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      Symptoms Associated with Vestibular Impairment in Veterans with Posttraumatic Stress Disorder

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      Journal: PLoS ONE
      Publisher: Public Library of Science

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          Abstract

          Posttraumatic stress disorder (PTSD) is a chronic and disabling, anxiety disorder resulting from exposure to life threatening events such as a serious accident, abuse or combat (DSM IV definition). Among veterans with PTSD, a common complaint is dizziness, disorientation and/or postural imbalance in environments such as grocery stores and shopping malls. The etiology of these symptoms in PTSD is poorly understood and some attribute them to anxiety or traumatic brain injury. There is a possibility that an impaired vestibular system may contribute to these symptoms since, symptoms of an impaired vestibular system include dizziness, disorientation and postural imbalance. To our knowledge, this is the first report to describe the nature of vestibular related symptoms in veterans with and without PTSD. We measured PTSD symptoms using the Posttraumatic Stress Disorder Checklist (PCL-C) and compared it to responses on vestibular function scales including the Dizziness Handicap Inventory (DHI), the Vertigo Symptom Scale Short Form (VSS-SF), the Chambless Mobility Inventory (CMI), and the Neurobehavioral Scale Inventory (NSI) in order to identify vestibular-related symptoms. Our findings indicate that veterans with worse PTSD symptoms report increased vestibular related symptoms. Additionally veterans with PTSD reported 3 times more dizziness related handicap than veterans without PTSD. Veterans with increased avoidance reported more vertigo and dizziness related handicap than those with PTSD and reduced avoidance. We describe possible contributing factors to increased reports of vestibular symptoms in PTSD, namely, anxiety, a vestibular component as well as an interactive effect of anxiety and vestibular impairment. We also present some preliminary analyses regarding the contribution of TBI. This data suggests possible evidence for vestibular symptom reporting in veterans with PTSD, which may be explained by possible underlying vestibular impairment, worthy of further exploration.

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          Symptoms, anxiety and handicap in dizzy patients: development of the vertigo symptom scale.

          Lucy Yardley, Elaine Masson, Carl Verschuur … (1992)
          Questionnaires assessing symptoms, anxiety and handicap were completed by 127 vertiginous patients. Factor analysis identified four distinct symptom clusters which formed the basis for the construction of scales quantifying the number and frequency of symptoms of: (a) vertigo (of long and short duration); (b) autonomic sensations and anxiety arousal; and (c) somatization. Scores on the vertigo severity scale were significantly related to clinical diagnosis and had near-zero correlations with measures of anxiety. Vertigo severity, autonomic signs and depressed mood each independently contributed to variance in handicap, taking precedence over the relationship between handicap and trait and state anxiety. Our findings suggest that the familiar association between anxiety and vertigo may be mediated principally by autonomic symptomatology arising as a result of somatopsychic and psychosomatic processes.
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            Prevalence, assessment, and treatment of mild traumatic brain injury and posttraumatic stress disorder: a systematic review of the evidence.

            Kathleen Carlson, Shannon Kehle, Laura Meis … (2016)
            Iraq and Afghanistan war veterans are returning from combat having sustained traumatic brain injury, mostcommonly mild traumatic brain injury (mTBI), and experiencing posttraumatic stress disorder (PTSD). Clinical guidelines for mTBI and PTSDdo not focus on the co-occurrence of these conditions (mTBI/PTSD). A synthesis of the evidence on prevalence, diagnostic accuracy, andtreatment effectiveness for mTBI/PTSD would be of use to clinicians, researchers, and policymakers. We conducteda systematic review of studies identified through PubMed, PsycINFO, REHABDATA, Cochrane Library, pearling, and expert recommendations. Peer-reviewed English language studies published between 1980 and June, 2009 were included if they reported frequencies of traumatic braininjury and PTSD, or diagnostic accuracy or treatment effectiveness specific to mTBI/PTSD. Thirty-four studies metinclusion criteria. None evaluated diagnostic accuracy or treatment effectiveness. Studies varied considerably in design. Frequency ofmTBI/PTSD ranged from 0% to 89%. However, in 3 large studies evaluating Iraq and Afghanistan war veterans, frequencies ofprobable mTBI/PTSD were from 5% to 7%; among those with probable mTBI, frequencies of probable PTSD were from 33% to 39%. The wide range of mTBI/PTSD frequency levels was likely due to variation across studyparameters, including aims and assessment methods. Studies using consistent, validated methods to define and measure mTBI history andPTSD are needed.
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              Measurement properties of the Dizziness Handicap Inventory by cross-sectional and longitudinal designs

              Anne-Lise Tamber, Kjersti Wilhelmsen, Liv Inger Strand (2009)
              Background The impact of dizziness on quality of life is often assessed by the Dizziness Handicap Inventory (DHI), which is used as a discriminate and evaluative measure. The aim of the present study was to examine reliability and validity of a translated Norwegian version (DHI-N), also examining responsiveness to important change in the construct being measured. Methods Two samples (n = 92 and n = 27) included participants with dizziness of mainly vestibular origin. A cross-sectional design was used to examine the factor structure (exploratory factor analysis), internal consistency (Cronbach's α), concurrent validity (Pearson's product moment correlation r), and discriminate ability (ROC curve analysis). Longitudinal designs were used to examine test-retest reliability (intraclass correlation coefficient (ICC) statistics, smallest detectable difference (SDD)), and responsiveness (Pearson's product moment correlation, ROC curve analysis; area under the ROC curve (AUC), and minimally important change (MIC)). The DHI scores range from 0 to 100. Results Factor analysis revealed a different factor structure than the original DHI, resulting in dismissal of subscale scores in the DHI-N. Acceptable internal consistency was found for the total scale (α = 0.95). Concurrent correlations between the DHI-N and other related measures were moderate to high, highest with Vertigo Symptom Scale-short form-Norwegian version (r = 0.69), and lowest with preferred gait (r = - 0.36). The DHI-N demonstrated excellent ability to discriminate between participants with and without 'disability', AUC being 0.89 and best cut-off point = 29 points. Satisfactory test-retest reliability was demonstrated, and the change for an individual should be ≥ 20 DHI-N points to exceed measurement error (SDD). Correlations between change scores of DHI-N and other self-report measures of functional health and symptoms were high (r = 0.50 - 0.57). Responsiveness of the DHI-N was excellent, AUC = 0.83, discriminating between self-perceived 'improved' versus 'unchanged' participants. The MIC was identified as 11 DHI-N points. Conclusions The DHI-N total scale demonstrated satisfactory measurement properties. This is the first study that has addressed and demonstrated responsiveness to important change of the DHI, and provided values of SDD and MIC to help interpret change scores.
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                Author and article information

                Contributors
                Christian Schmahl: Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (iso-abbrev): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, CA USA )
                ISSN (Electronic): 1932-6203
                Publication date (Electronic): 29 December 2016
                Publication date Collection: 2016
                Volume: 11
                Issue: 12
                Electronic Location Identifier: e0168803
                Affiliations
                [1 ]Department of Pharmacology, Physiology and Neuroscience, Rutgers Biomedical Health Sciences, Newark, New Jersey, United States of America
                [2 ]War Related Illness and Injury Study Center, Veterans Affairs New Jersey Healthcare System, East Orange, New Jersey, United States of America
                [3 ]Cardiovascular Electronics, National University of Ireland Galway, Galway, Ireland
                Central Institute of Mental Health, GERMANY
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                • Conceptualization: JMS HKC YOH.

                • Data curation: YOH.

                • Formal analysis: YOH HKC JMS.

                • Funding acquisition: JMS.

                • Investigation: YOH.

                • Methodology: JMS HMC YOH.

                • Project administration: HKC JMS.

                • Resources: JMS HKC.

                • Supervision: HKC JMS.

                • Validation: JMS HKC YOH.

                • Visualization: YOH HKC JMS.

                • Writing – original draft: YOH.

                • Writing – review & editing: YOH HKC JMS.

                Author information
                http://orcid.org/0000-0003-4032-220X
                Article
                Publisher ID: PONE-D-16-27638
                DOI: 10.1371/journal.pone.0168803
                PMC ID: 5199023
                PubMed ID: 28033352
                SO-VID: b69d5811-006d-430a-a6b3-73ccbcb7a7b0
                License:

                This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.

                History
                Date received : 11 July 2016
                Date accepted : 5 December 2016
                Page count
                Figures: 6, Tables: 2, Pages: 18
                Funding
                Funded by: This work was supported by the War Related Illness and Injury Study Center (WRIISC) and the Office of Public Health within the Department of Veteran Affairs.
                This work was supported by the War Related Illness and Injury Study Center (WRIISC) and the Office of Public Health within the Department of Veteran Affairs. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Subject: Research Article
                Subject: Medicine and Health Sciences
                Subject: Otorhinolaryngology
                Subject: Otology
                Subject: Vertigo
                Subject: Medicine and Health Sciences
                Subject: Mental Health and Psychiatry
                Subject: Neuropsychiatric Disorders
                Subject: Anxiety Disorders
                Subject: Post-Traumatic Stress Disorder
                Subject: Medicine and Health Sciences
                Subject: Mental Health and Psychiatry
                Subject: Neuroses
                Subject: Anxiety Disorders
                Subject: Post-Traumatic Stress Disorder
                Subject: Medicine and Health Sciences
                Subject: Critical Care and Emergency Medicine
                Subject: Trauma Medicine
                Subject: Traumatic Injury
                Subject: Head Injury
                Subject: Medicine and Health Sciences
                Subject: Critical Care and Emergency Medicine
                Subject: Trauma Medicine
                Subject: Traumatic Injury
                Subject: Neurotrauma
                Subject: Traumatic Brain Injury
                Subject: Research and Analysis Methods
                Subject: Research Design
                Subject: Clinical Research Design
                Subject: Symptom Scales
                Subject: Biology and Life Sciences
                Subject: Psychology
                Subject: Emotions
                Subject: Anxiety
                Subject: Social Sciences
                Subject: Psychology
                Subject: Emotions
                Subject: Anxiety
                Subject: Medicine and Health Sciences
                Subject: Mental Health and Psychiatry
                Subject: Neuropsychiatric Disorders
                Subject: Anxiety Disorders
                Subject: Panic Disorder
                Subject: Medicine and Health Sciences
                Subject: Mental Health and Psychiatry
                Subject: Neuroses
                Subject: Anxiety Disorders
                Subject: Panic Disorder
                Subject: Research and Analysis Methods
                Subject: Mathematical and Statistical Techniques
                Subject: Statistical Methods
                Subject: Regression Analysis
                Subject: Linear Regression Analysis
                Subject: Physical Sciences
                Subject: Mathematics
                Subject: Statistics (Mathematics)
                Subject: Statistical Methods
                Subject: Regression Analysis
                Subject: Linear Regression Analysis
                Custom metadata
                Data Availability All data were collected at the VA and the signed subject consent forms did not make provision for making individual data records publicly available, even in de-identified form. However the authors can provide the “metadata” – i.e. the numerical (aggregated data) results used to generate the figures. Requests for access can be sent to: Research Service (15), VA New Jersey Health Care System, 385 Tremont Avenue, East Orange, NJ, 07018, Attn: Data Access Request or to Corresponding author, Helena Chandler at Helena.chandler@ 123456va.gov .

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