressure can fall significantly making the person dizzy. On starting a diuretic the person should not stand up too quickly and often within a few days this side effect seems to lessen. More seriously prolonged use of diuretics can lower potassium which has effects on the heart. After every few months a blood test is necessary and in some cases a potassium supplement is required.

There is no need to restrict water intake. The Japanese have treated Meniere’s sufferers by giving them 70ml of plain water per kilogram body weight daily as this lowers sodium which decreases intracellular fluid. This is only helpful when there is a bathroom handy!

Urea is an osmotic diuretic which has a very simple chemical formula CO(NH2)2. It is a major constituent of urine and the fertiliser put on the ground is often made from cattle urine. Those who take urea to control their Meniere’s disease will be relieved to know that the urea used medically is made chemically rather than biologically! Urea acts by drawing intracellular fluid into the

blood stream and it probably removes some endolymph. The other osmotic diuretics are glycerol which tastes like diesel oil and isosorbide which tastes sickly sweet. Studies of osmotic diuretics show that the hearing improves temporarily both subjectively and objectively (electrocochleography shows a reduction in the summating potential). Hence urea is given as a diagnostic test for Meniere’s because the hearing only improves when endolymphatic hydrops is present.

Usually 30 grams of urea is taken in a minimum amount of fluid as it tastes foul. Excessive urea damages the liver and kidneys so it cannot be given to people with liver or kidney problems. In otherwise healthy people the maximum safe daily dose is 1gram /per kilogram body weight.

A few hardy souls take urea on a daily basis to prevent attacks and to maintain hearing. Most sufferers only use it as a ‘Cinderella medicine’ which guarantees freedom from attacks for 3-4 hours. It can be used to attend important events such as weddings but when the clock strikes the third time, any protection from vertigo is lost!

STEP FOUR - Betahistine

Betahistine dihydrochloride (Serc™) is a vasodilator; a substance which dilates blood vessels. The use of vasodilators is based on a concept that reduced blood flow in the cochlea results in an accumulation of metabolites and a consequent rise in osmotic pressure causing a transfer of fluid into the endolymph compartment. The stria vascularis is the blood vessel within the endolymph compartment of the inner ear and it is hoped that vasodilatation of this vessel decreases the metabolite accumulation and increases the radial absorption of endolymph.

Based on this theory in the 1950’s the cervical sympathetic nerve supply to

10 l Equilibrium September 2016

the ear was destroyed surgically[5]. Apart from its effect on the ear, it also caused constriction of the pupil of the eye, loss of sweating on the same side of the face and a dropping eyelid. It was soon abandoned! Less dramatically, a vasodilator medication called nictotinic acid was given causing flushing of the face. Betahistine hydrochloride replaced nictotinic acid as it did not cause flushing of the skin and some experimental evidence showed it did have an effect on the blood flow[6] through the cochlea. However, the original hypothesis that there is a vascular cause of Meniere’s disease is in doubt.

Betahistine (Serc®) has become the most utilised treatment in Europe. The long term use is supposed to lessen the likelihood of future attacks of vertigo and to halt the loss of hearing. There is no advantage in taking it when an attack is pending or during an attack. The scientific evidence is blurred and the Cochrane review states that ‘there is insufficient evidence to say whether betahistine has any effect on Meniere’s disease’[7].

References

1 Mygind SR, Dedering D (1932) Significance of water metabolism in general pathology as demonstrated by experiments on ear. Acta Otolaryngol, 17, 424-466.

2 Harrison MS, Naftalin I (1968) Meniere’s Disease: Mechanism and Management. Springfield, Charles C Thomas

3 Klockhoff I, Lindblom U (1967) Meniere’s disease and hydrochlorothiazide- a critical analysis of symptoms and therapeutic effects. Acta Otolaryngol, 63, 347-365.

4 Ruckenstein MJ, Rutka JA, Hawke M (1991) The treatment of Meniere’s disease: Torok revisited. Laryngoscope, 101, 620-622

5 Pass ERG, Seymour JC (1948) Cervical sympathectomy in the treatment of Meniere’s disease. J Laryngol, 812-821

6 Wilmot T J, Menon GN (1976) Betahistine in Meniere’s disease, J Laryngol 90, 833-840

7 James A, Burton MJ (2001) Betahistine for Meniere’s disease or syndrome Cochrane Database of Systemic Reviews 1: CD001873 DOI 101002/2/14651858 2001

“The No Salt Cookbook” written by Meniere’s sufferer Emily George.

In her recipes Emily focuses on using a wide variety of foods to suit different tastes, using herbs and spices for flavour rather than salt.

This hardcover cookbook contains 86 recipes covering little bites, entrees, soups, salads, mains, side dishes and sweets each with a full colour photo

Purchase your copy today for $35 + P&H. To order your copy call Whirled Foundation on 03 9783 9233 or 1300 368 818.

THE NO SALT COOK BOOK

Equilibrium September 2016 l 11

Art

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Double Trouble? Mental Health and Vestibular Disorders

References:

1. Eckhardt-Henn, A., et al (2003). Anxiety disorders and other psychiatric subgroups in patients complaining of dizziness. Journal of Anxiety Disorders, 17, 369-388.

2. Savastino M., Marioni G., & Aita M. (2007). Psychological characteristics of patients with Meniere’s disease compared with patients with vertigo, tinnitus, or hearing loss. Ear Nose Throat Journal, 86, 148-156.

3. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

4. Grunfeld, E. A., et al (2003). Screening for depression among neuro-otology patients with and without identifiable vestibular lesions. International Journal of Audiology, 42, 161-165.

5. Burker, E.J., et al (1995). Predictors of fear of falling in dizzy and nondizzy elderly. Psychology and Aging, 10, 104-110.

6. Maudoux, A., et al (2012). Auditory resting-state network connectivity in tinnitus: A functional MRI study. PLoS ONE, 7(5): e36222.

7. Balaban, C.D., Jabob, R. G., & Furman, J. M. (2011). Neurologic bases for comorbidity of balance disorders, anxiety disorders and migraine: neurotherapeutic implications. Expert Reviews in Neurotherapy, 11, 379-394.

8. Jacob R.G., et al (1996). Panic, agoraphobia, and vestibular dysfunction. American Journal of Psychiatry, 153, 503-512.

9. Clark, D. B., et al (1994). Panic in otolaryngology patients presenting with dizziness or hearing loss. American Journal of Psychiatry, 151, 1223-1225.

10. Jacob, R. G., et al (1992). Vestibular symptoms, panic, and phobia. Annals of Clinical Psychiatry, 4, 163-174.

11. Eckhardt-Henn, A. et al (2003). Anxiety disorders and other psychiatric subgroups in patients complaining of dizziness. Journal of Anxiety Disorders, 17, 369-388.

12. Marciano, E., et al. (2003). Psychiatric comorbidity in a population of outpatients affected by tinnitus. International Journal of Audiology, 42, 4-9.

13. Harrop-Griffiths, J., et al. (1987). Chronic tinnitus: Association with psychiatric diagnoses. Journal of Psychosomatic Research, 31, 613-621.

14. Hiller, W., Janca, A., & Burke, K. C. (1997). Association between tinnitus and somatoform disorders. Journal of Psychosomatic Research, 43, 613-624.

15. Schecklmann, M., et al (2015). Psychophysiological associations between chronic tinnitus and sleep: A cross validation of tinnitus and insomnia questionnaires. BioMed Research International, 2015, ID 461090

16. Furman, J. M. & Jacob, R. G. (1997). Psychiatric dizziness. Neurology, 48, 1161-1166.

17. Eagger, S., et al (1992). Psychiatric morbidity in patients with peripheral vestibular disorder: a clinical and neuro-otological study. Journal of Neurology, Neurosurgery, and Psychiatry, 55, 383-387.

18. Kogan, E., et al (2008). Comorbidity between balance and anxiety disorders: Verification in a Normal Population. The Journal of Psychology, 142, 601-613.

19. Yardley, L., et al (1995). Effects of anxiety arousal and mental stress on the vestibulo-ocular reflex. Acta Oto-Laryngologica, 115, 597-602

20. Kroenke, K., et al (2007). Psychiatric disorders and functional impairment in patients with persistent dizziness. Journal of General Internal Medicine, 8, 530-535.

21. Eckhardt-Henn, A., et al (2008). Psychiatric comorbidity in different organic vertigo syndromes. Journal of Neurology, 255, 420-428.

22. American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Arlington, VA: Author.

23. Yardley, L., et al (1995). Relationship between balance system function and agoraphobic avoidance. Behaviour Research and Therapy, 33, 435-439.

24. Holzel, B. K., et al (2011). Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry Research, 191, 36-43.

25. Yardley, L. (2000). Overview of psychologic effects of chronic dizziness and balance disorders. Otolaryngologic Clinics of North America, 33, 603-616.

26. Saman, Y., et al (2012). Interactions between stress and vestibular compensation – a review. Frontiers in Neurology, 3, 1-8.

27. Best, C., et al (2006). Interaction of somatoform and vestibular disorders. Journal of Neurology, Neurosurgery & Psychiatry, 77, 658-664

28. Andersson, G., & Vretblad, P. (2000). Tinnitus and anxiety sensitivity. Scandinavian Journal of Behaviour Therapy, 29, 57-64.

29. Hesser, H., & Andersson, G. (2009). The role of anxiety sensitivity and behavioral avoidance in tinnitus disability. International Journal of Audiology, 48, 295-299.

30. Hagnebo, C., Melin, L., & Andersson, G. (1999). Coping strategies and anxiety sensitivity in Meniere’s disease. Psychology, Health & Medicine, 4, 17-26.

31. Asmundson, G. J. G., Wright, K. D., & Hadjistavropoulos, H. D. (2000). Anxiety sensitivity and disabling chronic health conditions. Scandinavian Journal of Behaviour Therapy, 29, 100-117.

32. Cima, R. F., Crombez, G., & Vlaeyen, J. W. (2011). Catastrophizing and fear of tinnitus predict quality of life in patients with chronic

tinnitus. Ear Hear, 32, 634-641.

33. Magnusson, P. A., Nilsson, A., & Henriksson N. G. (1977). Psychogenic vertigo within an anxiety frame of reference: an experimental study. British Journal of Medical Psychology, 50, 187-201.

34. Fried, R. & Grimaldi, J. (1993). The psychology and physiology of breathing in behavioral medicine, clinical psychology, and psychiatry. New York: Plenum Press.

35. Martinez, D. P., et al (2007). Cognitive behavioural therapy for tinnitus. Cochrane Database Systematic Reviews, 1, CD005233.

36. Hoare, D. J., et al (2011). Systematic review and meta-analyses of randomized controlled trials examining tinnitus management. Laryngoscope, 121, 1555-1564.

37. Grewal, R., et al (2016). Clinical efficacy of tinnitus retraining therapy and cognitive behavioural therapy in the treatment of subjective tinnitus: a systematic review. The Journal of Laryngology & Otology, 130, S39-S44.

38. Johansson, M., et al (2001). Randomized controlled trial of vestibular rehabilitation combined with cognitive-behavioural therapy for dizziness in older people. Otolaryngology Head & Neck Surgery, 125, 151-156

39. Andersson G., et al (2006). A controlled trial of cognitive-behavior therapy combined with vestibular rehabilitation in the treatment of dizziness. Behaviour Research & Therapy, 44, 1265-1273.

40. Mahoney, A. E. J., Edelman, S., & Cremer, P. D. (2012). Cognitive behaviour therapy for chronic subjective dizziness: longer-term gains and predictors of disability. American Journal of Otolaryngology, 34, 115-120.

41. Jauregui-Renaud, K., Padron, L. A. V., & Gomez, N. S. C. (2007). The effect of vestibular rehabilitation supplemented by training of the breathing rhythm or proprioception exercises, in patients with chronic peripheral vestibular disease. Journal of Vestibular Research, 17, 63-72.

42. Hesser, H., et al (2009). Clients’ in-session acceptance and cognitive defusion behaviors in acceptance-based treatment of tinnitus distress. Behaviour Research and Therapy, 47, 523-528.

43. Naber, C. M., et al (2011). Interdisciplinary treatment for vestibular dysfunction: the effectiveness of mindfulness, cognitive-behavioral techniques, and vestibular rehabilitation. Otolaryngology – Head & Neck Surgery, 145,

117-124.

44. Philippot, P., et al (2012). A randomized controlled trial of mindfulness-based cognitive therapy for treating tinnitus. Clinical Psychology & Psychotherapy, 19, 411-419.

45. Roland, L. T., et al (2015). Effects of mindfulness based stress reduction therapy on subjective bother and neural connectivity in chronic tinnitus. Otolaryngology – Head & Neck Surgery, 152, 919-926.

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Important Notice and Disclaimer

Information in Equilibrium is not intended to be a substitute for individual professional medical advice, diagnosis, or treatment.

You should not alter, discontinue, or refrain from taking any medication, or refrain from having any other medical treatment, as a consequence of information obtained from this newsletter. Unless you are medically qualified, you should not diagnose your own condition, or the condition of others. You should always consult a medical practitioner (such as a GP or a specialist) for advice about these matters.

Never disregard professional medical advice or delay in seeking it because of something you have read here.

Opinions and views expressed in letters and articles in this newsletter may not necessarily represent the views of the Whirled Foundation Inc. or the editors of Equilibrium.

Whirled Foundation Inc., its Committee of Management, and the editors of Equilibrium expressly disclaim any and all liability resulting from the use of information published in any edition of Equilibrium.

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Whirled Foundation welcomes articles from health and other professionals, personal stories, letters to the editor, recipes and other articles related to vestibular disorders, and the management strategies for vertigo tinnitus and hearing loss.Material for publication needs to be received by the dates as listed below.(Insert fee covers insertion only, not printing)For contact details regarding the submission of material, see contact details below.

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Most people are able to tolerate prochlorperazine and side effects are uncommon, but can include:

• tremors(shaking)

• abnormalorinvoluntarybodyandfacialmovements

• sleepiness

If you are vomiting, there is a prochlorperazine 3mg tablet available which you place inside your mouth between your gums and cheek.

Corticosteroids

Corticosteroids such as prednisolone may be recommended if your symptoms are particularly severe. They are often effective at reducing inflammation.

Antibiotics

If your labyrinthitis is thought to be caused by a bacterial infection, you will be prescribed antibiotics. Depending on how serious the infection is, this could either be antibiotic tablets or capsules (oral antibiotics) or antibiotic injections (intravenous antibiotics).

CHRONIC LABYRINTHITIS

A small number of people experience dizziness and vertigo for months or even years. This is sometimes known as chronic labyrinthitis.

The symptoms are not usually as severe as when you first get the condition, although even mild dizziness can have a considerable impact on your quality of life, employment and other daily activities.

WHEN TO SEEK FURTHER ADVICE

Contact your GP if you develop additional symptoms that suggest your condition may be getting worse. If this happens, you may be admitted to hospital. These symptoms include:

• mentalconfusion

• slurredspeech

• doublevision

• weaknessornumbnessinonepartofyourbody

• achangeinthewayyouusuallywalk

Also contact your GP if you do not notice any improvement after three weeks. You may need to be referred to an ear, nose and throat (ENT) specialist.

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