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Quimby AE, Brant JA, Staab JP, Ruckenstein MJ. Development and Initial Validation of a Meniere's Disease Quality of Life Instrument: The MenQOL. Laryngoscope 2024. [PMID: 38689521 DOI: 10.1002/lary.31478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 04/08/2024] [Accepted: 04/12/2024] [Indexed: 05/02/2024]
Abstract
OBJECTIVE To design and validate a disease-specific quality of life instrument for Meniere's disease. METHODS We used a sequential process of expert input, patient focus groups, and analyses of responses to draft questionnaires to create a 24-item Meniere's disease quality of life (MenQOL) instrument. The MenQOL and the SF-36v2 were administered to a cohort of 50 patients with Meniere's disease and 60 comparison patients with tinnitus, vertigo, or hearing loss from other causes identified at a tertiary academic center. We performed exploratory factor analysis, Cronbach's α, between group comparisons of total MenQOL scores, and regression analyses between the MenQOL and SF-36v2 to evaluate the instrument's factor structure, internal consistency, face validity, and external validity. Segregation of the instrument into domains was assessed by exploratory factor analysis. RESULTS Exploratory factor analysis revealed that the MenQOL has a single domain. Cronbach's α = 0.914 indicated high internal consistency for the instrument as a whole. Mean MenQOL scores showing significantly worse quality of life among patients with Meniere's disease than comparison participants (52.5 ± 15.8 vs. 43.2 ± 12.6; p = 0.0051), indicating good construct validity. Significant inverse relationships in bivariate linear regressions between total MenQOL scores and SF-36v2 physical (slope = -0.94, p < 0.0001) and mental (slope = -1.16, p < 0.0001) composite scores showed acceptable concurrent validity. CONCLUSIONS We have described the initial development of the MenQOL, a simple, valid patient-reported outcome measure that, subject to further study, may be used to assess the effects of treatment on disease-specific quality of life in patients with Meniere's disease. LEVEL OF EVIDENCE 3 Laryngoscope, 2024.
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Affiliation(s)
- Alexandra E Quimby
- Department of Otorhinolaryngology - Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
- Department of Otolaryngology and Communication Sciences, SUNY Upstate Medical University, Syracuse, New York, U.S.A
| | - Jason A Brant
- Department of Otorhinolaryngology - Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadlephia, Pennsylvania, U.S.A
| | - Jeffrey P Staab
- Departments of Psychiatry and Psychology and Otorhinolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Michael J Ruckenstein
- Department of Otorhinolaryngology - Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A
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Gentry MT, Somers K, Hendricks J, Staab JP. A Multi-aim Redesign of the Residency Training Experience in Outpatient Psychiatry. Acad Psychiatry 2024:10.1007/s40596-024-01951-5. [PMID: 38504055 DOI: 10.1007/s40596-024-01951-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 02/22/2024] [Indexed: 03/21/2024]
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Varma R, Staab JP, Matey ET, Wright JA, Deb B, Lazaridis KN, Szarka LA, Bailey KR, Bharucha AE. Most patients with disorders of gut-brain interaction receive pharmacotherapy with major or moderate drug-gene interactions. Neurogastroenterol Motil 2024; 36:e14722. [PMID: 38072827 DOI: 10.1111/nmo.14722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 10/25/2023] [Accepted: 11/28/2023] [Indexed: 01/25/2024]
Abstract
BACKGROUND How variations predicted by pharmacogenomic testing to alter drug metabolism and therapeutic response affect outcomes for patients with disorders of gut- brain interaction is unclear. AIMS To assess the prevalence of pharmacogenomics-predicted drug-gene interactions and symptom outcomes for patients with disorders of gut-brain interaction. METHODS Patients who were treated in our clinical practice for functional dyspepsia/bowel disorder underwent pharmacogenomic testing. The change in symptoms from baseline to 6 months was compared for patients with variations in CYP2D6 and CYP2C19, which metabolize neuromodulators, and SLC6A4, which encodes the sodium- dependent serotonin transporter. RESULTS At baseline, 79 of 94 participants (84%) had at least one predicted major drug- gene interaction, and all 94 (100%) had at least one predicted moderate interaction. For the 44 participants who completed a survey of their symptoms at 6 months, the mean (SD) irritable bowel syndrome-symptom severity score decreased from 284 (71) at baseline to 231 (95) at 6 months (p < 0.001). Among patients taking selective serotonin reuptake inhibitors, the decrease in symptom severity (p = 0.03) and pain (p = 0.002) scores from baseline to 6 months was greater for patients with a homozygous SLC6A4 long/long genotype (n = 30) (ie, increased serotonin transporter activity) than for patients with homozygous short/short or heterozygous long/short genotypes (n = 64). Symptom outcomes were not affected by CYP2D6 or CYP2C19 variations. CONCLUSIONS The homozygous SLC6A4 long/long genotype confers better symptom resolution for patients with disorders of gut-brain interaction who take selective serotonin reuptake inhibitors than do the homozygous short/short or heterozygous long/short genotypes.
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Affiliation(s)
- Revati Varma
- Research Fellow in the Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Jeffrey P Staab
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric T Matey
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Brototo Deb
- Research Fellow in the Division of Gastroenterology and Hepatology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | | | - Lawrence A Szarka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kent R Bailey
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Perez DL, Nicholson TR, Asadi-Pooya AA, Butler M, Carson AJ, David AS, Deeley Q, Diez I, Edwards MJ, Espay AJ, Gelauff JM, Jungilligens J, Hallett M, Kanaan RAA, Tijssen MAJ, Kozlowska K, LaFrance WC, Marapin RS, Maurer CW, Reinders AATS, Sojka P, Staab JP, Stone J, Szaflarski JP, Aybek S. Response to the Letter Concerning the Publication: Neuroimaging in Functional Neurological Disorder: State of the Field and Research Agenda. Perez DL et al. Neuroimage Clin. 2021;30:102623. Neuroimage Clin 2024; 41:103573. [PMID: 38309187 PMCID: PMC10847796 DOI: 10.1016/j.nicl.2024.103573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/25/2024] [Accepted: 01/26/2024] [Indexed: 02/05/2024]
Affiliation(s)
- David L Perez
- Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Timothy R Nicholson
- Neuropsychiatry Research & Education Group, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ali A Asadi-Pooya
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Jefferson Comprehensive Epilepsy Centre, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Matthew Butler
- Neuropsychiatry Research & Education Group, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Alan J Carson
- Centre for Clinical Brain Sciences, The University of Edinburgh, EH16 4SB, UK
| | - Anthony S David
- Division of Psychiatry, Institute of Mental Health, University College London, London, UK
| | - Quinton Deeley
- South London and Maudsley NHS Foundation Trust, London UK Institute of Psychiatry Psychology and Neuroscience, King's College London, London, UK
| | - Ibai Diez
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mark J Edwards
- Institute of Psychiatry, Psychology and Neuroscience, King's College 16 De Crespigny Park, London, SE5 8AF, UK
| | - Alberto J Espay
- James J. and Joan A. Gardner Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH, USA
| | | | - Johannes Jungilligens
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Germany
| | - Mark Hallett
- National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD, USA
| | - Richard A A Kanaan
- Department of Psychiatry, University of Melbourne, Austin Health, Heidelberg, Australia
| | - Marina A J Tijssen
- Expertise Center Movement Disorders Groningen, University Medical Center Groningen, Groningen, University of Groningen, the Netherlands
| | - Kasia Kozlowska
- The Children's Hospital at Westmead, Westmead Institute of Medical Research, University of Sydney Medical School, Sydney, NSW, Australia
| | - W Curt LaFrance
- Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, RI, USA
| | - Ramesh S Marapin
- Expertise Center Movement Disorders Groningen, University Medical Center Groningen, Groningen, University of Groningen, the Netherlands
| | - Carine W Maurer
- Department of Neurology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA
| | - Antje A T S Reinders
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Petr Sojka
- Department of Neurology and Centre of Clinical Neuroscience, Charles University, 1st Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic
| | - Jeffrey P Staab
- Departments of Psychiatry and Psychology and Otorhinolaryngology-Head and Neck Surgery, Mayo Clinic Rochester, MN, USA
| | - Jon Stone
- Centre for Clinical Brain Sciences, The University of Edinburgh, EH16 4SB, UK
| | - Jerzy P Szaflarski
- University of Alabama at Birmingham Epilepsy Center, Department of Neurology, University of Alabama at Birmingham, AL, USA
| | - Selma Aybek
- Faculté des Sciences et de Médecine, Université de Fribourg, Chemin du Musée 5, 1700 Fribourg, Suisse
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Eggers SDZ, Staab JP. Vestibular migraine and persistent postural perceptual dizziness. Handb Clin Neurol 2024; 199:389-411. [PMID: 38307659 DOI: 10.1016/b978-0-12-823357-3.00028-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/04/2024]
Abstract
Dizziness is a common symptom among patients in primary care, general neurology, and headache clinic practices. Vestibular migraine is conceptualized as a condition of recurrent attacks of vestibular symptoms attributed to migraine. It is now considered the most common cause of spontaneous episodic vertigo. Persistent postural-perceptual dizziness (PPPD) has more recently been defined based on four previous clinical entities as a syndrome of chronic daily dizziness, unsteadiness, or nonspinning vertigo that fluctuates and is exacerbated by postural, motion, or visual factors. Although PPPD is more often precipitated by other conditions causing vertigo, unsteadiness, or dizziness, it is discussed at length in this chapter because vestibular migraine is among the most common triggers for development of PPPD. Pathophysiology of each is incompletely understood, and with lack of biomarkers, the diagnosis of each rests on consensus-derived, symptom-based criteria. Areas of uncertainty exist regarding some overlapping symptoms that may create potential diagnostic confusion between the conditions. This chapter provides a comprehensive review of the current state of vestibular migraine and PPPD, including diagnostic and management guidance for when they occur separately, together, or along with other common comorbidities.
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Affiliation(s)
- Scott D Z Eggers
- Department of Neurology, Mayo Clinic, Rochester, MN, United States.
| | - Jeffrey P Staab
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States; Department of Otorhinolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, MN, United States
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Park JH, Sarwar S, Hassett LC, Staab JP, Fipps DC. Clinical Characterization, Course, and Treatment of Othello Syndrome: A Case Series and Systematic Review of the Literature. J Acad Consult Liaison Psychiatry 2024; 65:89-105. [PMID: 37832650 DOI: 10.1016/j.jaclp.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/12/2023] [Accepted: 09/29/2023] [Indexed: 10/15/2023]
Abstract
BACKGROUND Othello syndrome (OS) is a condition characterized by a delusion of jealousy that one's spouse is having extramarital affairs. As in the eponymous Shakespearean tragedy, there is an unfortunate risk of violence. For patients with these symptoms, consultation-liaison psychiatrists may be asked to assist with evaluating the differential diagnosis, assessing safety, and developing treatment options. OBJECTIVE This study's objective was to solidify current knowledge of the clinical presentations and management of OS through a systematic review of the literature and description of 2 new cases. METHODS We conducted a literature search from the start of relevant databases through August 2023 to identify English language case reports of adults (≥18 years) with OS that described clinical evaluations, biological treatments, and outcomes. We extracted demographics, proposed etiologies, treatment choices and responses, duration of delusions, comorbid psychiatric symptoms, neuro-radiographic findings, and presence of physical violence. We reported clinical findings for 2 new cases. RESULTS Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we screened 705 abstracts and conducted full-text reviews of 118 articles to identify 73 cases published from 1983 to 2023 meeting inclusion criteria. The mean age was 58.2 years with male predominance (M:F = 1.88). Etiologies included primary psychiatric disorders (16, 22%), other medical conditions (38, 52%), and medications or other substances (19, 26%). Delusional disorder, cerebrovascular accident, and dopaminergic agonists were the most common etiologies, respectively, in these groups. Antipsychotics were the most common treatment (57, 78%). Symptom remission was reported in 51 (70%) cases. The average duration of OS was 39.5 months. Of 32 cases reporting brain imaging insults, 12 of 20 (60%) showed right-sided lesions, and 8 of 20 (40%) showed left-sided lesions, with 9 of 32 (28%) located in the frontal lobes. The most commonly co-existing psychiatric symptom was depression (14, 19%). Violence was reported in 25 cases (34%). Our 2 new cases were consistent with these findings. CONCLUSIONS OS may be a manifestation of several neuropsychiatric conditions, primarily delusional disorder, cerebrovascular accident, Alzheimer's dementia, and the use of dopaminergic agonists. One-third of cases include violent behaviors. It appears to respond to antipsychotic medications, but treatment is delayed more than 3 years on average. Available data have not localized OS to a specific brain region.
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Affiliation(s)
- Jin Hong Park
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, MN
| | - Sheharyar Sarwar
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, MN
| | - Leslie C Hassett
- Mayo Medical Libraries, Mayo Clinic College of Medicine, Rochester, MN
| | - Jeffrey P Staab
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, MN
| | - David C Fipps
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, MN.
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Dunlap PM, Alradady FA, Costa CM, Delitto A, Terhorst L, Sparto PJ, Furman JM, Marchetti GF, Staab JP, Chueh J, Whitney SL. The Psychometric Properties of the 9-Item Vestibular Activities Avoidance Instrument. Phys Ther 2023; 103:pzad094. [PMID: 37459243 DOI: 10.1093/ptj/pzad094] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 04/24/2023] [Accepted: 07/02/2023] [Indexed: 12/29/2023]
Abstract
OBJECTIVE The purpose of this study was to establish the psychometric properties of the 9-Item Vestibular Activities Avoidance Instrument (VAAI-9), a patient-reported outcome measure developed to identify fear avoidance beliefs in persons with vestibular disorders. METHODS This prospective cohort study included 100 participants 18 years and older seeking care at a balance disorders clinic for dizziness. Participants completed the VAAI-9, the Dizziness Handicap Inventory (DHI), and other patient-reported outcomes at the initial visit and the 3-month follow-up. To measure test-retest reliability, the VAAI-9 was completed again 5 days after the initial visit and was analyzed using a 2-way mixed ICC for absolute agreement. Internal consistency was determined using the Cronbach alpha. The Spearman correlation coefficient was used to assess convergent validity of the VAAI-9 with other outcomes. Receiver operating characteristic curves were used to identify baseline VAAI-9 cutoff scores for those who reported mild (DHI ≤ 30) or moderate or severe (DHI > 30) perceived disability at the 3-month follow-up. RESULTS The mean age of the study cohort was 49 (SD = 16) years; 73 (73%) were women. Seventy-one participants completed the 5-day follow-up, and 68 completed the 3-month follow-up. The VAAI-9 demonstrated excellent internal consistency (α = 0.91) and test-retest reliability (ICC = 0.90). Baseline VAAI-9 scores had moderate to strong associations with other outcome measures at baseline and 3 months. A baseline VAAI-9 score of 26 or higher had a sensitivity of 80.6% and a specificity of 78.4% for identifying a DHI score of >30 at 3 months (area under the curve = 0.86). CONCLUSIONS The results provide evidence of excellent reliability and validity for the 9-item VAAI in persons with vestibular disorders. A baseline VAAI-9 score of ≥26 identified individuals at risk of persistent moderate to severe disability due to dizziness. IMPACT Initial levels of fear avoidance beliefs measured using the VAAI-9 provided important prognostic information about outcomes for persons with vestibular symptoms.
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Affiliation(s)
- Pamela M Dunlap
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Fai A Alradady
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Anthony Delitto
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lauren Terhorst
- School of Health and Rehabilitation Sciences Data Center and Department of Occupational Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Patrick J Sparto
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joseph M Furman
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Gregory F Marchetti
- Department of Physical Therapy, Duquesne University, Pittsburgh, Pennsylvania, USA
| | - Jeffrey P Staab
- Departments of Psychiatry and Psychology and Otorhinolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jasmine Chueh
- School of Health Professions, Stony Brook University, Stony Brook, New York, USA
| | - Susan L Whitney
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Liou H, Gentry MT, Leung JG, Mara KC, Staab JP, Rummans TA. Trends in Stimulant and Sedative/Hypnotic Dispensing: An Exploratory Study. J Atten Disord 2023; 27:1512-1519. [PMID: 37496458 DOI: 10.1177/10870547231187167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
OBJECTIVE To investigate patterns and trends of co-prescriptions of stimulants and sedatives within the last 6 years at a tertiary care center. METHOD Patients 18 years of age and older who were dispensed at least one stimulant prescription from an institutional pharmacy between 1/1/2015 and 7/1/2021 were included. Prescription data for any co-prescribed sedative/hypnotic were collected. RESULTS Both the number of stimulant dispenses and the number of patients with stimulant dispenses increased significantly with yearly incidence rate ratios of 1.115 (95% CI [1.110, 1.119]) and 1.090 (95% CI [1.084, 1.096]), respectively. The number of patients with a stimulant dispensed who also had a benzodiazepine or "Z-drug" sedative-hypnotic dispensed at any point in the search timeframe increased significantly with incidence rate ratios of 1.077 and 1.092, respectively. The number of stimulant dispenses, number of patients with stimulant dispenses, and number of patients with a stimulant dispensed who also had both a benzodiazepine and Z-drug dispensed at any point in the search timeframe increased significantly more in Non-White than in White patients. CONCLUSIONS The results confirm previous findings of increases in dispensing of stimulants over the past 6 years and report increased polypharmacy of stimulants and sedative-hypnotics.
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Affiliation(s)
| | | | | | | | | | - Teresa A Rummans
- Mayo Clinic, Rochester, MN, USA
- Mayo Clinic, Jacksonville, FL, USA
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Trinidade A, Cabreira V, Goebel JA, Staab JP, Kaski D, Stone J. Predictors of persistent postural-perceptual dizziness (PPPD) and similar forms of chronic dizziness precipitated by peripheral vestibular disorders: a systematic review. J Neurol Neurosurg Psychiatry 2023; 94:904-915. [PMID: 36941047 DOI: 10.1136/jnnp-2022-330196] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 02/23/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND The literature on predictors of persistent postural-perceptual dizziness (PPPD) following peripheral vestibular insults has not been systematically reviewed. METHODS We systematically reviewed studies on predictors of PPPD and its four predecessors (phobic postural vertigo, space-motion discomfort, chronic subjective dizziness and visual vertigo). Investigations focused on new onset chronic dizziness following peripheral vestibular insults, with a minimum follow-up of 3 months. Precipitating events, promoting factors, initial symptoms, physical and psychological comorbidities and results of vestibular testing and neuroimaging were extracted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS We identified 13 studies examining predictors of PPPD or PPPD-like chronic dizziness. Anxiety following vestibular injury, dependent personality traits, autonomic arousal and increased body vigilance following precipitating events and visual dependence, but not the severity of initial or subsequent structural vestibular deficits or compensation status, were the most important predictors of chronic dizziness. Disease-related abnormalities of the otolithic organs and semi-circular canals and age-related brain changes seem to be important only in a minority of patients. Data on pre-existing anxiety were mixed. CONCLUSIONS After acute vestibular events, psychological and behavioural responses and brain maladaptation are the most likely predictors of PPPD, rather than the severity of changes on vestibular testing. Age-related brain changes appear to have a smaller role and require further study. Premorbid psychiatric comorbidities, other than dependent personality traits, are not relevant for the development of PPPD.
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Affiliation(s)
- Aaron Trinidade
- Department of Otolaryngology, Southend University Hospital, Southend-on-Sea, UK
- Faculty of Medicine, Anglia Ruskin University Medical School, Chelmsford, UK
| | - Verónica Cabreira
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Joel A Goebel
- Department of Neuro-otology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Jeffrey P Staab
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA
| | - Diego Kaski
- Department of Neuro-otology, University College London, London, UK
| | - Jon Stone
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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Abstract
Persistent postural-perceptual dizziness (PPPD) is a functional neuro-otologic (vestibular) disorder manifesting dizziness, unsteadiness, or nonspinning vertigo lasting 3 months or more and exacerbated by upright posture, active or passive motion, and complex visual stimuli. PPPD is the most common cause of chronic vestibular symptoms. Early pathophysiologic models of PPPD emphasized the adverse effects of anxiety on postural control and spatial orientation. More recent concepts added predictive processing of sensory inputs and alterations in motion perception. Herein, a third-generation model incorporates prioritization of postural stability over fluid locomotion to explain symptoms, physiologic and neuroimaging data, and effects of current treatments.
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Affiliation(s)
- Jeffrey P Staab
- Department of Psychiatry and Psychology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA; Department of Otorhinolaryngology-Head and Neck Surgery, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
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Duque L, Garza I, Cascino GD, Staab JP. Functional neurological seizures and migraine: A systematic review and case series. Epilepsy Behav 2023; 147:109437. [PMID: 37717461 DOI: 10.1016/j.yebeh.2023.109437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 08/23/2023] [Accepted: 09/03/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND The seizure subtype of functional neurological disorder (FND-seizures) is a common neuropsychiatric condition manifesting with episodic epilepsy-like events. Despite the common belief that FND-seizures are precipitated by psychological stressors, neurological disorders may also be triggers. In 1890, Babinski described four cases of FND symptoms associated with migraine attacks. Despite the passing of more than 130 years since this first clinical observation, the relationship between FND-seizures and migraine is not fully elucidated. OBJECTIVES (1) To complete a systematic review of the literature that investigated potential associations between FND-seizures and migraine and the response of FND seizures to treatment with migraine prophylactic medications (2). To undertake a retrospective study of patients with FND-seizures and migraine, including response to migraine prophylaxis. METHODS (1) Using PRISMA methods, we completed a systematic review of EMBASE and Scopus databases from inception to March 31, 2021, for literature on FND-seizures and migraine. (2) Our multi-disciplinary team, including subspecialists in psychosomatic medicine, epilepsy, and headache disorders, reviewed consecutive patients diagnosed with FND-seizures and migraine to assess potential causal associations and responses to standard migraine prophylactic medications. RESULTS (1) The search yielded seven studies from 126 screened manuscripts (N = 1,186 patients with FND-seizures; mean age 38.7 years; 72.6% female). They varied substantially in design, population, diagnostic measures, and outcomes. Nevertheless, all studies found associations between FND-seizures and migraine, which were stronger than those between epileptic seizures and migraine in comparative investigations, but provided limited information on treatment response. (2) In our case series, investigators reached unanimous consensus that migraine attacks triggered FND-seizures in 28/43 (65.1%) patients reviewed (mean age, 38.8 years; 74% female). In 19/26 (73%) patients with adequate follow-up data, treatment with migraine prophylactic medications alone (no behavioral interventions) concomitantly reduced FND-seizure and headache frequency by >50%. CONCLUSION Our systematic review and case series indicate that migraine attacks may trigger FND-seizures, perhaps more often that currently understood, and suggest that migraine prophylaxis may reduce FND-seizure frequency in such cases. To validate these observations, fully powered prospective investigations are required.
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Affiliation(s)
- Laura Duque
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA; Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Ivan Garza
- Department of Neurology (Headache Division), Mayo Clinic, Rochester, MN, USA
| | - Gregory D Cascino
- Department of Neurology (Epilepsy Division), Mayo Clinic, Rochester, MN, USA
| | - Jeffrey P Staab
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA; Department of Otorhinolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, MN.
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Callister MN, Klanderman MC, Boddu SP, Moutvic MA, Geissler EN, Traver KJ, Staab JP, Hassan A. Outpatient Motor Retraining for Functional Movement Disorder: Predictors of a Favorable Short-Term Response. Mov Disord Clin Pract 2023; 10:1377-1387. [PMID: 37772308 PMCID: PMC10525056 DOI: 10.1002/mdc3.13844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 06/13/2023] [Accepted: 06/22/2023] [Indexed: 09/30/2023] Open
Abstract
Background Treating functional movement disorder (FMD) with motor retraining is effective but resource intensive. Objectives Identify patient, disease, and program variables associated with favorable treatment outcomes. Methods Retrospective review of the 1 week intensive outpatient FMD program at Mayo Clinic in Minnesota from February 2019 to August 2021. Outcomes included patient-reported measures (Canadian Occupational Performance Measure-Performance and Satisfaction subscales [COPM-P and COPM-S, range 0-10] and Global Rating of Change [GROC, -7 to +7]) and a retrospective investigator-rated scale (0-3, worse/not improved to significantly improved/resolved). Linear regression models identified variables predicting favorable outcomes. Results Participants (n = 201, 74% female, mean age = 46) had median FMD duration of 24 months. The commonest FMD subtypes were gait disorder (65%), tremor (41%) and weakness (17%); 53% had ≥2 subtypes. Most patients (88%) completed a therapeutic screening process before program entry. Patient-reported outcomes at the end of the week improved substantially (COPM-P average change 3.8 ± 1.9; GROC post-program average 5.5 ± 1.7). Available investigator-rated outcomes from short-term follow-up were also positive (102/122 [84%] moderately to significantly improved/resolved). Factors predicting greater improvement in COPM-P were completing therapeutic screening, higher number of non-motor symptoms, shorter FMD duration, earlier program entry, lower baseline COPM scores, and (among screened patients) higher GROC between therapeutic screening and program start. Conclusion Patients with diverse FMD subtypes improved substantially over a 1 week period. Utilization of therapeutic screening and greater improvement between therapeutic screening and program start were novel predictors of favorable outcomes. Non-motor symptoms did not preclude positive responses, although patients with predominant non-motor burden were excluded.
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Affiliation(s)
| | | | - Sayi P. Boddu
- Mayo Clinic Alix School of MedicineScottsdaleArizonaUSA
| | - Margaret A. Moutvic
- Department of Physical Medicine and RehabilitationMayo ClinicRochesterMinnesotaUSA
| | | | - Katie J. Traver
- Department of Physical Medicine and RehabilitationMayo ClinicRochesterMinnesotaUSA
| | - Jeffrey P. Staab
- Department of Psychiatry and PsychologyMayo ClinicRochesterMinnesotaUSA
| | - Anhar Hassan
- Department of NeurologyMayo ClinicRochesterMinnesotaUSA
- Beacon HospitalDublinIreland
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Ehlers SL, Gudenkauf LM, Kacel EL, Hanna SM, Sinicrope PS, Patten CA, Morrison EL, Snuggerud J, Bevis D, Kirsch JL, Staab JP, Price KAR, Wahner-Hendrickson AE, Ruddy KJ. Real-World Implementation of Best-Evidence Cancer Distress Management: Truly Comprehensive Cancer Care. J Natl Compr Canc Netw 2023; 21:627-635. [PMID: 37308123 DOI: 10.6004/jnccn.2023.7009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 02/03/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Cancer distress management is an evidence-based component of comprehensive cancer care. Group-delivered cognitive behavioral therapy for cancer distress (CBT-C) is the first distress treatment associated with replicated survival advantages in randomized clinical trials. Despite research supporting patient satisfaction, improved outcomes, and reduced costs, CBT-C has not been tested sufficiently within billable clinical settings, profoundly reducing patient access to best-evidence care. This study aimed to adapt and implement manualized CBT-C as a billable clinical service. PATIENTS AND METHODS A stakeholder-engaged, mixed-methods, hybrid implementation study design was used, and the study was conducted in 3 phases: (1) stakeholder engagement and adaptation of CBT-C delivery, (2) patient and therapist user testing and adaptation of CBT-C content, and (3) implementation of practice-adapted CBT-C as a billable clinical service focused on evaluation of reach, acceptability, and feasibility across stakeholder perspectives. RESULTS A total of 40 individuals and 7 interdisciplinary group stakeholders collectively identified 7 primary barriers (eg, number of sessions, workflow concerns, patient geographic distance from center) and 9 facilitators (eg, favorable financial model, emergence of oncology champions). CBT-C adaptations made before implementation included expanding eligibility criteria beyond breast cancer, reducing number of sessions to 5 (10 total hours), eliminating and adding content, and revising language and images. During implementation, 252 patients were eligible; 100 (40%) enrolled in CBT-C (99% covered by insurance). The primary reason for declining enrollment was geographic distance. Of enrollees, 60 (60%) consented to research participation (75% women; 92% white). All research participants completed at least 60% of content (6 of 10 hours), with 98% reporting they would recommend CBT-C to family and friends. CONCLUSIONS CBT-C implementation as a billable clinical service was acceptable and feasible across cancer care stakeholder measures. Future research is needed to replicate acceptability and feasibility results in more diverse patient groups, test effectiveness in clinical settings, and reduce barriers to access via remote delivery platforms.
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Affiliation(s)
- Shawna L Ehlers
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Lisa M Gudenkauf
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth L Kacel
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Sherrie M Hanna
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Pam S Sinicrope
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Christi A Patten
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Eleshia L Morrison
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Jill Snuggerud
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Danielle Bevis
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Janae L Kirsch
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Jeffrey P Staab
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
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Staab JP. Comment on: "Persistent-postural perceptual dizziness (PPPD): Yes, it is a psychosomatic condition!". J Vestib Res 2023; 33:283-285. [PMID: 31561402 DOI: 10.3233/ves-190680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jeffrey P Staab
- Chair, Behavioral Subcommittee of the Classification Committee of the Bárány Society; Professor of Psychiatry; Consultant, Departments of Psychiatry and Psychology and Otorhinolaryngology - Head and Neck Surgery; Director, Fellowship in Consultation-Liaison Psychiatry, Mayo Clinic Rochester, MN, USA
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15
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Alhassan A, Staab JP. (155) Implication of Prevalence of Adversity in Different Functional Disorders. J Acad Consult Liaison Psychiatry 2022. [DOI: 10.1016/j.jaclp.2022.10.157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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16
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Singh K, García-Gomar MG, Cauzzo S, Staab JP, Indovina I, Bianciardi M. Structural connectivity of autonomic, pain, limbic, and sensory brainstem nuclei in living humans based on 7 Tesla and 3 Tesla MRI. Hum Brain Mapp 2022; 43:3086-3112. [PMID: 35305272 PMCID: PMC9188976 DOI: 10.1002/hbm.25836] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/09/2022] [Accepted: 03/06/2022] [Indexed: 11/18/2022] Open
Abstract
Autonomic, pain, limbic, and sensory processes are mainly governed by the central nervous system, with brainstem nuclei as relay centers for these crucial functions. Yet, the structural connectivity of brainstem nuclei in living humans remains understudied. These tiny structures are difficult to locate using conventional in vivo MRI, and ex vivo brainstem nuclei atlases lack precise and automatic transformability to in vivo images. To fill this gap, we mapped our recently developed probabilistic brainstem nuclei atlas developed in living humans to high‐spatial resolution (1.7 mm isotropic) and diffusion weighted imaging (DWI) at 7 Tesla in 20 healthy participants. To demonstrate clinical translatability, we also acquired 3 Tesla DWI with conventional resolution (2.5 mm isotropic) in the same participants. Results showed the structural connectome of 15 autonomic, pain, limbic, and sensory (including vestibular) brainstem nuclei/nuclei complex (superior/inferior colliculi, ventral tegmental area‐parabrachial pigmented, microcellular tegmental–parabigeminal, lateral/medial parabrachial, vestibular, superior olivary, superior/inferior medullary reticular formation, viscerosensory motor, raphe magnus/pallidus/obscurus, parvicellular reticular nucleus‐alpha part), derived from probabilistic tractography computation. Through graph measure analysis, we identified network hubs and demonstrated high intercommunity communication in these nuclei. We found good (r = .5) translational capability of the 7 Tesla connectome to clinical (i.e., 3 Tesla) datasets. Furthermore, we validated the structural connectome by building diagrams of autonomic/pain/limbic connectivity, vestibular connectivity, and their interactions, and by inspecting the presence of specific links based on human and animal literature. These findings offer a baseline for studies of these brainstem nuclei and their functions in health and disease, including autonomic dysfunction, chronic pain, psychiatric, and vestibular disorders.
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Affiliation(s)
- Kavita Singh
- Brainstem Imaging Laboratory, Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - María Guadalupe García-Gomar
- Brainstem Imaging Laboratory, Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Escuela Nacional de Estudios Superiores, Juriquilla, Universidad Nacional Autónoma de México, Querétaro, Mexico
| | - Simone Cauzzo
- Brainstem Imaging Laboratory, Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Life Sciences Institute, Sant'Anna School of Advanced Studies, Pisa, Italy.,Research Center E. Piaggio, University of Pisa, Pisa, Italy
| | - Jeffrey P Staab
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Otorhinolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Iole Indovina
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Italy.,Laboratory of Neuromotor Physiology, IRCCS Santa Lucia Foundation, Rome, Italy
| | - Marta Bianciardi
- Brainstem Imaging Laboratory, Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Division of Sleep Medicine, Harvard University, Boston, Massachusetts, USA
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17
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Arshad Q, Saman Y, Sharif M, Kaski D, Staab JP. Magnitude Estimates Orchestrate Hierarchal Construction of Context-Dependent Representational Maps for Vestibular Space and Time: Theoretical Implications for Functional Dizziness. Front Integr Neurosci 2022; 15:806940. [PMID: 35185485 PMCID: PMC8855482 DOI: 10.3389/fnint.2021.806940] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/20/2021] [Indexed: 12/24/2022] Open
Abstract
Maintaining balance necessitates an accurate perceptual map of the external world. Neuro-physiological mechanisms of locomotor control, sensory perception, and anxiety systems have been viewed as separate entities that can on occasion affect each other (i.e., walking on ice). Emerging models are more integrated, that envision sensory perception and threat assessment as a fundamental component of balance. Here we present an empirically based theoretical argument that vestibular cortical areas construct magnitude estimates of our environment via neural integration of incoming sensory signals. In turn, these cortically derived magnitude estimates, construct context-dependent vestibulo-spatial and vestibulo-temporal, representational maps of the external world, and ensure an appropriate online scaling factor for associated action-perceptual risk. Thus, threat signals are able to exert continuous influence on planning movements, predicting outcomes of motion of self and surrounding objects, and adjusting tolerances for discrepancies between predicted and actual estimates. Such a process affects the degree of conscious attention directed to spatial and temporal aspects of motion stimuli, implying that maintaining balance may follow a Bayesian approach in which the relative weighting of vestibulo-spatial and vestibulo-temporal signals and tolerance for discrepancies are adjusted in accordance with the level of threat assessment. Here, we seek to mechanistically explain this process with our novel empirical concept of a Brainstem Cortical Scaling Metric (BCSM), which we developed from a series of neurophysiological studies illustrating the central role of interhemispheric vestibulo-cortical asymmetries for balance control. We conclude by using the BCSM to derive theoretical predictions of how a dysfunctional BCSM can mechanistically account for functional dizziness.
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Affiliation(s)
- Qadeer Arshad
- Neuro-Otology Unit, Department of Brain Sciences, Charing Cross Hospital Campus, Imperial College London, London, United Kingdom
- inAmind Laboratory, Department of Neuroscience, Psychology and Behaviour, University of Leicester, Leicester, United Kingdom
- Department of Clinical and Motor Neurosciences, Institute of Neurology, University College London, London, United Kingdom
| | - Yougan Saman
- inAmind Laboratory, Department of Neuroscience, Psychology and Behaviour, University of Leicester, Leicester, United Kingdom
| | - Mishaal Sharif
- inAmind Laboratory, Department of Neuroscience, Psychology and Behaviour, University of Leicester, Leicester, United Kingdom
| | - Diego Kaski
- Department of Clinical and Motor Neurosciences, Institute of Neurology, University College London, London, United Kingdom
| | - Jeffrey P. Staab
- Departments of Psychiatry and Psychology and Otorhinolaryngology – Head and Neck Surgery, Mayo Clinic, Rochester, MN, United States
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18
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McCaslin DL, Shepard NT, Hollman JH, Staab JP. Characterization of Postural Sway in Patients With Persistent Postural-Perceptual Dizziness (PPPD) Using Wearable Motion Sensors. Otol Neurotol 2022; 43:e243-e251. [PMID: 34699399 DOI: 10.1097/mao.0000000000003393] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To extend previous investigations of postural control in patients with persistent-postural perceptual dizziness (PPPD). STUDY DESIGN Case-controlled, cross-sectional, observational investigation. SETTING Tertiary care center. PATIENTS Fifteen patients with PPPD, 15 control volunteers. INTERVENTIONS Measurement of anterior-posterior (AP) and medial-lateral (ML) sway at the waist using wearable accelerometers during posturography; assessment of reach and gait. MAIN OUTCOME MEASURES Peak-to-peak AP and ML sway displacement on the six conditions of the Sensory Organization Test (SOT); Scores on the SOT, Functional Reach Test (FRT), and Dynamic Gait Index (DGI). RESULTS Compared to control volunteers, patients with PPPD had significantly greater sway displacement at the waist in the AP direction in SOT conditions 3, 5, and 6 and in the ML direction in SOT conditions 2 and 4, resulting in significantly lower median equilibrium scores on the composite index and all six SOT conditions. Patients with PPPD had significantly lower scores on the FRT and DGI that were not correlated with SOT performance. AP sway in conditions 3 and 6 differentiated patients with PPPD from controls with high sensitivity (≥0.87) and specificity (≥0.87). CONCLUSIONS This study replicated previous work showing poor SOT performance by patients with PPPD who had greater AP sway associated with visual dependence and greater ML sway in low demand conditions than controls. Patients with PPPD also performed poorer on the FRT and DGI, but lack of correlation with SOT scores suggested different mechanisms of impairment in postural control, reach, and ambulation. AP sway demonstrated potential as a diagnostic marker.
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Affiliation(s)
- Devin L McCaslin
- Department of Otorhinolaryngology - Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan
| | - Neil T Shepard
- Department of Otorhinolaryngology - Head and Neck Surgery, Mayo Clinic
| | - John H Hollman
- Program in Physical Therapy, Mayo Clinic School of Health Sciences
| | - Jeffrey P Staab
- Department of Otorhinolaryngology - Head and Neck Surgery, Mayo Clinic
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
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19
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Marinelli JP, Anzalone CL, Prummer CM, Poling GL, Staab JP, Tombers NM, Lohse CM, Carlson ML. Electrical stimulation of the cochlea for treatment of chronic disabling tinnitus: an open-label trial towards the development of an implantable device. J Transl Med 2022; 20:56. [PMID: 35093126 PMCID: PMC8800213 DOI: 10.1186/s12967-022-03271-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 01/22/2022] [Indexed: 11/13/2022] Open
Abstract
Background Chronic tinnitus affects millions of people globally and constitutes the most commonly compensated disability among military service members in the United States. Existing treatment options largely surround helping patients cope with their disease as opposed to directly suppressing tinnitus perception. The current study investigated the efficacy of electrical stimulation of the cochlea on chronic disabling tinnitus. Methods In this single-arm, open-label clinical trial, 22 adult subjects with severe-range asymmetric or unilateral non-pulsatile tinnitus underwent electrical stimulation of the cochlea through use of an extra-cochlear electrode positioned on the cochlear promontory. Each subject underwent 3 stimulation treatments over 3 weeks at 7-day intervals. Tinnitus severity was determined by Tinnitus Handicap Inventory (THI), Tinnitus Functional Index (TFI), and Tinnitus Visual Analog Scale (VAS). Inclusion criteria required subjects have no worse than moderate sensorineural hearing loss determined by pre-enrollment audiometric testing. The primary outcome was nadir post-treatment THI scores, obtained at seven timepoints following electrical stimulation, with clinically significant improvement defined as a decrease of ≥ 7. Results All 22 (100%) subjects experienced clinically significant improvement in the THI during the study period with a mean decrease in scores of − 31 (95% CI − 38 to − 25) from a baseline of 48. Twenty (91%) experienced clinically significant improvement detectable on at least two of the three tinnitus survey instruments and 17 (77%) experienced clinically significant improvement detectable on all three survey instruments (i.e., THI, TFI, and VAS). Eight (36%) subjects reported either complete (THI of 0; n = 3) or near-complete (THI 1–4; n = 5) suppression of their tinnitus following a stimulation session. Thirteen (59%) subjects reported a nadir following stimulation at or below the threshold for “no or slight handicap” on the THI (≤ 16). No adverse events were observed. Conclusions These findings establish the foundation for the development of an extra-cochlear implantable device that delivers electrical stimulation to the cochlea for the treatment of disabling tinnitus. For patients considering device implantation, trans-tympanic cochlear promontory stimulation can facilitate patient selection. Trial Registration ClinicalTrials.gov Identifier: NCT03759834. URL: https://clinicaltrials.gov/ct2/show/NCT03759834 Supplementary Information The online version contains supplementary material available at 10.1186/s12967-022-03271-4.
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20
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Fipps DC, Staab JP, Allen ND. Case Report: Right Insular Stroke Causing Simultaneous Onset of a Functional Vestibular Disorder and Psychiatric Disorder-Persistent Postural-Perceptual Dizziness and Post-stroke Depression. Front Psychiatry 2022; 13:841072. [PMID: 35530020 PMCID: PMC9070051 DOI: 10.3389/fpsyt.2022.841072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 02/28/2022] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Persistent postural-perceptual dizziness (PPPD) is a chronic functional vestibular disorder that can be precipitated by acquired brain injuries. Poststroke depression (PSD) is the most common psychiatric sequela of stroke, affecting 33% of stroke survivors. Pathophysiologic mechanisms of PPPD and PSD are not fully understood. CASE REPORT A 40-year-old woman developed new, debilitating chronic dizziness exacerbated by her own motion and exposure to visual motion stimuli plus prolonged depressive symptoms, both beginning within days after a localized right insular stroke. A collaborative evaluation by specialists in neurology, otorhinolaryngology, optometry, and psychiatry concluded that the insular stroke caused simultaneous onset of PPPD and PSD. DISCUSSION Prior case reports described short-lived vertigo following insular strokes, but no long-term vestibular symptoms without ongoing nystagmus or gait ataxia. In this case, chronic dizziness and motion sensitivity continued in the absence of focal neurologic deficits, invoking the possibility that changes in functioning of brain networks subserving spatial orientation persisted despite otherwise adequate recovery from the stroke, a mechanism previously proposed for PPPD. This case also reinforced prior work implicating pathways through the insula in PSD. Co-occurrence of PPPD and PSD offers insights into simultaneous functions of the insula in multiple networks in human brain.
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Affiliation(s)
- David C Fipps
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Jeffrey P Staab
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States.,Department of Otorhinolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN, United States
| | - Nicholas D Allen
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
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21
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Cha YH, Baloh RW, Cho C, Magnusson M, Song JJ, Strupp M, Wuyts F, Staab JP. Mal de débarquement syndrome diagnostic criteria: Consensus document of the Classification Committee of the Bárány Society. J Vestib Res 2021; 30:285-293. [PMID: 32986636 PMCID: PMC9249277 DOI: 10.3233/ves-200714] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
We present diagnostic criteria for mal de débarquement syndrome (MdDS) for inclusion into the International Classification of Vestibular Disorders. The criteria include the following: 1] Non-spinning vertigo characterized by an oscillatory perception (‘rocking,’ ‘bobbing,’ or ‘swaying’) present continuously or for most of the day; 2] Onset occurs within 48 hours after the end of exposure to passive motion, 3] Symptoms temporarily reduce with exposure to passive motion (e.g. driving), and 4] Symptoms persist for >48 hours. MdDS may be designated as “in evolution,” if symptoms are ongoing but the observation period has been less than 1 month; “transient,” if symptoms resolve at or before 1 month and the observation period extends at least to the resolution point; or “persistent” if symptoms last for more than 1 month. Individuals with MdDS may develop co-existing symptoms of spatial disorientation, visual motion intolerance, fatigue, and exacerbation of headaches or anxiety. Features that distinguish MdDS from vestibular migraine, motion sickness, and persistent postural perceptual dizziness (PPPD) are reviewed. Motion-moderated oscillatory vertigo can also occur without a motion trigger, typically following another vestibular disorder, a medical illness, heightened psychological stress, or metabolic disturbance. Terminology for this non-motion triggered presentation has been varied as it has features of both MdDS and PPPD. Further research is needed into its phenomenological and biological relationship to MdDS, PPPD, and other vestibular disorders.
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Affiliation(s)
- Yoon-Hee Cha
- Department of Neurology, University of Minnesota, Minneapolis, MN, USA
| | - Robert W Baloh
- Department of Neurology, University of California Los Angeles, Los Angeles, CA, USA
| | - Catherine Cho
- Department of Neurology and Otolaryngology-Head and Neck Surgery, NYU Grossman School of Medicine, NY, USA
| | - Måns Magnusson
- Department of Otorhinolaryngology, Lund University, Lund, Sweden
| | - Jae-Jin Song
- Department of Otorhinolaryngology Head-and-Neck Surgery, Seoul National University Bundang Hospital, Seoul, South Korea
| | - Michael Strupp
- Department of Neurology and German Center for Vertigo and Balance Disorders, Ludwig Maximilians University, Munich, Germany
| | - Floris Wuyts
- Lab for Equilibrium Investigations and Aerospace (LEIA), University of Antwerp, Antwerp, Belgium
| | - Jeffrey P Staab
- Departments of Psychiatry and Psychology and Otorhinolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN., USA
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22
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Staab JP. To the Editor: Let's Make "Provider" a Dirty Word. J Grad Med Educ 2021; 13:736. [PMID: 34721810 PMCID: PMC8527953 DOI: 10.4300/jgme-d-21-00453.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Jeffrey P Staab
- Professor and Chair, Department of Psychiatry and Psychology, and Director, Fellowship in Consultation-Liaison Psychiatry, Mayo Clinic
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23
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Indovina I, Passamonti L, Mucci V, Chiarella G, Lacquaniti F, Staab JP. Brain Correlates of Persistent Postural-Perceptual Dizziness: A Review of Neuroimaging Studies. J Clin Med 2021; 10:4274. [PMID: 34575385 PMCID: PMC8468644 DOI: 10.3390/jcm10184274] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/10/2021] [Accepted: 09/15/2021] [Indexed: 01/08/2023] Open
Abstract
Persistent postural-perceptual dizziness (PPPD), defined in 2017, is a vestibular disorder characterized by chronic dizziness that is exacerbated by upright posture and exposure to complex visual stimuli. This review focused on recent neuroimaging studies that explored the pathophysiological mechanisms underlying PPPD and three conditions that predated it. The emerging picture is that local activity and functional connectivity in multimodal vestibular cortical areas are decreased in PPPD, which is potentially related to structural abnormalities (e.g., reductions in cortical folding and grey-matter volume). Additionally, connectivity between the prefrontal cortex, which regulates attentional and emotional responses, and primary visual and motor regions appears to be increased in PPPD. These results complement physiological and psychological data identifying hypervigilant postural control and visual dependence in patients with PPPD, supporting the hypothesis that PPPD arises from shifts in interactions among visuo-vestibular, sensorimotor, and emotional networks that overweigh visual over vestibular inputs and increase the effects of anxiety-related mechanisms on locomotor control and spatial orientation.
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Affiliation(s)
- Iole Indovina
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, 98125 Messina, Italy
- Laboratory of Neuromotor Physiology, IRCCS Santa Lucia Foundation, 00179 Rome, Italy; (V.M.); (F.L.)
| | - Luca Passamonti
- Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK;
- Institute of Bioimaging & Molecular Physiology, National Research Council, 20054 Milano, Italy
| | - Viviana Mucci
- Laboratory of Neuromotor Physiology, IRCCS Santa Lucia Foundation, 00179 Rome, Italy; (V.M.); (F.L.)
- School of Science, Western Sydney University, Sydney, NSW 2000, Australia
| | - Giuseppe Chiarella
- Unit of Audiology, Department of Experimental and Clinical Medicine, Magna Græcia University, 88100 Catanzaro, Italy;
| | - Francesco Lacquaniti
- Laboratory of Neuromotor Physiology, IRCCS Santa Lucia Foundation, 00179 Rome, Italy; (V.M.); (F.L.)
- Department of Systems Medicine and Centre of Space BioMedicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Jeffrey P. Staab
- Departments of Psychiatry and Psychology and Otorhinolaryngology—Head and Neck Surgery, Mayo Clinic, Rochester, MN 55905, USA
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Dunlap PM, Sparto PJ, Marchetti GF, Furman JM, Staab JP, Delitto A, Klatt BN, Whitney SL. Fear Avoidance Beliefs Are Associated With Perceived Disability in Persons With Vestibular Disorders. Phys Ther 2021; 101:6297426. [PMID: 34120180 DOI: 10.1093/ptj/pzab147] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 03/05/2021] [Accepted: 04/26/2021] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the association between fear-avoidance beliefs and disability in 3 months in people with vestibular disorders while accounting for demographic and clinical characteristics. METHODS This prospective cohort study included people aged 18 to 100 years who reported dizziness. Participants were recruited from a balance disorders clinic and outpatient physical therapy clinics. All participants completed the Vestibular Activities Avoidance Instrument (VAAI) and the Hospital Anxiety and Depression Scale at baseline and the Vestibular Activities and Participation measure (VAP), dizziness Visual Analogue Scale (VAS), and 12-item Short Form Health Questionnaire at baseline and 3-month follow-up. A modified version of the VAAI included 9 items abstracted from the 81-item VAAI. The relationships between 9-item VAAI scores and follow-up measures of disability were assessed using Spearman correlation coefficients. Linear regression models were analyzed to determine the effect of fear-avoidance beliefs on follow-up VAP score while accounting for baseline outcome measures. RESULTS All participants (n = 404) completed the baseline assessment (mean age = 54 years), and 286 (71%) completed the 3-month assessment. The mean 9-item VAAI score was 25 (SD = 14) at baseline and was significantly associated with VAP (ρ = 0.54), 12-item Short Form Health Questionnaire component scores (ρ = -0.53; -0.44), and dizziness VAS at follow-up (ρ = 0.37). Approximately 38% of the variation in VAP score at follow-up was predicted by age, number of medications, 9-item VAAI score, dizziness VAS, and Hospital Anxiety and Depression Scale-depression score when considered together (R2 = 0.38). CONCLUSION Fear-avoidance beliefs are associated with measures of disability at 3 months and are predictive of activity limitations and participation restrictions at 3 months when controlling for age, medications, baseline dizziness, and depression symptom severity in people with vestibular disorders. IMPACT Measurement of fear-avoidance beliefs may provide important prognostic information, suggesting that an assessment of fear-avoidance beliefs could be used by clinicians to identify individuals at greater risk of disability after a vestibular disorder. LAY SUMMARY Fear-avoidance beliefs in people who have vestibular disorders are associated with disability at 3 months and predict limitations in daily activities at 3 months.
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Affiliation(s)
- Pamela M Dunlap
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Patrick J Sparto
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Gregory F Marchetti
- Department of Physical Therapy, Duquesne University, Pittsburgh, Pennsylvania, USA
| | - Joseph M Furman
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jeffrey P Staab
- Departments of Psychiatry and Psychology and Otolaryngology Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Anthony Delitto
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Brooke N Klatt
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Susan L Whitney
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Balzekas I, Sladky V, Nejedly P, Brinkmann BH, Crepeau D, Mivalt F, Gregg NM, Pal Attia T, Marks VS, Wheeler L, Riccelli TE, Staab JP, Lundstrom BN, Miller KJ, Van Gompel J, Kremen V, Croarkin PE, Worrell GA. Invasive Electrophysiology for Circuit Discovery and Study of Comorbid Psychiatric Disorders in Patients With Epilepsy: Challenges, Opportunities, and Novel Technologies. Front Hum Neurosci 2021; 15:702605. [PMID: 34381344 PMCID: PMC8349989 DOI: 10.3389/fnhum.2021.702605] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 06/29/2021] [Indexed: 01/10/2023] Open
Abstract
Intracranial electroencephalographic (iEEG) recordings from patients with epilepsy provide distinct opportunities and novel data for the study of co-occurring psychiatric disorders. Comorbid psychiatric disorders are very common in drug-resistant epilepsy and their added complexity warrants careful consideration. In this review, we first discuss psychiatric comorbidities and symptoms in patients with epilepsy. We describe how epilepsy can potentially impact patient presentation and how these factors can be addressed in the experimental designs of studies focused on the electrophysiologic correlates of mood. Second, we review emerging technologies to integrate long-term iEEG recording with dense behavioral tracking in naturalistic environments. Third, we explore questions on how best to address the intersection between epilepsy and psychiatric comorbidities. Advances in ambulatory iEEG and long-term behavioral monitoring technologies will be instrumental in studying the intersection of seizures, epilepsy, psychiatric comorbidities, and their underlying circuitry.
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Affiliation(s)
- Irena Balzekas
- Bioelectronics, Neurophysiology, and Engineering Laboratory, Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Biomedical Engineering and Physiology Graduate Program, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN, United States
- Mayo Clinic Alix School of Medicine, Rochester, MN, United States
- Mayo Clinic Medical Scientist Training Program, Rochester, MN, United States
| | - Vladimir Sladky
- Bioelectronics, Neurophysiology, and Engineering Laboratory, Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Faculty of Biomedical Engineering, Czech Technical University in Prague, Kladno, Czechia
| | - Petr Nejedly
- Bioelectronics, Neurophysiology, and Engineering Laboratory, Department of Neurology, Mayo Clinic, Rochester, MN, United States
- The Czech Academy of Sciences, Institute of Scientific Instruments, Brno, Czechia
| | - Benjamin H. Brinkmann
- Bioelectronics, Neurophysiology, and Engineering Laboratory, Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Daniel Crepeau
- Bioelectronics, Neurophysiology, and Engineering Laboratory, Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Filip Mivalt
- Bioelectronics, Neurophysiology, and Engineering Laboratory, Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Faculty of Electrical Engineering and Communication, Department of Biomedical Engineering, Brno University of Technology, Brno, Czechia
| | - Nicholas M. Gregg
- Bioelectronics, Neurophysiology, and Engineering Laboratory, Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Tal Pal Attia
- Bioelectronics, Neurophysiology, and Engineering Laboratory, Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Victoria S. Marks
- Bioelectronics, Neurophysiology, and Engineering Laboratory, Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Biomedical Engineering and Physiology Graduate Program, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN, United States
| | - Lydia Wheeler
- Bioelectronics, Neurophysiology, and Engineering Laboratory, Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Biomedical Engineering and Physiology Graduate Program, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN, United States
- Mayo Clinic Alix School of Medicine, Rochester, MN, United States
| | - Tori E. Riccelli
- Mayo Clinic Alix School of Medicine, Rochester, MN, United States
| | - Jeffrey P. Staab
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, MN, United States
| | - Brian Nils Lundstrom
- Bioelectronics, Neurophysiology, and Engineering Laboratory, Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Kai J. Miller
- Bioelectronics, Neurophysiology, and Engineering Laboratory, Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - Jamie Van Gompel
- Bioelectronics, Neurophysiology, and Engineering Laboratory, Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - Vaclav Kremen
- Bioelectronics, Neurophysiology, and Engineering Laboratory, Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Czech Institute of Informatics, Robotics and Cybernetics, Czech Technical University in Prague, Prague, Czechia
| | - Paul E. Croarkin
- Bioelectronics, Neurophysiology, and Engineering Laboratory, Department of Neurology, Mayo Clinic, Rochester, MN, United States
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
| | - Gregory A. Worrell
- Bioelectronics, Neurophysiology, and Engineering Laboratory, Department of Neurology, Mayo Clinic, Rochester, MN, United States
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Bonsu A, Walker P, Edey J, Rea P, Kaski D, Kheradmand A, Saman Y, Staab JP, Arshad Q. Time to consider the role of rationalisation in health psychology. Public Health 2021; 196:59-61. [PMID: 34147997 DOI: 10.1016/j.puhe.2021.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/26/2021] [Accepted: 05/12/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objective of this study was to determine the interaction between psychological factors, belief systems, and engagement around public health initiatives. STUDY DESIGN We conducted a longitudinal observational study, utilising convenience sampling to examine illness-related perception in the immediate and medium-term stages of the first wave of the SARS-CoV-2 pandemic in the UK. METHODS Weekly questionnaires assessed our primary measure, illness-related perception, using The Health Anxiety Inventory. Other psychological measures included apathy, loneliness, depersonalisation, state anxiety, trait anxiety as well as personality traits. Multiple regressions were performed to determine which psychological factors predicted the variance of health anxiety every week using the enter method. RESULTS A combination of psychological variables that varied over time and were modulated by external events predicted the evolution of illness-related perception and associated aversion to perceived threat. CONCLUSION Our findings highlight how in the face of a public health crisis, psychological factors play a determining role in the synthesis of beliefs as well as guiding human behaviour.
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Affiliation(s)
- A Bonsu
- Division of Brain Sciences, Department of Medicine, Charing Cross Hospital Campus, Imperial College London, W6 8RF, UK
| | - P Walker
- InAmind Laboratory, Department of Psychology, Neuroscience and Behaviour, University of Leicester, Leicester, UK
| | - J Edey
- InAmind Laboratory, Department of Psychology, Neuroscience and Behaviour, University of Leicester, Leicester, UK
| | - P Rea
- InAmind Laboratory, Department of Psychology, Neuroscience and Behaviour, University of Leicester, Leicester, UK
| | - D Kaski
- Department of Clinical and Motor Neurosciences, UCL, Institute of Neurology, WC1N 3BG, UK
| | - A Kheradmand
- Department of Neurology, Johns Hopkin University, USA
| | - Y Saman
- InAmind Laboratory, Department of Psychology, Neuroscience and Behaviour, University of Leicester, Leicester, UK
| | - J P Staab
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA.
| | - Q Arshad
- Division of Brain Sciences, Department of Medicine, Charing Cross Hospital Campus, Imperial College London, W6 8RF, UK; InAmind Laboratory, Department of Psychology, Neuroscience and Behaviour, University of Leicester, Leicester, UK.
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Perez DL, Nicholson TR, Asadi-Pooya AA, Bègue I, Butler M, Carson AJ, David AS, Deeley Q, Diez I, Edwards MJ, Espay AJ, Gelauff JM, Hallett M, Horovitz SG, Jungilligens J, Kanaan RAA, Tijssen MAJ, Kozlowska K, LaFaver K, LaFrance WC, Lidstone SC, Marapin RS, Maurer CW, Modirrousta M, Reinders AATS, Sojka P, Staab JP, Stone J, Szaflarski JP, Aybek S. Neuroimaging in Functional Neurological Disorder: State of the Field and Research Agenda. Neuroimage Clin 2021; 30:102623. [PMID: 34215138 PMCID: PMC8111317 DOI: 10.1016/j.nicl.2021.102623] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 03/03/2021] [Indexed: 02/06/2023]
Abstract
Functional neurological disorder (FND) was of great interest to early clinical neuroscience leaders. During the 20th century, neurology and psychiatry grew apart - leaving FND a borderland condition. Fortunately, a renaissance has occurred in the last two decades, fostered by increased recognition that FND is prevalent and diagnosed using "rule-in" examination signs. The parallel use of scientific tools to bridge brain structure - function relationships has helped refine an integrated biopsychosocial framework through which to conceptualize FND. In particular, a growing number of quality neuroimaging studies using a variety of methodologies have shed light on the emerging pathophysiology of FND. This renewed scientific interest has occurred in parallel with enhanced interdisciplinary collaborations, as illustrated by new care models combining psychological and physical therapies and the creation of a new multidisciplinary FND society supporting knowledge dissemination in the field. Within this context, this article summarizes the output of the first International FND Neuroimaging Workgroup meeting, held virtually, on June 17th, 2020 to appraise the state of neuroimaging research in the field and to catalyze large-scale collaborations. We first briefly summarize neural circuit models of FND, and then detail the research approaches used to date in FND within core content areas: cohort characterization; control group considerations; task-based functional neuroimaging; resting-state networks; structural neuroimaging; biomarkers of symptom severity and risk of illness; and predictors of treatment response and prognosis. Lastly, we outline a neuroimaging-focused research agenda to elucidate the pathophysiology of FND and aid the development of novel biologically and psychologically-informed treatments.
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Affiliation(s)
- David L Perez
- Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Timothy R Nicholson
- Section of Cognitive Neuropsychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ali A Asadi-Pooya
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz Iran; Department of Neurology, Jefferson Comprehensive Epilepsy Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Indrit Bègue
- Division of Adult Psychiatry, Department of Psychiatry, University of Geneva, Geneva Switzerland; Service of Neurology Department of Clinical Neuroscience, University of Geneva, Geneva, Switzerland
| | - Matthew Butler
- Section of Cognitive Neuropsychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Alan J Carson
- Centre for Clinical Brain Sciences, The University of Edinburgh, EH16 4SB, UK
| | - Anthony S David
- Institute of Mental Health, University College London, London, UK
| | - Quinton Deeley
- South London and Maudsley NHS Foundation Trust, London UK Institute of Psychiatry Psychology and Neuroscience, King's College London, London, UK
| | - Ibai Diez
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mark J Edwards
- Neurosciences Research Centre, St George's University of London, London, UK
| | - Alberto J Espay
- James J. and Joan A. Gardner Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH, USA
| | - Jeannette M Gelauff
- Department of Neurology, Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1117, Amsterdam, Netherlands
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Silvina G Horovitz
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Johannes Jungilligens
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Germany
| | - Richard A A Kanaan
- Department of Psychiatry, University of Melbourne, Austin Health Heidelberg, Australia
| | - Marina A J Tijssen
- Expertise Center Movement Disorders Groningen, University Medical Center Groningen, Groningen, University of Groningen, The Netherlands
| | - Kasia Kozlowska
- The Children's Hospital at Westmead, Westmead Institute of Medical Research, University of Sydney Medical School, Sydney, NSW, Australia
| | - Kathrin LaFaver
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - W Curt LaFrance
- Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, RI, USA
| | - Sarah C Lidstone
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Ramesh S Marapin
- Expertise Center Movement Disorders Groningen, University Medical Center Groningen, Groningen, University of Groningen, The Netherlands
| | - Carine W Maurer
- Department of Neurology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA
| | - Mandana Modirrousta
- Department of Psychiatry, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3T 2N2, Canada
| | - Antje A T S Reinders
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Petr Sojka
- Department of Psychiatry, University Hospital Brno, Czech Republic
| | - Jeffrey P Staab
- Departments of Psychiatry and Psychology and Otorhinolaryngology-Head and Neck Surgery, Mayo Clinic Rochester, MN, USA
| | - Jon Stone
- Centre for Clinical Brain Sciences, The University of Edinburgh, EH16 4SB, UK
| | - Jerzy P Szaflarski
- University of Alabama at Birmingham Epilepsy Center, Department of Neurology, University of Alabama at Birmingham Birmingham, AL, USA
| | - Selma Aybek
- Neurology Department, Psychosomatic Medicine Unit, Bern University Hospital Inselspital, University of Bern, Bern, Switzerland
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Dunlap PM, Marchetti GF, Sparto PJ, Staab JP, Furman JM, Delitto A, Whitney SL. Exploratory Factor Analysis of the Vestibular Activities Avoidance Instrument. JAMA Otolaryngol Head Neck Surg 2021; 147:144-150. [PMID: 33237289 DOI: 10.1001/jamaoto.2020.4203] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Importance Fear avoidance is a behavioral response to dizziness that can lead to chronic symptoms and maladaptation of the vestibular system, but there is no valid and reliable clinical measure of fear avoidance for persons with dizziness. Although the Vestibular Activities Avoidance Instrument (VAAI) was developed to identify fear avoidance beliefs in persons with dizziness, it was considered too long for clinical use. Objective To continue development of the VAAI for clinical use by reducing its length and by assessing the internal consistency and construct validity through associations with measures of disability, quality of life, and psychological well-being. Design, Setting, and Participants This prospective cohort study conducted from February 2018 to December 2019 at a tertiary care balance disorders clinic and in outpatient physical therapy clinics in the United States included 404 adults with dizziness. Main Outcomes and Measures Participants completed the 81-item VAAI, the Vestibular Activities and Participation (VAP) measure, the 12-Item Short Form Health Survey (SF-12), and the Hospital Anxiety and Depression Scale (HADS) at baseline. Exploratory factor analysis of the VAAI was conducted to reduce the number of items. Internal consistency of the reduced VAAI was determined by calculating the Cronbach α. Convergent validity was assessed by examining the associations between the reduced VAAI and the VAP, the SF-12, and the HADS using Spearman correlation coefficients. Results Data from 404 adults (mean [SD] age, 54.0 [17.0] years; 64.6% women) were included in the analyses. The exploratory factor analysis indicated that 2 factors explained the underlying constructs of the 81-Item VAAI. The first factor was retained and measured the construct of fear avoidance. The VAAI was reduced to 9 items (VAAI-9). The VAAI-9 showed excellent internal consistency (Cronbach α = 0.92) and was positively associated with the VAP (ρ = 0.81) and the HADS anxiety (ρ = 0.47) and depression (ρ = 0.64) subscales, and negatively associated with physical (ρ = -0.76) and mental (ρ = -0.47) health-related quality of life. Conclusions and Relevance These findings indicate that the VAAI-9 is a short, internally consistent, valid measure of fear avoidance and is associated with quality of life, activity limitations and participation restrictions, and psychological well-being. The next steps in the development of the VAAI-9 will include validation in an external sample, assessment of test-retest validity, and prospective investigations of its association with future disability.
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Affiliation(s)
- Pamela M Dunlap
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Gregory F Marchetti
- Department of Physical Therapy, Duquesne University, Pittsburgh, Pennsylvania
| | - Patrick J Sparto
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jeffrey P Staab
- Department of Otorhinolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota.,Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota
| | - Joseph M Furman
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anthony Delitto
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Susan L Whitney
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania
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Trinidade A, Harman P, Stone J, Staab JP, Goebel JA. Assessment of Potential Risk Factors for the Development of Persistent Postural-Perceptual Dizziness: A Case-Control Pilot Study. Front Neurol 2021; 11:601883. [PMID: 33551961 PMCID: PMC7859446 DOI: 10.3389/fneur.2020.601883] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 12/29/2020] [Indexed: 12/21/2022] Open
Abstract
Objectives: (1) To assess whether neuroticism, state anxiety, and body vigilance are higher in patients with persistent postural-perceptual dizziness (PPPD) compared to a recovered vestibular patient group and a non-dizzy patient group; (2) To gather pilot data on illness perceptions of patients with PPPD. Materials and Methods: 15 cases with PPPD and two control groups: (1) recovered vestibular patients (n = 12) and (2) non-dizzy patients (no previous vestibular insult, n = 12). Main outcome measures: Scores from the Big Five Inventory (BFI) of personality traits, Generalized Anxiety Disorder - 7 (GAD-7) scale, Body Vigilance Scale (BVS), Dizziness Handicap Inventory (DHI), modified Vertigo Symptom Scale (VSS) and Brief Illness Perception Questionnaire (BIPQ). Results: Compared to non-dizzy patients, PPPD cases had higher neuroticism (p = 0.02), higher introversion (p = 0.008), lower conscientiousness (p = 0.03) and higher anxiety (p = 0.02). There were no differences between PPPD cases and recovered vestibular patients in BFI and GAD-7. PPPD cases had higher body vigilance to dizziness than both control groups and their illness perceptions indicated higher levels of threat than recovered vestibular patients. Conclusion: PPPD patients showed statistically significant differences to non-dizzy patients, but not recovered vestibular controls in areas such as neuroticism and anxiety. Body vigilance was increased in PPPD patients when compared with both recovered vestibular and non-dizzy patient groups. PPPD patients also exhibited elements of negative illness perception suggesting that this may be the key element driving the development of PPPD. Large scale studies focusing on this area in the early stages following vestibular insult are needed.
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Affiliation(s)
- Aaron Trinidade
- Southend University Hospital NHS Foundation Trust, Southend-on-Sea, United Kingdom
| | - Paula Harman
- Southend University Hospital NHS Foundation Trust, Southend-on-Sea, United Kingdom
| | - Jon Stone
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Joel A Goebel
- Washington University in St. Louis School of Medicine, St. Louis, MO, United States
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Abstract
OBJECTIVE The Dizziness Handicap Inventory (DHI) is a 25-item self-report quantifying dizziness-related physical and emotional symptoms and restrictions in daily activities. DHI scores do not correlate with severity of structural vestibular deficits; thus, high DHI scores may reflect other causes of morbidity. This study investigated the relationship between total DHI scores and the presence of structural, functional, and psychiatric disorders in tertiary neurotology patients. STUDY DESIGN Retrospective. SETTING Tertiary center. PATIENTS Eighty-five patients who underwent multidisciplinary neurotologic evaluations. INTERVENTION Diagnostic. MAIN OUTCOME MEASURE(S) Active illnesses identified by a multidisciplinary neurotology team were abstracted from medical records, cataloged as structural, functional, or psychiatric disorders, and used to group patients into diagnostic categories: structural (structural disorders only), functional (functional disorders with/without structural disorders), and psychiatric (psychiatric disorders with/without other conditions). DHI scores were compared across diagnostic categories. Sensitivities and specificities of DHI scores for identifying structural versus functional or psychiatric disorders were calculated. RESULTS Mean DHI scores differed significantly by diagnostic category (structural 35 ± 18, functional 64 ± 15, and psychiatric 65 ± 19), before and after adjusting for age and sex (p < 0.001, Hedges' g>1.62 for structural versus functional and psychiatric categories). DHI≤30 (mild handicap) had specificity = 0.98 for structural disorders alone, whereas DHI>60 (severe handicap) had specificity = 0.88 for functional or psychiatric disorders. CONCLUSIONS In this tertiary cohort, categories of illnesses had large effects on total DHI scores. Patients with scores ≤30 were likely to have structural disorders alone, whereas those with scores >60 were likely to have functional or psychiatric disorders, with or without coexisting structural conditions.
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Affiliation(s)
| | - Jeffrey P Staab
- Department of Otolaryngology-Head and Neck Surgery
- Department of Psychiatry and Psychology
| | - Christine M Lohse
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
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31
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Bednarczuk NF, Staab JP. An Extreme Presentation of Migraine: Suicidal Ideation as a Migraine Aura. Psychosomatics 2020; 61:795-798. [PMID: 32416958 DOI: 10.1016/j.psym.2020.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 04/05/2020] [Accepted: 04/06/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Nadja F Bednarczuk
- Faculty of Medicine, Imperial College London, London, UK; Department of Medicine, King's College Hospital, London, UK
| | - Jeffrey P Staab
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN.
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Kim HA, Bisdorff A, Bronstein AM, Lempert T, Rossi-Izquierdo M, Staab JP, Strupp M, Kim JS. Hemodynamic orthostatic dizziness/vertigo: Diagnostic criteria. J Vestib Res 2020; 29:45-56. [PMID: 30883381 PMCID: PMC9249281 DOI: 10.3233/ves-190655] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 02/25/2019] [Indexed: 11/15/2022]
Abstract
This paper presents the diagnostic criteria for hemodynamic orthostatic dizziness/vertigo to be included in the International Classification of Vestibular Disorders (ICVD). The aim of defining diagnostic criteria of hemodynamic orthostatic dizziness/vertigo is to help clinicians to understand the terminology related to orthostatic dizziness/vertigo and to distinguish orthostatic dizziness/vertigo due to global brain hypoperfusion from that caused by other etiologies. Diagnosis of hemodynamic orthostatic dizziness/vertigo requires: A) five or more episodes of dizziness, unsteadiness or vertigo triggered by arising or present during upright position, which subsides by sitting or lying down; B) orthostatic hypotension, postural tachycardia syndrome or syncope documented on standing or during head-up tilt test; and C) not better accounted for by another disease or disorder. Probable hemodynamic orthostatic dizziness/vertigo is defined as follows: A) five or more episodes of dizziness, unsteadiness or vertigo triggered by arising or present during upright position, which subsides by sitting or lying down; B) at least one of the following accompanying symptoms: generalized weakness/tiredness, difficulty in thinking/concentrating, blurred vision, and tachycardia/palpitations; and C) not better accounted for by another disease or disorder. These diagnostic criteria have been derived by expert consensus from an extensive review of 90 years of research on hemodynamic orthostatic dizziness/vertigo, postural hypotension or tachycardia, and autonomic dizziness. Measurements of orthostatic blood pressure and heart rate are important for the screening and documentation of orthostatic hypotension or postural tachycardia syndrome to establish the diagnosis of hemodynamic orthostatic dizziness/vertigo.
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Affiliation(s)
- Hyun Ah Kim
- Department of Neurology, Keimyung University Dongsan Hospital, Daegu, South Korea
| | - Alexandre Bisdorff
- Department of Neurology, Centre Hospitalier Emile Mayrisch, Esch-sur-Alzette, Luxembourg
| | - Adolfo M. Bronstein
- Department of Neuro-otology, Division of Brain Sciences, Imperial College London, Charing Cross Hospital Campus, London, UK
| | - Thomas Lempert
- Department of Neurology, Schlosspark-Klinik, Berlin, Germany
| | | | - Jeffrey P. Staab
- Departments of Psychiatry and Psychology and Otorhinolaryngology – Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | - Michael Strupp
- Department of Neurology and German Center for Vertigo and Balance Disorders, Ludwig Maximilians University, Munich, Germany
| | - Ji-Soo Kim
- Department of Neurology, Seoul National University College of Medicine, Dizziness Center, Seoul National University Bundang Hospital, Seongnam, South Korea
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Suarez L, Dunlay SM, Schettle SD, Stulak JM, Staab JP. Associations of depressive symptoms with outcomes in patients implanted with left ventricular assist devices. Gen Hosp Psychiatry 2020; 64:93-98. [PMID: 32008725 DOI: 10.1016/j.genhosppsych.2019.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 12/11/2019] [Accepted: 12/30/2019] [Indexed: 12/01/2022]
Abstract
OBJECTIVE We examined characteristics of depressive symptoms in patients who received left ventricular assist devices (LVAD) to assess their effects on negative outcomes post-implantation. METHODS We retrospectively identified 203 adults with pre-operative PHQ-9 scores who underwent LVAD placement as bridge to transplant (BTT) or destination therapy (DT). We analyzed effects of PHQ-9 total, somatic, and cognitive/affective scores and proportion of patients with clinical depression on all-cause mortality, rehospitalization, major bleeding, and neurologic events post-implantation, controlling for demographics and other medical comorbidities. RESULTS Mean total PHQ-9 scores did not differ between 81 BTT and 122 DT patients (BTT 6.4 vs. DT 7.5, p = 0.12). A higher proportion of DT patients had clinical depression (BTT 22% vs. DT 39%, p = 0.015). Somatic symptoms accounted for three-quarters of total scores in both groups. PHQ-9 domains were not associated with negative outcomes post-implantation. CONCLUSION Depression severity did not differ based on implant strategy, but more DT patients had clinical depression. Somatic symptoms were the biggest contributor to depressive symptoms. Pre-implantation PHQ-9 scores were not associated with outcomes, possibly because depression was mild in both groups. Additional work is needed in LVAD patients to better characterize depressive symptoms and their unique effects on clinical course and well-being.
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Affiliation(s)
- Laura Suarez
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States of America.
| | - Shannon M Dunlay
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States of America; Department of Health Sciences Research, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States of America.
| | - Sarah D Schettle
- Department of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States of America.
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States of America.
| | - Jeffrey P Staab
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, United States of America.
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Singh K, Indovina I, Augustinack JC, Nestor K, García-Gomar MG, Staab JP, Bianciardi M. Probabilistic Template of the Lateral Parabrachial Nucleus, Medial Parabrachial Nucleus, Vestibular Nuclei Complex, and Medullary Viscero-Sensory-Motor Nuclei Complex in Living Humans From 7 Tesla MRI. Front Neurosci 2020; 13:1425. [PMID: 32038134 PMCID: PMC6989551 DOI: 10.3389/fnins.2019.01425] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 12/17/2019] [Indexed: 11/13/2022] Open
Abstract
The lateral parabrachial nucleus, medial parabrachial nucleus, vestibular nuclei complex, and medullary viscero-sensory-motor (VSM) nuclei complex (the latter including among others the solitary nucleus, vagus nerve nucleus, and hypoglossal nucleus) are anatomically and functionally connected brainstem gray matter structures that convey signals across multiple modalities between the brain and the spinal cord to regulate vital bodily functions. It is remarkably difficult to precisely extrapolate the location of these nuclei from ex vivo atlases to conventional 3 Tesla in vivo images; thus, a probabilistic brainstem template in stereotaxic neuroimaging space in living humans is needed. We delineated these nuclei using single-subject high contrast 1.1 mm isotropic resolution 7 Tesla MRI images. After precise coregistration of nuclei labels to stereotaxic space, we generated a probabilistic template of their anatomical locations. Finally, we validated the nuclei labels in the template by assessing their inter-rater agreement, consistency across subjects and volumes. We also performed a preliminary comparison of their location and microstructural properties to histologic sections of a postmortem human brainstem specimen. In future, the resulting probabilistic template of these brainstem nuclei in stereotaxic space may assist researchers and clinicians in evaluating autonomic, vestibular and VSM nuclei structure, function and connectivity in living humans using conventional 3 Tesla MRI scanners.
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Affiliation(s)
- Kavita Singh
- Brainstem Imaging Laboratory, Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Iole Indovina
- Department of Medicine and Surgery, Saint Camillus International University of Health and Medical Sciences, Rome, Italy.,Laboratory of Neuromotor Physiology, IRCCS Santa Lucia Foundation, Rome, Italy
| | - Jean C Augustinack
- Laboratory for Computational Neuroimaging, Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Kimberly Nestor
- Laboratory for Computational Neuroimaging, Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - María G García-Gomar
- Brainstem Imaging Laboratory, Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Jeffrey P Staab
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States.,Department of Otorhinolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, MN, United States
| | - Marta Bianciardi
- Brainstem Imaging Laboratory, Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
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Indovina I, Conti A, Lacquaniti F, Staab JP, Passamonti L, Toschi N. Reduced betweenness centrality of a sensory-motor vestibular network in subclinical agoraphobia. Annu Int Conf IEEE Eng Med Biol Soc 2020; 2019:4342-4345. [PMID: 31946829 DOI: 10.1109/embc.2019.8857332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Agoraphobic patients feel dizzy in crowded open spaces and respond to this symptom with excessive fear and avoidance. These clinical features show great similitude with the newly defined syndrome of persistent postural perceptual dizziness (PPPD). Patients with PPPD show decreased activity and connectivity in regions of the vestibular cortex. Due to the great overlap between these two conditions, we hypothesized that individuals with sub-clinical agoraphobia would show reduction in the connectivity features of these regions. We selected a group of healthy individuals from the Human Connectome Project that self-reported agoraphobia episodes, and compared it with a control group. We accurately matched the two groups for psychological measures and personality traits in order to study the neural correlates of vestibular symptoms independently of possible psychiatric vulnerabilities. We found that the agoraphobia group showed reduced betweenness centrality of a network encompassing key regions of the vestibular cortex. Dysfunctions of the vestibular cortex may explain the dizziness symptom for a disorder previously labelled as psychogenic.
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Abstract
Persistent postural-perceptual dizziness (PPPD) was defined for the International Classification of Vestibular Disorders in 2017. It is a chronic vestibular disorder that manifests with waxing and waning symptoms of dizziness, unsteadiness, or nonspinning vertigo that last for 3 months or more and are exacerbated by upright posture, active or passive motion of self, and exposure to environments with complex or moving visual stimuli. Triggers of PPPD include a wide variety of conditions that may cause vestibular symptoms or disrupt balance functioning, including neuro-otologic and other medical conditions and psychological distress. The diagnosis is made by identifying key symptoms in patients' histories and conducting physical examinations and diagnostic testing of sufficient detail to establish PPPD as opposed to other illnesses. Ongoing research is providing insights into the pathophysiological mechanisms underlying PPPD and support for multimodality treatment plans incorporating specially adapted vestibular rehabilitation, serotonergic medications, and cognitive-behavior therapy.
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Affiliation(s)
- Jeffrey P Staab
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota.,Department of Otorhinolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
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37
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Passamonti L, Riccelli R, Lacquaniti F, Staab JP, Indovina I. Brain responses to virtual reality visual motion stimulation are affected by neurotic personality traits in patients with persistent postural-perceptual dizziness. J Vestib Res 2019; 28:369-378. [PMID: 30856138 DOI: 10.3233/ves-190653] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Persistent postural perceptual dizziness (PPPD) is a common vestibular disorder of persistent dizziness and unsteadiness, exacerbated by upright posture, self-motion, and exposure to complex or moving visual stimuli. Previous functional magnetic resonance imaging (fMRI) studies found dysfunctional activity in the visual-vestibular cortices in patients with PPPD. Clinical studies showed that the anxiety-related personality traits of neuroticism and introversion may predispose individuals to PPPD. However, the effects of these traits on brain function in patients with PPPD versus healthy controls (HCs) have not been studied. METHODS To investigate potential differential effects of neuroticism and introversion on functioning of their visuo-vestibular networks, 15 patients with PPPD and 15 HCs matched for demographics and motion sickness susceptibility underwent fMRI during virtual reality simulation of a rollercoaster ride in vertical and horizontal directions. RESULTS Neuroticism positively correlated with activity in the inferior frontal gyrus (IFg), and enhanced connectivity between the IFg and occipital regions in patients with PPPD relative to HCs during vertical versus horizontal motion comparison. CONCLUSIONS In patients with PPPD, neuroticism increased the activity and connectivity of neural networks that mediate attention to visual motion cues during vertical motion. This mechanism may mediate visual control of balance in neurotic patients with PPPD.
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Affiliation(s)
- Luca Passamonti
- Department of Clinical Neurosciences, University of Cambridge, UK.,Institute of Bioimaging and Molecular Physiology, National Research Council, Milan, Italy
| | - Roberta Riccelli
- Institute of Bioimaging and Molecular Physiology, National Research Council, Catanzaro, Italy
| | - Francesco Lacquaniti
- Laboratory of Neuromotor Physiology, IRCCS Santa Lucia Foundation, Rome, Italy.,Centre of Space BioMedicine, University of Rome Tor Vergata, Rome, Italy
| | - Jeffrey P Staab
- Department of Psychiatry and Psychology and Otorhinolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | - Iole Indovina
- Laboratory of Neuromotor Physiology, IRCCS Santa Lucia Foundation, Rome, Italy.,Saint Camillus International University of Health Sciences, Rome, Italy
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Indovina I, Conti A, Lacquaniti F, Staab JP, Passamonti L, Toschi N. Lower Functional Connectivity in Vestibular-Limbic Networks in Individuals With Subclinical Agoraphobia. Front Neurol 2019; 10:874. [PMID: 31456740 PMCID: PMC6701404 DOI: 10.3389/fneur.2019.00874] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 07/26/2019] [Indexed: 02/02/2023] Open
Abstract
Background: Agoraphobia was described in 1871 as a condition of fear-related alterations in spatial orientation and locomotor control triggered by places or situations that might cause a patient to panic and feel trapped. In contemporary nosology, however, this original concept of agoraphobia was split into two diagnostic entities, i.e., the modern anxiety disorder of agoraphobia, consisting solely of phobic/avoidant symptoms in public spaces, and the recently defined vestibular disorder of persistent postural perceptual dizziness (PPPD), characterized by dizziness, and unsteadiness exacerbated by visual motion stimuli. Previous neuroimaging studies found altered brain activity and connectivity in visual-vestibular networks of patients with PPPD vs. healthy controls. Neuroticism and introversion, which pre-dispose to both agoraphobia and PPPD, influenced brain responses to vestibular and visual motion stimuli in patients with PPPD. Similar neuroimaging studies have not been undertaken in patients with agoraphobia in its current definition. Given their shared history and pre-disposing factors, we sought to test the hypotheses that individuals with agoraphobic symptoms have alterations in visual-vestibular networks similar to those of patients with PPPD, and that these alterations are influenced by neuroticism and introversion. Methods: Drawing from the Human Connectome Project (HCP) database, we matched 52 participants with sub-clinical agoraphobia and 52 control subjects without agoraphobic symptoms on 19 demographic and psychological/psychiatric variables. We then employed a graph-theoretical framework to compare resting-state functional magnetic resonance images between groups and evaluated the interactive effects of neuroticism and introversion on the brain signatures of agoraphobia. Results: Individuals with subclinical agoraphobia had lower global clustering, efficiency and transitivity relative to controls. They also had lower connectivity metrics in two brain networks, one positioned to process incoming visual space-motion information, assess threat, and initiate/inhibit behavioral responses (visuospatial-emotional network) and one positioned to control and monitor locomotion (vestibular-navigational network). Introversion interacted with agoraphobic symptoms to lower the connectivity of the visuospatial-emotional network. This contrasted with previous findings describing neuroticism-associated higher connectivity in a narrower visual-spatial-frontal network in patients with PPPD. Conclusion: Functional connectivity was lower in two brain networks in subclinical agoraphobia as compared to healthy controls. These networks integrate visual vestibular and emotional response to guide movement in space.
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Affiliation(s)
- Iole Indovina
- Department of Medicine and Surgery, Saint Camillus International University of Health and Medical Sciences, Rome, Italy,Laboratory of Neuromotor Physiology, IRCCS Santa Lucia Foundation, Rome, Italy,*Correspondence: Iole Indovina
| | - Allegra Conti
- Laboratory of Neuromotor Physiology, IRCCS Santa Lucia Foundation, Rome, Italy
| | - Francesco Lacquaniti
- Laboratory of Neuromotor Physiology, IRCCS Santa Lucia Foundation, Rome, Italy,Department of Systems Medicine and Centre of Space BioMedicine, University of Rome Tor Vergata, Rome, Italy
| | - Jeffrey P. Staab
- Departments of Psychiatry and Psychology and Otorhinolaryngology–Head and Neck Surgery, Mayo Clinic, Rochester, MN, United States
| | - Luca Passamonti
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom,Institute of Bioimaging and Molecular Physiology, National Research Council, Milan, Italy,Luca Passamonti
| | - Nicola Toschi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy,Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Boston, MA, United States
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Affiliation(s)
- Natasha Mirza
- Department of Otorhinolaryngology–Head and Neck Surgery
| | - Cesar Ruiz
- Department of Otorhinolaryngology–Head and Neck Surgery
| | - Eric D. Baum
- Department of Otorhinolaryngology–Head and Neck Surgery
| | - Jeffrey P. Staab
- Department of Otorhinolaryngology–Head and Neck Surgery
- Department of Psychiatry, University of Pennsylvania, Philadelphia
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Abstract
Research over the last 4 decades has revealed a great deal of information about psychiatric and functional causes, consequences, and comorbidity of vestibular syndromes. Primary care clinicians, neurologists, and otologists who are willing to set aside the 20th century notion of "psychogenic dizziness" and incorporate 21st century concepts about 5 behavioral entities into their practices will be rewarded for their efforts with a marked improvement in diagnostic acumen and therapeutic effectiveness. Panic attacks may cause or contribute to acute or episodic vestibular symptoms. Generalized anxiety and depression do the same for chronic vestibular symptoms. Fear of falling causes considerable functional impairment, particularly in the elderly. Persistent postural-perceptual dizziness, a newly defined functional vestibular disorder that was 145 years in the making, is the most common cause of chronic dizziness in neurotologic practice. These 5 disorders are the primary diagnoses in 8-10% of patients who consult neurologists or otologists for vestibular symptoms and may be present in up to 50% of patients with structural vestibular disorders. They affect the clinical course of other illnesses and outcomes of medical and surgical interventions. Fortunately, when recognized properly, they are among the most treatment responsive of all conditions that cause vestibular symptoms.
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Palmer BA, Frye MA, Vickers Douglas KS, Staab JP, Bright RP, Schleck CD, Mandrekar JN, Mahapatra S, Beckman TJ, Wittich CM. Validation of a Teaching Effectiveness Assessment in Psychiatry Continuing Medical Education. Acad Psychiatry 2018; 42:458-463. [PMID: 28685348 DOI: 10.1007/s40596-017-0763-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 06/23/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE Little is known about factors associated with effective continuing medical education (CME) in psychiatry. The authors aimed to validate a method to assess psychiatry CME teaching effectiveness and to determine associations between teaching effectiveness scores and characteristics of presentations, presenters, and participants. METHODS This cross-sectional study was conducted at the Mayo Clinic Psychiatry Clinical Reviews and Psychiatry in Medical Settings. Presentations were evaluated using an eight-item CME teaching effectiveness instrument, its content based on previously published instruments. Factor analysis, internal consistency and interrater reliabilities, and temporal stability reliability were calculated. Associations were determined between teaching effectiveness scores and characteristics of presentations, presenters, and participants. RESULTS In total, 364 participants returned 246 completed surveys (response rate, 67.6%). Factor analysis revealed a unidimensional model of psychiatry CME teaching effectiveness. Cronbach α for the instrument was excellent at 0.94. Item mean score (SD) ranged from 4.33 (0.92) to 4.71 (0.59) on a 5-point scale. Overall interrater reliability was 0.84 (95% CI, 0.75-0.91), and temporal stability was 0.89 (95% CI, 0.77-0.97). No associations were found between teaching effectiveness scores and characteristics of presentations, presenters, and participants. CONCLUSIONS This study provides a new, validated measure of CME teaching effectiveness that could be used to improve psychiatry CME. In contrast to prior research in other medical specialties, CME teaching effectiveness scores were not associated with use of case-based or interactive presentations. This outcome suggests the need for distinctive considerations regarding psychiatry CME; a singular approach to CME teaching may not apply to all medical specialties.
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Lee JO, Lee ES, Kim JS, Lee YB, Jeong Y, Choi BS, Kim JH, Staab JP. Altered brain function in persistent postural perceptual dizziness: A study on resting state functional connectivity. Hum Brain Mapp 2018; 39:3340-3353. [PMID: 29656497 DOI: 10.1002/hbm.24080] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 03/29/2018] [Accepted: 04/03/2018] [Indexed: 11/09/2022] Open
Abstract
This study used resting state functional magnetic resonance imaging (rsfMRI) to investigate whole brain networks in patients with persistent postural perceptual dizziness (PPPD). We compared rsfMRI data from 38 patients with PPPD and 38 healthy controls using whole brain and region of interest analyses. We examined correlations among connectivity and clinical variables and tested the ability of a machine learning algorithm to classify subjects using rsfMRI results. Patients with PPPD showed: (a) increased connectivity of subcallosal cortex with left superior lateral occipital cortex and left middle frontal gyrus, (b) decreased connectivity of left hippocampus with bilateral central opercular cortices, left posterior opercular cortex, right insular cortex and cerebellum, and (c) decreased connectivity between right nucleus accumbens and anterior left temporal fusiform cortex. After controlling for anxiety and depression as covariates, patients with PPPD still showed decreased connectivity between left hippocampus and right inferior frontal gyrus, bilateral temporal lobes, bilateral insular cortices, bilateral central opercular cortex, left parietal opercular cortex, bilateral occipital lobes and cerebellum (bilateral lobules VI and V, and left I-IV). Dizziness handicap, anxiety, and depression correlated with connectivity in clinically meaningful brain regions. The machine learning algorithm correctly classified patients and controls with a sensitivity of 78.4%, specificity of 76.9%, and area under the curve = 0.88 using 11 connectivity parameters. Patients with PPPD showed reduced connectivity among the areas involved in multisensory vestibular processing and spatial cognition, but increased connectivity in networks linking visual and emotional processing. Connectivity patterns may become an imaging biomarker of PPPD.
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Affiliation(s)
- Jin-Ok Lee
- Department of Neurology, Seoul National University of College of Medicine, Seoul National University Bundang Hospital, Republic of Korea
| | - Eek-Sung Lee
- Department of Neurology, Soonchunhyang University Bucheon Hospital, Republic of Korea
| | - Ji-Soo Kim
- Department of Neurology, Seoul National University of College of Medicine, Seoul National University Bundang Hospital, Republic of Korea
| | - Young-Beom Lee
- Department of Bio and Brain Engineering, Korea Advanced Institute of Science and Technology, Republic of Korea.,KI for Health Science and Technology, Korea Advanced Institute of Science and Technology, Republic of Korea
| | - Yong Jeong
- Department of Bio and Brain Engineering, Korea Advanced Institute of Science and Technology, Republic of Korea.,KI for Health Science and Technology, Korea Advanced Institute of Science and Technology, Republic of Korea
| | - Byung Se Choi
- Department of Radiology, Seoul National University Bundang Hospital, Republic of Korea
| | - Jae-Hyoung Kim
- Department of Radiology, Seoul National University Bundang Hospital, Republic of Korea
| | - Jeffrey P Staab
- Departments of Psychiatry and Psychology and Otorhinolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
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Popkirov S, Staab JP, Stone J. Persistent postural-perceptual dizziness (PPPD): a common, characteristic and treatable cause of chronic dizziness. Pract Neurol 2017; 18:5-13. [PMID: 29208729 DOI: 10.1136/practneurol-2017-001809] [Citation(s) in RCA: 131] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2017] [Indexed: 01/13/2023]
Abstract
Persistent postural-perceptual dizziness (PPPD) is a newly defined diagnostic syndrome that unifies key features of chronic subjective dizziness, phobic postural vertigo and related disorders. It describes a common chronic dysfunction of the vestibular system and brain that produces persistent dizziness, non-spinning vertigo and/or unsteadiness. The disorder constitutes a long-term maladaptation to a neuro-otological, medical or psychological event that triggered vestibular symptoms, and is usefully considered within the spectrum of other functional neurological disorders. While diagnostic tests and conventional imaging usually remain negative, patients with PPPD present in a characteristic way that maps on to positive diagnostic criteria. Patients often develop secondary functional gait disorder, anxiety, avoidance behaviour and severe disability. Once recognised, PPPD can be managed with effective communication and tailored treatment strategies, including specialised physical therapy (vestibular rehabilitation), serotonergic medications and cognitive-behavioural therapy.
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Affiliation(s)
- Stoyan Popkirov
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Jeffrey P Staab
- Department of Psychiatry and Psychology and Otorhinolaryngology - Head and Neck Surgery, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Jon Stone
- Centre for Clinical Brain Sciences, University of Edinburgh, Western General Hospital, Edinburgh, UK
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Riccelli R, Passamonti L, Toschi N, Nigro S, Chiarella G, Petrolo C, Lacquaniti F, Staab JP, Indovina I. Altered Insular and Occipital Responses to Simulated Vertical Self-Motion in Patients with Persistent Postural-Perceptual Dizziness. Front Neurol 2017; 8:529. [PMID: 29089920 PMCID: PMC5650964 DOI: 10.3389/fneur.2017.00529] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 09/22/2017] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Persistent postural-perceptual dizziness (PPPD) is a common functional vestibular disorder characterized by persistent symptoms of non-vertiginous dizziness and unsteadiness that are exacerbated by upright posture, self-motion, and exposure to complex or moving visual stimuli. Recent physiologic and neuroimaging data suggest that greater reliance on visual cues for postural control (as opposed to vestibular cues-a phenomenon termed visual dependence) and dysfunction in central visuo-vestibular networks may be important pathophysiologic mechanisms underlying PPPD. Dysfunctions are thought to involve insular regions that encode recognition of the visual effects of motion in the gravitational field. METHODS We tested for altered activity in vestibular and visual cortices during self-motion simulation obtained via a visual virtual-reality rollercoaster stimulation using functional magnetic resonance imaging in 15 patients with PPPD and 15 healthy controls (HCs). We compared between groups differences in brain responses to simulated displacements in vertical vs horizontal directions and correlated the difference in directional responses with dizziness handicap in patients with PPPD. RESULTS HCs showed increased activity in the anterior bank of the central insular sulcus during vertical relative to horizontal motion, which was not seen in patients with PPPD. However, for the same comparison, dizziness handicap correlated positively with activity in the visual cortex (V1, V2, and V3) in patients with PPPD. CONCLUSION We provide novel insight into the pathophysiologic mechanisms underlying PPPD, including functional alterations in brain processes that affect balance control and reweighting of space-motion inputs to favor visual cues. For patients with PPPD, difficulties using visual data to discern the effects of gravity on self-motion may adversely affect balance control, particularly for individuals who simultaneously rely too heavily on visual stimuli. In addition, increased activity in the visual cortex, which correlated with severity of dizziness handicap, may be a neural correlate of visual dependence.
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Affiliation(s)
- Roberta Riccelli
- Laboratory of Neuromotor Physiology, IRCCS Santa Lucia Foundation, Rome, Italy
- Centre of Space BioMedicine, University of Rome Tor Vergata, Rome, Italy
| | - Luca Passamonti
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- Institute of Bioimaging and Molecular Physiology, National Research Council, Catanzaro, Italy
| | - Nicola Toschi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
- Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Boston, MA, United States
| | - Salvatore Nigro
- Institute of Bioimaging and Molecular Physiology, National Research Council, Catanzaro, Italy
| | - Giuseppe Chiarella
- Unit of Audiology, Department of experimental and clinical medicine, Magna Græcia University, Catanzaro, Italy
| | - Claudio Petrolo
- Unit of Audiology, Department of experimental and clinical medicine, Magna Græcia University, Catanzaro, Italy
| | - Francesco Lacquaniti
- Laboratory of Neuromotor Physiology, IRCCS Santa Lucia Foundation, Rome, Italy
- Centre of Space BioMedicine, University of Rome Tor Vergata, Rome, Italy
| | - Jeffrey P. Staab
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, United States
- Department of Otorhinolaryngology – Head and Neck Surgery, Mayo Clinic, Rochester, MN, United States
| | - Iole Indovina
- Laboratory of Neuromotor Physiology, IRCCS Santa Lucia Foundation, Rome, Italy
- Centre of Space BioMedicine, University of Rome Tor Vergata, Rome, Italy
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45
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Staab JP, Eckhardt-Henn A, Horii A, Jacob R, Strupp M, Brandt T, Bronstein A. Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the committee for the Classification of Vestibular Disorders of the Bárány Society. J Vestib Res 2017; 27:191-208. [PMID: 29036855 PMCID: PMC9249299 DOI: 10.3233/ves-170622] [Citation(s) in RCA: 334] [Impact Index Per Article: 47.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 08/21/2017] [Indexed: 12/21/2022]
Abstract
This paper presents diagnostic criteria for persistent postural-perceptual dizziness (PPPD) to be included in the International Classification of Vestibular Disorders (ICVD). The term PPPD is new, but the disorder is not. Its diagnostic criteria were derived by expert consensus from an exhaustive review of 30 years of research on phobic postural vertigo, space-motion discomfort, visual vertigo, and chronic subjective dizziness. PPPD manifests with one or more symptoms of dizziness, unsteadiness, or non-spinning vertigo that are present on most days for three months or more and are exacerbated by upright posture, active or passive movement, and exposure to moving or complex visual stimuli. PPPD may be precipitated by conditions that disrupt balance or cause vertigo, unsteadiness, or dizziness, including peripheral or central vestibular disorders, other medical illnesses, or psychological distress. PPPD may be present alone or co-exist with other conditions. Possible subtypes await future identification and validation. The pathophysiologic processes underlying PPPD are not fully known. Emerging research suggests that it may arise from functional changes in postural control mechanisms, multi-sensory information processing, or cortical integration of spatial orientation and threat assessment. Thus, PPPD is classified as a chronic functional vestibular disorder. It is not a structural or psychiatric condition.
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Affiliation(s)
- Jeffrey P. Staab
- Departments of Psychiatry and Psychology and Otorhinolaryngology – Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Arata Horii
- Department of Otorhinolaryngology, Niigata University, Niigata, Japan
| | - Rolf Jacob
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael Strupp
- Department of Neurology and German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Germany
| | - Thomas Brandt
- Department of Neurology and German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Germany
| | - Adolfo Bronstein
- Neuro-Otology Unit, Division of Brain Sciences, Imperial College London, London, UK
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Riccelli R, Indovina I, Staab JP, Nigro S, Augimeri A, Lacquaniti F, Passamonti L. Neuroticism modulates brain visuo-vestibular and anxiety systems during a virtual rollercoaster task. Hum Brain Mapp 2016; 38:715-726. [PMID: 27677756 PMCID: PMC6866907 DOI: 10.1002/hbm.23411] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 08/10/2016] [Accepted: 09/16/2016] [Indexed: 02/02/2023] Open
Abstract
Different lines of research suggest that anxiety‐related personality traits may influence the visual and vestibular control of balance, although the brain mechanisms underlying this effect remain unclear. To our knowledge, this is the first functional magnetic resonance imaging (fMRI) study that investigates how individual differences in neuroticism and introversion, two key personality traits linked to anxiety, modulate brain regional responses and functional connectivity patterns during a fMRI task simulating self‐motion. Twenty‐four healthy individuals with variable levels of neuroticism and introversion underwent fMRI while performing a virtual reality rollercoaster task that included two main types of trials: (1) trials simulating downward or upward self‐motion (vertical motion), and (2) trials simulating self‐motion in horizontal planes (horizontal motion). Regional brain activity and functional connectivity patterns when comparing vertical versus horizontal motion trials were correlated with personality traits of the Five Factor Model (i.e., neuroticism, extraversion‐introversion, openness, agreeableness, and conscientiousness). When comparing vertical to horizontal motion trials, we found a positive correlation between neuroticism scores and regional activity in the left parieto‐insular vestibular cortex (PIVC). For the same contrast, increased functional connectivity between the left PIVC and right amygdala was also detected as a function of higher neuroticism scores. Together, these findings provide new evidence that individual differences in personality traits linked to anxiety are significantly associated with changes in the activity and functional connectivity patterns within visuo‐vestibular and anxiety‐related systems during simulated vertical self‐motion. Hum Brain Mapp 38:715–726, 2017. © 2016 The Authors Human Brain Mapping Published by Wiley Periodicals, Inc.
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Affiliation(s)
- Roberta Riccelli
- Department of Medical and Surgical Sciences; University “Magna Graecia,”; Catanzaro Italy
| | - Iole Indovina
- Laboratory of Neuromotor Physiology; IRCCS Santa Lucia Foundation; Rome 00179 Italy
- Centre of Space BioMedicine, University of Rome Tor Vergata; Rome 00173 Italy
| | - Jeffrey P. Staab
- Departments of Psychiatry and Psychology and Otorhinolaryngology - Head and Neck Surgery; Mayo Clinic; Rochester Minnesota USA
| | - Salvatore Nigro
- Institute of Bioimaging and Molecular Physiology, National Research Council; Catanzaro 88100 Italy
| | - Antonio Augimeri
- Institute of Bioimaging and Molecular Physiology, National Research Council; Catanzaro 88100 Italy
| | - Francesco Lacquaniti
- Laboratory of Neuromotor Physiology; IRCCS Santa Lucia Foundation; Rome 00179 Italy
- Centre of Space BioMedicine, University of Rome Tor Vergata; Rome 00173 Italy
- Department of Systems Medicine; University of Rome Tor Vergata; Rome 00133 Italy
| | - Luca Passamonti
- Institute of Bioimaging and Molecular Physiology, National Research Council; Catanzaro 88100 Italy
- Department of Clinical Neurosciences; University of Cambridge; Cambridge United Kingdom
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Thompson KJ, Goetting JC, Staab JP, Shepard NT. Retrospective review and telephone follow-up to evaluate a physical therapy protocol for treating persistent postural-perceptual dizziness: A pilot study. J Vestib Res 2016; 25:97-103; quiz 103-4. [PMID: 26410674 DOI: 10.3233/ves-150551] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Persistent postural-perceptual dizziness (PPPD) (formerly chronic subjective dizziness) may be treated using the habituation form of vestibular and balance rehabilitation therapy (VBRT), but therapeutic outcomes have not been formally investigated. OBJECTIVE This pilot study gathered the first data on the efficacy of VBRT for individuals with well-characterized PPPD alone or PPPD plus neurotologic comorbidities (vestibular migraine or compensated vestibular deficits). METHODS Twenty-six participants were surveyed by telephone an average of 27.5 months after receiving education about PPPD and instructions for home-based VBRT programs. Participants were queried about exercise compliance, perceived benefits of therapy, degree of visual or motion sensitivity remaining, disability level, and other interventions. RESULTS Twenty-two of 26 participants found physical therapy consultation helpful. Fourteen found VBRT exercises beneficial, including 8 of 12 who had PPPD alone and 6 of 14 who had PPPD with co-morbidities. Of the 14 participants who found VBRT helpful, 7 obtained relief of sensitivity to head/body motion, 5 relief of sensitivity to visual stimuli, and 4 complete remission. Comparable numbers for the 12 participants who found VBRT not helpful were 1 (head/body motion), 3 (visual stimuli), and 0 (remission). CONCLUSIONS This pilot study offers the first data supporting the habituation form of VBRT for treatment of PPPD.
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Affiliation(s)
- Karla J Thompson
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - Jay C Goetting
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - Jeffrey P Staab
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Neil T Shepard
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, MN, USA
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Söhsten E, Bittar RS, Staab JP. Posturographic profile of patients with persistent postural-perceptual dizziness on the sensory organization test. J Vestib Res 2016; 26:319-26. [DOI: 10.3233/ves-160583] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Eliane Söhsten
- Department of Otorhinolaryngology, Division of Otoneurology, Hospital das Clínicas, Medical School, Universidade de São Paulo (USP), São Paulo, SP, Brazil
| | - Roseli S.M. Bittar
- Department of Otorhinolaryngology, Division of Otoneurology, Medical School, Universidade de São Paulo (USP), São Paulo, SP, Brazil
| | - Jeffrey P. Staab
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
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Abstract
Functional and psychiatric disorders that cause vestibular symptoms (i.e., vertigo, unsteadiness, and dizziness) are common. In fact, they are more common than many well-known structural vestibular disorders. Neurologists and otologists are more likely to encounter patients with vestibular symptoms due to persistent postural-perceptual dizziness or panic disorder than Ménière's disease or bilateral vestibular loss. Successful approaches to identifying functional and psychiatric causes of vestibular symptoms can be incorporated into existing practices without much difficulty. The greatest challenge is to set aside dichotomous thinking that strongly emphasizes investigations of structural diseases in favor of a three-pronged approach that assesses structural, functional, and psychiatric disorders simultaneously. The pathophysiologic mechanisms underlying functional and psychiatric causes of vestibular symptoms are better understood than many clinicians realize. Research methods such as advanced posturographic analysis and functional brain imaging will push this knowledge further in the next few years. Treatment plans that include patient education, vestibular rehabilitation, cognitive and behavioral therapies, and medications substantially reduce morbidity and offer the potential for sustained remission when applied systematically. Diagnostic and therapeutic approaches are necessarily multidisciplinary in nature, but they are well within the purview of collaborative care teams or networks of clinicians coordinated with the neurologists and otologists whom patients consult first.
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Affiliation(s)
- M Dieterich
- Department of Neurology, Ludwig-Maximilians-University Munich, Klinikum Grosshadern, Munich, Germany; German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-University Munich, Klinikum Grosshadern, Munich, Germany.
| | - J P Staab
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - T Brandt
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-University Munich, Klinikum Grosshadern, Munich, Germany
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Abstract
Behavioral factors have long been recognized as affecting spatial orientation and balance function. Neuroanatomic and neurophysiologic studies conducted worldwide over the last 30 years have substantially advanced our knowledge about the inherently strong connectivity among threat/anxiety, vestibular, visual, and somatosensory systems in the brain. Clinical investigations have shed greater light on the nature of functional and psychiatric disorders that manifest or magnify vestibular morbidity. Concepts of these syndromes have changed over 150 years. Even their nomenclature has had different meanings in different eras. This chapter will review functional and psychiatric vestibular disorders. Terminology will follow the International Classification of Diseases, 11th edition, beta draft and the International Classification of Vestibular Disorders. Anxiety plays a central role in behavioral vestibular morbidity. Anxiety, traumatic stress, obsessive, and depressive disorders may be primary causes of episodic and chronic vestibular symptoms or secondary complications of other vestibular disorders. These psychiatric illnesses affect 30-50% of patients who consult neurologists or otologists for vestibular symptoms. Coexisting psychiatric disorders adversely affect treatment for patients with structural vestibular diseases, especially when unrecognized. Persistent postural-perceptual dizziness is the leading cause of long-term vestibular disability. Fortunately, pharmacologic, psychotherapeutic, and rehabilitative treatments of these illnesses have improved in recent years.
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Affiliation(s)
- J P Staab
- Department of Psychiatry and Psychology, and Department of Otorhinolaryngology - Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA.
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