A Randomized Controlled Trial Evaluating Integrative Psychotherapeutic Group Treatment Compared to Self-Help Groups in Functional Vertigo/Dizziness

Karina Limburg, Katharina Radziej, Heribert Sattel, Peter Henningsen, Marianne Dieterich, Thomas Probst, Rachel Dale, Claas Lahmann, Karina Limburg, Katharina Radziej, Heribert Sattel, Peter Henningsen, Marianne Dieterich, Thomas Probst, Rachel Dale, Claas Lahmann

Abstract

We tested the efficacy of an integrative psychotherapeutic group treatment (IPGT) in reducing vertigo/dizziness-related impairment along with depression, anxiety, and somatization by conducting a randomized controlled superiority trial comparing IPGT to self-help groups moderated by a clinical psychologist (SHG). Adult patients with functional vertigo and dizziness symptoms were randomly allocated to either the IPGT or SHG as active control group. Outcomes were assessed at baseline (t0), after treatment lasting 16 weeks (t1), and 12 months after treatment (t2). A total of 81 patients were assigned to IPGT and 78 patients were assigned to SHG. Vertigo-related impairment was reduced in both conditions (IPGT: t0-t1: d = 1.10, t0-t2: d = 1.06; SHG: t0-t1: d = 0.86, t0-t2: d = 1.29), showing the efficiency of both IPGT and SHG. Clinically relevant improvements were also obtained for depression in both groups. Linear mixed model analyses revealed no differences between groups for all outcomes (effect of group for the primary outcome: b = -1.15, SE = 2.13, t = -0.54, p = 0.59). Attrition rates were higher in SHG (52.6%) than in IPGT (28.4%). Both conditions improved primary and secondary outcomes while IPGT was better accepted by patients than SHG. Trial registration: ClinicalTrials.gov, Identifier: NCT02320851.

Keywords: dizziness; psychotherapy; randomized controlled trial; vertigo.

Conflict of interest statement

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

Figures

Figure 1
Figure 1
Study design and patient flow.

References

    1. Grill E., Heuberger M., Strobl R., Saglam M., Holle R., Linkohr B., Ladwig K.-H., Peters A., Schneider E., Jahn K., et al. Prevalence, Determinants, and consequences of vestibular hypofunction. results from the KORA-FF4 survey. Front. Neurol. 2018;9:1076. doi: 10.3389/fneur.2018.01076.
    1. Neuhauser H. Epidemiologie von Schwindelerkrankungen. Nervenarzt. 2009;80:887–894. doi: 10.1007/s00115-009-2738-9.
    1. Neuhauser H., von Brevern M., Radtke A., Lezius F., Feldmann M., Ziese T., Lempert T. Epidemiology of vestibular vertigo A neurotologic survey of the general population. Neurology. 2005;65:898–904. doi: 10.1212/01.wnl.0000175987.59991.3d.
    1. Neuhauser H., Radtke A., von Brevern M., Lezius F., Feldmann M., Lempert T. Burden of dizziness and vertigo in the community. Arch. Intern. Med. 2008;168:2118–2124. doi: 10.1001/archinte.168.19.2118.
    1. Dieterich M., Staab J.P. Functional dizziness: From phobicpostural vertigo and chronic subjective dizziness to persistent postural-perceptual dizziness. Curr. Opin. Neurol. 2017;30:107–113. doi: 10.1097/WCO.0000000000000417.
    1. Lahmann C., Henningsen P., Brandt T., Strupp M., Jahn K., Dieterich M., Eckhardt-Henn A., Feuerecker R., Dinkel A., Schmid G. Psychiatric comorbidity and psychosocial impairment among patients with vertigo and dizziness. J. Neurol. Neurosurg. Psychiatry. 2015;86:302–308. doi: 10.1136/jnnp-2014-307601.
    1. Limburg K., Sattel H., Dinkel A., Radziej K., Becker-Bense S., Lahmann C. Course and predictors of DSM-5 somatic symptom disorder in patients with vertigo and dizziness symptoms—A longitudinal study. Compr. Psychiatry. 2017;77:1–11. doi: 10.1016/j.comppsych.2017.05.003.
    1. Limburg K., Sattel H., Radziej K., Lahmann C. DSM-5 somatic symptom disorder in patients with vertigo and dizziness symptoms. J. Psychosom. Res. 2016;91:26–32. doi: 10.1016/j.jpsychores.2016.10.005.
    1. Nakao M., Yano E. Somatic symptoms for predicting depression: One-year follow-up study in annual health examinations. Psychiatry Clin. Neurosci. 2006;60:219–225. doi: 10.1111/j.1440-1819.2006.01489.x.
    1. Probst T., Dinkel A., Schmid G., Limburg K., Radziej K., Pieh C., Lahmann C. Psychological distress longitudinally mediates the effect vertigo symptoms exert on vertigo-related handicaps—Follow-up results of the Munich diagnostic and predictor study. J. Psychosom. Res. 2017;93:62–68. doi: 10.1016/j.jpsychores.2016.11.013.
    1. Schmid G., Henningsen P., Dieterich M., Sattel H., Lahmann C. Psychotherapy in dizziness: A systematic review. J. Neurol. Neurosurg. Psychiatry. 2011;82:601–606. doi: 10.1136/jnnp.2010.237388.
    1. Edelman S., Mahoney A.E., Cremer P.D. Cognitive behaviour therapy for chronic subjective dizziness: A randomized, controlled trial. Am. J. Otolaryngol. 2012;33:395–401. doi: 10.1016/j.amjoto.2011.10.009.
    1. Mahoney A.E., Edelman S., Cremer P.D. Cognitive behaviour therapy for chronic subjective dizziness: Longer-term gains and predictors of disability. Am. J. Otolaryngol. 2013;34:115–120. doi: 10.1016/j.amjoto.2012.09.013.
    1. Tschan R., Eckhardt-Henn A., Scheurich V., Best C., Dieterich M., Beutel M.E. Steadfast—Effectiveness of a cognitive-behavioural self-management program for patients with somatoform vertigo and dizziness. Psychother. Psychosom. Med. Psychol. 2012;62:111–119.
    1. Schmid D.A., Allum J.H., Sleptsova M., Gross S., Gaab J., Welge-Lüssen A., Schaefert R., Langewitz W. Effects of a program of cognitive-behavioural group therapy, vestibular rehabilitation, and psychoeducational explanations on patients with dizziness and no quantified balance deficit, compared to patients with dizziness and a quantified balance deficit. J. Psychosom. Res. 2018;105:21–30. doi: 10.1016/j.jpsychores.2017.11.020.
    1. Toshishige Y., Kondo M., Kabaya K., Watanabe W., Fukui A., Kuwabara J., Nakayama M., Iwasaki S., Furukawa T.A., Akechi T. Cognitive-behavioural therapy for chronic subjective dizziness: Predictors of improvement in Dizziness Handicap Inventory at 6 months posttreatment. Acta Otolaryngol. 2020;140:827–832. doi: 10.1080/00016489.2020.1772994.
    1. Kuwabara J., Kondo M., Kabaya K., Watanabe W., Shiraishi N., Sakai M., Toshishige Y., Ino K., Nakayama M., Iwasaki S., et al. Acceptance and commitment therapy combined with vestibular rehabilitation for persistent postural-perceptual dizziness: A pilot study. Am. J. Otolaryngol. 2020;41:102609. doi: 10.1016/j.amjoto.2020.102609.
    1. Baydan M., Yigit O., Aksoy S. Does vestibular rehabilitation improve postural control of subjects with chronic subjective dizziness? PLoS ONE. 2020;15:e0238436. doi: 10.1371/journal.pone.0238436.
    1. Stikkelbroek Y., Bodden D.H., Deković M., van Baar A.L. Effectiveness and cost effectiveness of cognitive behavioural therapy (CBT) in clinically depressed adolescents: Individual CBT versus treatment as usual (TAU) BMC Psychiatry. 2013;13:314. doi: 10.1186/1471-244X-13-314.
    1. Holmberg J., Karlberg M., Harlacher U., Rivano-Fischer M., Magnusson M. Treatment of phobic postural vertigo. J. Neurol. 2006;253:500–506. doi: 10.1007/s00415-005-0050-6.
    1. Lahmann C., Henningsen P., Dieterich M., Radziej K., Schmid G. Tailored care for somatoform vertigo/dizziness: Study protocol for a randomised controlled trial evaluating integrative group psychotherapy. J. Neurol. 2015;262:1867–1875. doi: 10.1007/s00415-015-7784-6.
    1. Radziej K., Schmid-Mühlbauer G., Limburg K., Lahmann C. Tailored Care for Functional Vertigo/Dizziness—An Integrative Group Psychotherapy Approach. Psychother. Psychosom. Med. Psychol. 2017;67:245–251.
    1. Sattel H., Lahmann C., Gündel H., Guthrie E., Kruse J., Noll-Hussong M., Ohmann C., Ronel J., Sack M., Sauer N., et al. Brief psychodynamic interpersonal psychotherapy for patients with multisomatoform disorder: Randomised controlled trial. Br. J. Psychiatry. 2012;200:60–67. doi: 10.1192/bjp.bp.111.093526.
    1. Jacob R.G., Redfern M.S., Furman J.M. Space and motion discomfort and abnormal balance control in patients with anxiety disorders. J. Neurol. Neurosurg. Psychiatry. 2009;80:74–78. doi: 10.1136/jnnp.2007.136432.
    1. Schniepp R., Wuehr M., Huth S., Pradhan C., Brandt T., Jahn K. Gait characteristics of patients with phobic postural vertigo: Effects of fear of falling, attention, and visual input. J. Neurol. 2014;261:738–746. doi: 10.1007/s00415-014-7259-1.
    1. Schniepp R., Wuehr M., Pradhan C., Novozhilov S., Krafczyk S., Brandt T., Jahn K. Nonlinear Variability of Body Sway in Patients with Phobic Postural Vertigo. Front. Neurol. 2013;4:115. doi: 10.3389/fneur.2013.00115.
    1. Wuehr M., Brandt T., Schniepp R. Distracting attention in phobic postural vertigo normalizes leg muscle activity and balance. Neurology. 2017;88:284–288. doi: 10.1212/WNL.0000000000003516.
    1. Wuehr M., Pradhan C., Novozhilov S., Krafczyk S., Brandt T., Jahn K., Schniepp R. Inadequate interaction between open—and closed—loop postural control in phobic postural vertigo. J. Neurol. 2013;260:1314–1323. doi: 10.1007/s00415-012-6797-7.
    1. Structured Clinical Interview for DSM-IV. [(accessed on 28 April 2021)]; Available online: .
    1. Tschan R., Wiltink J., Best C., Beutel M.E., Dieterich M., Eckhardt-Henn A. Deutschsprachige Validierung des Vertigo Handicap Questionnaire (VHQ) anhand einer Patientenstichprobe mit vestibulärem und somatoformem Schwindel. Psychother. Psychosom. Med. Psychol. 2010;60:e1–e12. doi: 10.1055/s-0029-1243206.
    1. Yardley L., Putman J. Quantitative analysis of factors contributing to handicap and distress in vertiginous patients: A questionnaire study. Clin. Otolaryngol. 1992;17:231–236. doi: 10.1111/j.1365-2273.1992.tb01833.x.
    1. Tschan R., Wiltink J., Best C., Bense S., Dieterich M., Beutel M.E., Eckhardt-Henn A. Validation of the German version of the Vertigo Symptom Scale (VSS) in patients with organic or somatoform dizziness and healthy controls. J. Neurol. 2008;255:1168–1175. doi: 10.1007/s00415-008-0863-1.
    1. Kroenke K., Spitzer R.L., Williams J. The PHQ-15: Validity of a New Measure for Evaluating the Severity of Somatic Symptoms. Psychosom. Med. 2002;64:258–266. doi: 10.1097/00006842-200203000-00008.
    1. Margraf J., Ehlers A. Deutschsprachige Adaptation des Beck Anxiety Inventory von AT Beck und RA Stern [German Adaptation of the Beck Anxiety Inventory by AT Beck and RA Stern] Huber; Bern, Switzerland: 2007.
    1. Hautzinger M., Keller F., Kühner C. Beck Depressions-Inventar (BDI-II) Hogrefe Verlag; Göttingen, Germany: 2006.
    1. Bullinger M., Morfeld M., Kohlmann T., Nantke J., van den Bussche H., Dodt B., Dunkelberg S., Kirchberger I., Krüger-Bödecker A., Lachmann A., et al. SF-36 Health Survey in Rehabilitation Research. Findings from the North German Network for Rehabilitation Research, NVRF, within the rehabilitation research funding program. Rehabilitation. 2003;42:218–225.
    1. Morfeld M., Kirchberger I., Bullinger M. SF-36 Fragebogen zum Gesundheitszustand. Hogrefe; Göttingen, Germany: 2011. 2. ergänzte und überarbeitete Auflage.
    1. Cohen J. Statistical Power Analysis for the Behavioural Sciences. 2nd ed. Erlbaum; Hillsdale, NJ, USA: 1988.
    1. Angst F., Aeschlimann A., Angst J. The minimal clinically important difference raised the significance of outcome effects above the statistical level, with methodological implications for future studies. J. Clin. Epidemiol. 2017;82:128–136. doi: 10.1016/j.jclinepi.2016.11.016.
    1. Singer J.D., Willett J.B. Applied Longitudinal Data Analysis: Modeling Change and Event Occurrence. Oxford University Press; New York, NY, USA: 2003.
    1. IBM SPSS Statistics for Windows, Version 24.0. IBM Corp.; Armonk, NY, USA: 2016.
    1. Bates D., Mächler M., Bolker B.M., Walker S.C. Fitting linear mixed-effects models using lme4. J. Stat. Softw. 2015;67:1–48. doi: 10.18637/jss.v067.i01.
    1. Kristiansen L., Magnusson L.H., Juul-Kristensen B., Maeland S., Nordahl S.H.G., Hovland A.L., Sjobo T., Wilhelm K. Feasibility of integrating vestibular rehabilitation and cognitive behaviour therapy for people with persistent dizziness. Pilot Feasability Study. 2019;5:69. doi: 10.1186/s40814-019-0452-3.
    1. Falkenström F., Granström F., Holmqvist R. Therapeutic alliance predicts symptomatic improvement session by session. J. Couns. Psychol. 2013;60:317. doi: 10.1037/a0032258.
    1. Falkenström F., Granström F., Holmqvist R. Working alliance predicts psychotherapy outcome even while controlling for prior symptom improvement. Psychother. Res. 2014;24:146–159. doi: 10.1080/10503307.2013.847985.
    1. Mulder R., Murray G., Rucklidge J. Common versus specific factors in psychotherapy: Opening the black box. Lancet. 2017;4:953–962. doi: 10.1016/S2215-0366(17)30100-1.
    1. Nassan-Agha-Schroll H., Feichtinger R., Steidl J., Aigner M. Das Symptom Schwindel im Fokus der Psychiatrie. Psychopraxis Neuropraxis. 2020;23:36–40. doi: 10.1007/s00739-020-00620-0.
    1. Brandt T., Huppert D., Dieterich M. Phobic postural vertigo: A first follow-up. J. Neurol. 1994;241:191–195. doi: 10.1007/BF00863767.
    1. Huppert D., Strupp M., Rettinger N., Hecht J., Brandt T. Phobic postural vertigo. J. Neurol. 2005;252:564–569. doi: 10.1007/s00415-005-0699-x.
    1. van Gils A., Schoevers R.A., Bonvanie I.J., Gelauff J.M., Roest A.M., Rosmalen J.G. Self-help for medically unexplained symptoms: A systematic review and meta-analysis. Psychosom. Med. 2016;78:728–739. doi: 10.1097/PSY.0000000000000325.
    1. Burlingame G.M., McClendon D.T., Alonso J. Cohesion in group therapy. Psychotherapy. 2011;48:34. doi: 10.1037/a0022063.
    1. Payne A., Blanchard E.B. A controlled comparison of cognitive therapy and self-help support groups in the treatment of irritable bowel syndrome. J. Consult. Clin. Psychol. 1995;63:779. doi: 10.1037/0022-006X.63.5.779.
    1. Blanchard E.B., Lackner J.M., Sanders K., Krasnder S., Keefer L., Payne A., Gudleski G., Katz L., Rowell D., Sykes M., et al. A controlled evaluation of group cognitive therapy in the treatment of irritable bowel syndrome. Behav. Res. Ther. 2007;45:633–648. doi: 10.1016/j.brat.2006.07.003.
    1. Katsamanis M., Lehrer P.M., Escobar J.I., Gara M.A., Kotay A., Liu R. Psychophysiological treatment for patients with medically unexplained symptoms: A randomized controlled trial. Psychosomatics. 2011;52:218–229. doi: 10.1016/j.psym.2011.01.015.
    1. Thompson K.J., Goetting J.C., Staab J.P., Shepard N.T. Retrospective review and telephone follow-up to evaluate a physical therapy protocol for treating persistent postural-perceptual dizziness: A pilot study. J. Vestib. Res. 2015;25:97–104.
    1. Wortman M.S., Lokkerbol J., van der Wouden J.C., Visser B., van der Horst H.E., Olde Hartman T.C. Cost-effectiveness of interventions for medically unexplained symptoms: A systematic review. PLoS ONE. 2018;13:e0205278. doi: 10.1371/journal.pone.0205278.

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