INTRODUCTION

There are many symptoms that may be associated with the complaints of vertigo and other types of dizziness. Among them, otoneurological symptoms (tinnitus, hearing loss, otalgia, headache and nausea) and psychological ones (anxiety, depression and fear). Any concomitant clinical affection should be considered as the possible cause of vestibular disease and if there are simultaneous disorders, they should all be implied as possible etiological factors 1,2,3. Some psychological symptoms may be the cause, consequence or still coexist with episodes of vertigo under four aspects: a) psychiatric disorder (anxiety, for example) may cause crises; b) a psychiatric disorder, normally depression or panic syndrome, may be caused by a crisis; c) a psychological disorder may aggravate the crisis, and d) a psychological disorder may be represented by the crisis 4.

Among the psychological factors, depression, fear, panic and anxiety are pointed by the literature as the main symptoms concomitant with vertigo. In a study conducted with 75 vertigo patients, depression and panic were described as part of the differential diagnosis, emphasizing that they presented higher levels of psychological disorders as well as recurrent depressive episodes 5.

The influence of psychological factors in vestibular dysfunctions has been considered in the diagnosis of vertigo patients. Out of 206 patients with vertigo complaints, the level of anxiety, depression and fear, especially in female subjects, was significantly high 6. Anxiety was described as a comorbidity symptom to vertigo, whose influence may result in less favorable prognosis, with impairment of quality of life of otoneurological patients 7. The association between anxiety and depression in otoneurological disorders was pointed out in a group of 91 patients with labyrinthic and vestibular dysfunctions, emphasizing the importance of detecting psychological concomitant implications 8. Anxiety and fear, as well as memory disorders, are described as factors that may both aggravate crisis or delay recovery of otoneurological patients with vertigo complaints 9.

Subjective myths of otoneurological symptoms may negatively contributed to the recovery of vertigo patients, as pointed out by the study conducted with 101 patients with vestibular dysfunction in which three groups of beliefs were identified: concern with loss of control (triggering factor of anxiety and depression), fear, and anticipation of crises 10. The correlation between emotional stability (anxiety and fear) and maintenance of body balance was demonstrated in a comparative study among three groups: a) with complaint of vertigo/imbalance; b) with report of vertigo episodes, but no complaints; c) no complaints and/or vertigo episodes 11. The influence of agoraphobia in efficacy of vestibular rehabilitation in vertigo patients pointed to concomitance and comorbidity of symptoms 12.

Otoneuropsychology considers vertigo as one of the main manifestations of distress, as its somatic equivalent. Manifestations of distress, as well as anxiety, phobia, depression and fear deserve special attention in otoneurological diagnosis, management and prognosis 13. Vertigo episodes are followed by distress and vertigo manifestations are closely linked with neurosis and its nature, showing close relation between distress and its implications in the somatic process 14. There is a fine line between distress and anxiety. Whereas anxiety refers to the experience of psychological suffering, distress is understood as a comprehensive affective state that comprises anxiety and somatic manifestations (neurovegetative impairment) resulting from distress. Neurovegetative disturbances resulting from body imbalance are evidently similar to those resulting from distress and panic episodes 13, 15.

Psychological symptoms - depression, anxiety and fear - are pointed by the literature as comorbidity symptoms of vertigo, whose influence may result in less positive prognosis, with impairment of quality of life of patients. This comorbidity suggests that studies should be conducted to determine which are the main psychological manifestations concomitant to complaints of vertigo in otoneurological patients. Distress, for example, as the psychological equivalent of vertigo, together with anxiety, depression and fear, should be properly investigated as the possible psychological symptoms concomitant to vertigo and considered in the diagnosis, prognosis and management of otoneurological patients.

OBJECTIVE

The objective of the present study was to investigate the most frequent psychological symptoms associated with the complaint of vertigo in 846 medical charts of otoneurological patients seen by the Screening Division of the Ambulatory of Otoneurology and the Division of Otoneuropsychology, Federal University of Sao Paulo - Escola Paulista de Medicina, between 1999 and 2001.

METHOD

We studied 846 medical charts - 322 from January to December 1999, 238 from January to December 2000, and 286 from January to October 2001 - of patients with complaints of vertigo in the Screening Division of the Ambulatory of Otoneurology and the Division of Otoneuropsychology, Department of Otorhinolaryngology and Head and Neck Surgery, Federal University of Sao Paulo - Escola Paulista de Medicina. Complaints were recorded as reported by patients. The medical charts had been filled out by the multidisciplinary team comprising Otorhinolaryngologists, Otoneurologists, Speech Therapists and Psychologists, as provided by the ethics code of Federal University of Sao Paulo - Escola Paulista de Medicina.

Selection, inclusion and exclusion criteria and quantification of data recorded in the medical charts were made in four steps: screening, grouping, inclusion/exclusion and quantification. In the first step, we qualified all information recorded in the medical charts. In the second step, the information was grouped into 9 categories: 1) gender, 2) age, 3) otoneurological complaints (associated or/not with vertigo complaint), 4) associated, concomitant and/or previous diseases, 5) medication currently in use; 6) history of previous surgeries, 7) eating habits, 8) smoking, and 9) associated complaints (psychological, cardiovascular, metabolic and hormonal complaints). In the third step, we excluded medical charts of otoneurological patients without complaints of vertigo. Out of the total of 1,041 medical charts, we selected and included 846 in which vertigo was referred as the main complaint (associated or not with other otoneurological symptoms). In the last step, we quantified in absolute and relative values only data obtained in categories 1, 2, 3 and 9. From category 9, we included associated psychological symptoms, excluding any other symptom (cardiovascular, metabolic and hormonal). We included in category 9 only the medical charts in which there were psychological complaints and we excluded those in which there were no records, which does not mean that these patients did not have psychological complaints, but only that they were not recorded in their medical charts.

Out of the total of 846 medical charts, there was no record of age in 8. Data related to age were grouped in age ranges owing to the amplitude of options, and those that were not recorded were registered under "not included". In the category of psychological symptoms, we considered a) distress; b) anxiety; c) depression; d) fear, and e) memory disorders. The inclusion criteria for distress and anxiety were defined according to the psychoanalytical theory.

RESULTS

Out of the total of 846 medical charts with complaints of vertigo, 612 (72.34%) were female and 234 were male (27.66%), ages ranging from 20 to 80 years. The age range of lowest prevalence was 20 to 30 years (11%), divided into 69 female charts (74.2%) and 24 (25.8%) male charts. From 31 to 40 years, there were 120 cases (14.2%), divided into 85 (70.9%) female and 35 male (29.1%). The total number of medical charts in the age range 41 to 50 years was 207 (24.47%), divided into 145 (70.1%) female and 62 (29.9%) male. The age range of highest prevalence was 51 to 60 years (25.3%), with 150 (70%) female and 64 (30%) male charts. In the age range 61 to 70 years, there were respectively 112 (77.8%) and 32 (22.2%) female and male charts, totaling 144 (17.02%). Finally, we found 44 (73.3%) female and 16 (26.7%) male charts amounting to 60 (7.1%) charts in the age range 71 to 80 years. In the category "not included" we found 8 charts (0.9%) divided into 7 male (87.5%) and 1 female (12.5%) cases.

The concomitance of psychological symptoms to vertigo complaint was detected in 477 (56.38%) out of the total of 846 medical charts. Out of the total, 362 (75.9%) were female in the age range of 51 to 60 years, and 115 (24.1%) were male in the same age range. Among associated psychological symptoms (distress, anxiety, fear, depression and memory disorders), distress was the most prevalent one, reported in 226 (47.38%) of the total of 477 charts, 169 (35.43%) female and 57 (11.95%) male cases. Anxiety was the second most frequent symptom associated with vertigo, registered in 94 cases (19.71%), divided into 73 (15.3%) female cases and 21 (4.40%) male cases. Fear was reported by 46 female patients (9.64%) and 18 male patients (3.77%), amounting to 64 (13.42%) of the total of 477 medical charts. Depression was associated with vertigo complaint in 60 charts (12.58%), divided as 49 female patients (10.27%) and 11 male cases (2.3%). Finally, memory disorders were detected in 33 (6.92%) charts, being 25 (5.24%) female and 8 (1.68%) male patients.

DISCUSSION

The obtained results pointed to the association between vertigo and psychological symptoms in 56.38% of the cases, whereas the literature points to an association of 46.5%, with prevalence of depression (14.1%), anxiety and fear (10.3%)1. The presence of anxiety, depression and fear as psychological symptoms concomitant to vertigo has been specifically highlighted by the literature 1,5-12. Distress, however, is a new factor to be considered in the diagnosis of otoneurological patients with complaints of vertigo.

Otoneuropsychology considers vertigo as one of the main manifestations of distress and as its somatic equivalence 14. Distress, as well as anxiety, originates from hatred, but within an evolution perspective, distress comes before anxiety 13. It is within this perspective that distress, as well as anxiety, depression and fear should be considered as manifestations concomitant to vertigo, in diagnosis, prognosis and management of balance disorders. Therefore, the psychological symptom is the current representation of previous traumatically lived conflicts, and they can be reactivated, explaining the origin of vertigo 13. If a psychological disorder may be represented by a vertigo episode 4, then we should pose the following question: isn't distress the psychological representative of vertigo?

CONCLUSION

The psychological symptoms concomitant to vertigo complaint in medical charts of otoneurological patients were in decreasing order of frequency: distress, anxiety, fear, depression and memory disorders. Among them, distress is the psychological symptom of highest prevalence.

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