Comorbid disorders and therapy of persistent postural perceptual dizziness

Abstract

Persistent postural perceptual dizziness (PPPD) is the most common cause of vague chronic vertigo and severely limits patients' quality of life.Limited data are available on comorbidities, the typical treatment of patients with PPPD, and the efficacy of combination therapy for PPPD.Objective: to identify comorbid disorders and evaluate the efficacy of complex therapy in patients with PPPD.Material and methods. Sixty patients (mean age 42.5±13.8 years) with PPPD were studied. All patients were prescribed complex treatment that included antidepressants (selective serotonin reuptake inhibitors), vestibular exercises, and an educational program. In 28 patients, Arlevert (combination of cinnarizine 20 mg + dimenhydrinate 40 mg) was used as drug therapy. A clinical otoneurologic examination, videonystagmography, assessments by Hospital Anxiety and Depression Scale (HADS), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Spielberger State-Trait Anxiety Inventory (STAI), Dizziness Handicap Inventory (DHI) and otoneurologic examination were performed at baseline and at the end of treatment (mean, one month).Results. All patients had previous misdiagnoses, among which vertebrobasilar insufficiency and chronic cerebral ischemia predominated. Thirty two (53.33%) patients with PPPD had anxiety-depressive disorders (ADD) as the main comorbidity, 20 (33.33%) patients had migraine, 8 (13.33%) patients had previously had peripheral vestibular disorders that were not diagnosed. The severity of dizziness according to the otoneurological questionnaire and the DHI decreased after one month of therapy in the group with PPPD and ADD from 44.00±16.80 to 29.6±12.80 points (p<0.001), in the group with PPPD and peripheral vestibular disorders – from 49.20±14.04 to 31.60±17.69 points (p<0.001), in the group with PPPD and migraine – from 43.58±16.28 to 28.50±7.20 points (p<0.001). The severity of anxiety and depression according to BAI decreased in the group with PPPD and ADD from 30.00±6.99 to 16.12±4.16 points (p<0.001), in the group with PPPD and peripheral vestibular disorders – from 28.40±8.35 to 16.60±4.62 points (p<0.001), in the group with PPPD and migraine – from 24.11±3.80 to 14.26±3.43 points (p<0.001). The severity of depression according to BDI decreased in the group with PPPD and ADD from 9.62±5.26 to 6.25±3.20 points (p<0.001), in the group with PPPD and peripheral vestibular disorders – from 14.80±8.26 to 8.40±5.37 points (p<0.001), in the group with PPPD and migraine – from 11.32±5.10 to 6.53±3.44 points (p<0.001). The severity of anxiety according to HADS decreased in the group with PPPD and ADD from 13.75±3.20 to 9.25±2.43 points (p<0.001), in the group with PPPD and peripheral vestibular disorders – from 12.40±5.77 to 7.80±3.83 points (p<0.001), in the group with PPPD and migraine – from 14.26±3.16 to 8.74±2.18 points (p<0.001).The severity of depression according to HADS decreased in the group with PPPD and ADD from 4.88±4.12 to 3.88±3.09 points (p<0.001), in the group with PPPD and peripheral vestibular disorders – from 8.40±3.58 to 5.60±2.88 points (p<0.001), in the group with PPPD and migraine – from 5.74±3.11 to 3.47±2.32 points (p<0.001). Situational anxiety according to STAI decreased in the group with PPPD and ADD from 47.62±6.57 to 40.12±3.68 points (p<0.001), in the group with PPPD and peripheral vestibular disorders – from 58.20±7.85 to 48.00±7.65 points (p<0.001), in the group with PPPD and migraine – from 46.26±7.01 to 35.68±5.11 points (p<0.001). Personal anxiety according to STAI decreased in the group with PPPD and ADD from 52.25±10.73 to 42.12±7.06 points (p<0.001), in the group with PPPD and peripheral vestibular disorders – from 58.40±5.64 to 48.60±6.77 points (p<0.001), in the group with PPPD and migraine – from 53.32±8.78 to 40.63±5.60 points (p<0.001).Conclusion. Patients with PPPD are often misdiagnosed with cerebrovascular disease. The most common comorbid disorders in PPPD are anxiety disorders and migraine, and less commonly peripheral vestibular disorders. An integrated approach to the management of patients with PPPD, including treatment of comorbid disorders, is effective.