AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y H EA D A N D N E CK ME D I CI NE AN D SUR G E RY 3 4 ( 2 0 13 ) 59 25 9 5

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Adverse effects of health anxiety on management of a patient

with benign paroxysmal positional vertigo, vestibular
migraine and chronic subjective dizziness
Julie A. Honaker, PhD a,, Jane M. Gilbert, AuD b , Neil T. Shepard, PhD b ,
Daniel J. Blum, MD c , Jeffrey P. Staab, MD, MS d
a

Department of Special Education and Communication Disorders, University of Nebraska-Lincoln, Lincoln, NE, USA
Division of Audiology, Mayo Clinic, Rochester, MN, USA
c
Department of Otorhinolaryngology, Mayo Clinic, Rochester, MN, USA
d
Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
b

ARTI CLE I NFO

A BS TRACT

Article history:

Introduction: Care of patients with vestibular symptoms focuses primarily on physical

Received 15 June 2012

otoneurologic disorders; however, psychological factors can sustain symptoms, confound

assessment, and adversely affect treatment. Health anxiety is a particularly pernicious
process that simultaneously magnifies physical symptoms and inhibits medical care.
Objective: To demonstrate the excess morbidity caused by vestibular health anxiety and its
successful management in a patient with otoneurologic disease.
Method: Report of a 41-year-old woman with recurrent benign paroxysmal positional
vertigo, vestibular migraine, and chronic subjective dizziness, who expressed grave
concerns about her health, repeatedly questioned her otoneurologic diagnoses, and failed
physical therapy and medication treatment until her health anxiety and otoneurologic
illnesses were addressed simultaneously.
Conclusion: Health anxiety is an empirically validated concept that explains troublesome
health-related beliefs and behaviors. It is frustrating for patients and health care teams, but
can be treated successfully in otoneurology practice, thereby reducing physical symptoms,
emotional distress, functional impairment, and health care overutilization.
2013 Elsevier Inc. All rights reserved.

1.

Introduction

Patients with vestibular and balance complaints are often

divided into those with clinical signs of active vestibular or
neurological disorders and those without. The absence of
physical findings at the time of examination does not
necessarily rule out otoneurologic disease as a cause of
patients problems, and the presence of otoneurologic deficits

may not explain the full extent of their symptoms [13].

Psychological factors such as anxiety and depressive disorders, which are known to exist in at least one-third of tertiary
care otoneurology patients, may affect clinical presentations
and therapeutic outcomes [2]. There have been numerous
investigations of anxiety and depression in patients with
otoneurologic disorders, [49] but health anxiety has not been
studied in patients with vestibular complaints. Health anxiety

A portion of this paper was presented at the annual meeting of the American Academy of Audiology, San Diego, CA, April 16, 2010.
Corresponding author. Department of Special Education and Communication Disorders, 272 Barkley Memorial Center, University of
Nebraska-Lincoln, Lincoln, NE 68583-0731, USA. Tel.: +1 402 472 5493; fax: + 1 402 472 3814.
E-mail address: jhonaker2@unl.edu (J.A. Honaker).
0196-0709/$ see front matter 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjoto.2013.02.002

AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y H EA D A N D N E CK ME D I CI N E AN D SUR G E RY 3 4 ( 2 0 13 ) 59 25 9 5

(aka illness anxiety) is an empirically validated concept that is

likely to replace the older notion of hypochondriasis in the
psychiatric nomenclature in 2013 [10]. Health anxiety is a
condition in which patients maintain high levels of attention
to physical symptoms (body vigilance), focus on thoughts and
images of disease (disease preoccupation) worry about
becoming ill (disease fears), misinterpret bodily sensations
as evidence that they are afflicted with malignant illnesses
(disease conviction), and are not easily reassured by the
results of medical evaluations [1116]. Patients with high
levels of health anxiety overutilize medical care by repeatedly
requesting evaluations of physical symptoms (reassurance
seeking) [11,12,17]. Paradoxically, they may avoid medically
necessary appointments because of worries that their disease
convictions will be confirmed. Health anxious individuals
function poorly in social, occupational, and home settings
because they avoid activities that they believe could adversely
affect their health (disease-related avoidance) [18,19]. Health
anxiety may co-exist with other psychiatric disorders such as
anxiety or depression, though its psychological features are
unique [18,20]. It is not a diagnosis reserved for patients who
lack identifiable medical problems as it may occur in individuals with or without active physical illnesses [16,21].
Indeed, several features of otoneurologic diseases may be
particularly troublesome for patients prone to health anxiety.
These include the appearance of sudden and dramatic
physical symptoms (e.g., acute vertigo attacks) or, conversely,
vague and nagging symptoms that are difficult to describe and
evaluate (e.g., chronic dizziness). The possibility, however
small, that such symptoms could be caused by a lifethreatening condition (e.g., stroke) is especially difficult for
health anxious patients to tolerate. In such situations, the
clinicians diagnosis of a benign condition that is easily
treated (e.g., benign paroxysmal positional vertigo, BPPV) can
be strikingly at odds with patients worries about serious
disease. Patients attempts to avoid physical symptoms may
thwart therapeutic interventions, especially those that may
transiently provoke symptoms (e.g., canalith repositioning
maneuvers, CRM). We present here an illustrative case of a
patient with severe vestibular health anxiety that seriously
compromised management of her co-existing recurrent BPPV,
vestibular migraine (VM), and chronic subjective dizziness
(CSD). A treatment plan that incorporated behavioral interventions for health anxiety into otoneurologic therapies
succeeded in having the patient utilize home CRM effectively,
tolerate and receive benefit from migraine prophylactic and
CSD medications, return to work, and accept discharge from
tertiary care.

2.

Case Report

A 41 year old woman presented with a 20 year history of

vestibular symptoms, including intermittent episodes of brief
positional vertigo and recurrent attacks of migrainous headaches lasting for several hours accompanied by unsteadiness
and motion sensitivity. She developed persistent non-vertiginous dizziness and hypersensitivity to motion that were
exacerbated in environments with complex visual stimuli.
She also had a longstanding history of generalized anxiety

593

that was treated with extended release bupropion, but that

medication may have increased her headaches. Trials of
several other anxiolytic antidepressants had been discontinued in the past due to unacceptable side effects (e.g., weight
gain, low libido). On referral to our center, the patient
underwent a multidisciplinary evaluation, including audiometric and vestibular laboratory testing, otoneurologic and
psychiatric consultation, and physical therapy assessment.
Audiometric evaluation was unremarkable. Comprehensive vestibular and balance function evaluation consisting of
videonystagmography, rotational chair, cervical vestibular
evoked myogenic potentials (cVEMPs), computerized dynamic
posturography and postural evoked responses was entirely
normal. Her history of intermittent brief positional vertigo
was consistent with recurrent BPPV, which was not active at
the time of evaluation. Her migrainous headaches with
vestibular symptoms were diagnosed as VM and her daily
dizziness and motion sensitivity were diagnosed as CSD. The
patient was given a multimodality treatment plan that
included training in the use of home CRM for recurrences of
BPPV, daily home vestibular habituation exercises (head
movements, exposure to visual motion stimuli, and walking
with head turning exercises) to reduce her sensitivity to
motion stimuli, and gradual introduction of sertraline for
treatment of CSD with a plan to follow that with migraine
prophylactic or abortive medications for VM. The patient also
was advised to obtain cognitive behavior therapy for her coexisting generalized anxiety disorder.
Despite this comprehensive plan, the patient failed to
improve. She continued to have episodic vestibular symptoms
indicative of recurrent BPPV and VM and daily symptoms of
CSD. She was impatient with the titration of medications and
reported unacceptable side effects for each of three successive
medication trials. She shifted her focus to taking supplements
that she researched on the Internet. She varied the prescribed
vestibular habituation exercises and then discontinued them
altogether due to doubts about the benefit. A neurology
consultation was arranged for headache management, but the
patient dropped the migraine diet and abandoned the medication recommendations, which she felt were not helpful. She did
not follow-up with her established psychiatrist. During followup visits to our center, she repeatedly questioned her diagnoses
and requested more testing. She interpreted her continuing
symptoms as evidence of an undetected malignant illness. Over
the course of a year, she contacted our center more than 40
times by e-mail or telephone with similar inquiries. This failed
to improve her adherence to treatment and did not assuage her
increasing worries about having a serious neurologic disease.
We contemplated dismissing her from our practice, but opted
instead to engage her in a structured treatment plan that
simultaneously limited her health anxious behaviors and
established a consistent regimen of medications and vestibular
exercises. Elements of that plan are outlined in Table 1. The
patient gradually grew accustomed to the plans focus and
limits, which were implemented strictly, but respectfully. Over
the span of a few months, she restarted prescription medications (citalopram and bupropion) and consistently performed
her vestibular exercises. She became competent in selfassessment of symptom flare-ups and successfully used
home CRM and migraine abortive medications for recurrences

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Table 1 Features of health anxiety, clinical manifestations, and intervention strategies.

Features

Clinical Manifestations

Intervention strategies

Body Vigilance

Heightened attention to physical symptoms

Repeated checking of body for signs of disease

Structured format for symptom reports

Implemented a daily symptom log that included a 5-point
severity rating scale for vertigo, dizziness, and headache.
Required that all symptoms be recorded in log, which was
reviewed at each office visit.
Using symptom log, taught patient to recognize patterns of
BPPV, VM, and CSD.
Structured response to symptom flare-ups
Had patient perform home CRM for all episodes of brief
vestibular symptoms

Disease Preoccupation

Recurrent thoughts and images of disease

Focused on known diagnoses and treatment plan

Refocused discussions to treatment plan

Disease Fears

Fear of having or contracting a disease

Anxiety about possible contact with disease
related stimuli (e.g., dirt, blood)

Taught patient to counter disease fears by identifying

patterns of BPPV, VM, and CSD symptoms in daily log.

Disease Conviction

Belief about having a serious illness

Quickly countered all queries with firm, but polite

restatement of known diagnoses
Declined to debate alternative diagnoses

Reassurance Seeking

Excessive checking of sources of health

information (e.g., Internet)
Repeated consultations with medical
professionals regarding health status

Placed firm limits on reassurance seeking

Provided written material on diagnoses and treatment
strategies, including home CRM, vestibular habituation,
medications
Discouraged reading of other information
Politely, but firmly, refused to review other information
brought or sent by patient
Declined all requests to re-evaluate symptoms caused by
known diagnoses
Agreed to evaluate new or significantly different
symptoms (none developed)

Disease-Related Avoidance

Avoidance of disease-related stimuli (varies

from passive avoidance such as limiting activities
that may provoke symptoms or risk disease
exposure to active measures such as use of
medically dubious preventative measures)

Systematically countered avoidance

Home-based vestibular habituation exercises (started at
2 min twice daily)
Motion exposure exercises outside the home (incorporated
into necessary activities such as shopping and return to work)
Refused to discuss use of unproven remedies to prevent
vertigo and dizziness

of BPPV and episodes of VM, respectively. The frequency of

her e-mails and telephone calls decreased dramatically and
the few remaining contacts between scheduled office visits
were for straightforward reasons. She was able to meet all of
her family and work obligations. One year after implementation of this treatment plan she was discharged successfully
from tertiary care.

3.

Discussion

This patient had three neurotologic diagnoses, BPPV, VM, and

CSD, that usually are quite amenable to treatment, even when
they co-exist. From an otoneurologic standpoint, the patient
did not present a diagnostic or therapeutic dilemma. However,
her high level of health anxiety caused major morbidity and
undermined initial efforts at treatment. We chose not to
discharge her from our clinic at the height of her health
anxious behaviors, despite the difficult management prob-

lems that they presented, because her active otoneurologic

conditions warranted treatment. Instead, we incorporated
interventions for health anxiety into her otoneurologic plan of
care. The outcome of this case was ultimately favorable, but
earlier recognition and treatment of the patients health
anxiety would have been more beneficial.
Interventions for health anxiety are designed to counter
health-related fears and behaviors and refocus the patient on
known medical diagnoses and clinically indicated treatments.
The interventions listed in Table 1 addressed the core features
of health anxiety. We gave the patient a structured format for
recording her daily symptoms, which focused her body
vigilance on clinically important symptoms and enabled us to
teach her to recognize the patterns of her otoneurologic
conditions. This improved her ability to meaningfully report
her response to treatment and successfully use home management techniques such as CRM and migraine abortive medications for episodic recurrences. We politely, but consistently,
declined to answer reassurance-seeking questions or debate

AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y H EA D A N D N E CK ME D I CI N E AN D SUR G E RY 3 4 ( 2 0 13 ) 59 25 9 5

alternative diagnoses with her, although we did promise to

investigate any distinctly new or different symptoms that
might have developed. Individuals with health anxiety struggle
with uncertainty about their medical diagnoses. Repeatedly
offering reassurance has the paradoxical effect of reinforcing
health anxious beliefs because it keeps the focus of interactions
on the patients doubts and highlights the fact that no absolute
guarantee of diagnostic accuracy or therapeutic efficacy can be
made. Our refusal to respond to the patients health anxious
doubts reduced the time that she and we had previously
devoted to unproductive e-mails and phone calls. Finally, we
emphasized the benefits of consistent vestibular habituation
exercises to improve her physical and psychological tolerance
for motion stimuli, thereby counteracting her disease-related
avoidance of home and work activities.
The behavioral elements of this plan were designed by the
psychiatrist on our multidisciplinary team, but were carried
out by all clinicians and staff members who interacted with
the patient. This reduced the level of frustration and sense of
futility that pervaded our early interactions with her. For
otolaryngologists and other specialists who care for patients
with vestibular symptoms but practice outside a multidisciplinary clinic, a similar approach could be coordinated with a
consulting psychiatrist or psychologist. The behavioral health
specialist would not carry out the plan alone because health
anxiety manifests most strongly in medicalsurgical settings.

4.

Conclusion

Health anxiety is an empirically validated diagnosis that is

replacing the centuries-old concept of hypochondriasis. Left
unrecognized, health anxiety magnifies physical symptoms,
inhibits medical care, and interferes with the therapeutic
relationship between patients and their treating clinicians.
This case report demonstrates the pernicious effect of
vestibular health anxiety and its successful treatment with
interventions that can be incorporated into routine otoneurologic practice. As with many other chronic conditions, a
positive outcome was achieved only after a collaborative
treatment plan was developed that cohesively addressed all
physical and psychological aspects of the patients condition.

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