Journal of Psychosomatic Research 66 (2009) 111 – 118
Original articles
Cognitions associated with anxiety in Ménière's disease
Sarah E. Kirby⁎, Lucy Yardley
School of Psychology, University of Southampton, Southampton, UK
Received 1 October 2007; received in revised form 22 April 2008; accepted 20 May 2008
Abstract
Objectives: The purpose of this longitudinal study was to
identify cognitions associated with anxiety and maintenance of
anxiety in people with Ménière's disease. Method: At baseline,
participants completed the Hospital Anxiety and Depression Scale
(HADS), the Revised Illness Perception Questionnaire, the
Dizziness Beliefs Scale, the Fear–Avoidance Beliefs Question-
naire, the Intolerance of Uncertainty Scale, and measures of
demographic and illness characteristics. Participants were then
randomized to a no-treatment group or to receive one of two self-
help booklets, and completed the HADS again at 3-month follow-
up. Results: After symptom severity had been controlled for,
baseline anxiety was found to be associated with intolerance of
uncertainty, fear–avoidance of physical activity, belief that
Keywords: Anxiety disorder; Vestibular; Ménière's disease; Attitudes; Questionnaire design
Introduction
Ménière's disease is an incurable chronic disorder of the
inner ear that is characterized by recurrent spontaneous
attacks of severe vertigo (a strong sense of spinning),
progressive hearing loss that becomes permanent in one or
both ears, a sense of fullness or pressure in the ear(s), and
intermittent spells of loud tinnitus (a buzzing, ringing, or
roaring sound) [1]. There are close neurological links
between the vestibular system and the autonomic system,
with the consequence that vestibular disturbance directly
provokes autonomic symptoms such as nausea, pallor, and
sweating (as in motion sickness). Following an acute attack
of vertigo, dizziness gradually diminishes as the central
⁎ Corresponding author. School of Psychology, University of South-
ampton, Highfield, SO17 1BJ Southampton, UK. Tel.: +44 23 8059 2581;
fax: +44 2380 594597.
E-mail address: sarah.kirby@soton.ac.uk (S.E. Kirby).
0022-3999/08/$ – see front matter © 2009 Elsevier Inc. All rights reserved.
doi:10.1016/j.jpsychores.2008.05.027
dizziness would develop into a severe attack of vertigo, and
several illness perception subscales (emotional representations,
consequences, psychological causes, and perceived treatment
effectiveness). Anxiety on follow-up was predicted by higher
baseline levels of autonomic/somatic symptoms and intolerance of
uncertainty, and by reporting less understanding of the illness.
These longitudinal relationships were found in those who did and
who did not receive self-help booklets. Conclusions: Our findings
suggest that intolerance of uncertainty is associated with anxiety in
Ménière's disease. A controlled trial is needed to see whether
anxiety might be reduced in Ménière's disease by helping patients
tolerate and cope with uncertainty.
© 2009 Elsevier Inc. All rights reserved.
balance system habituates to the change in vestibular
function. However, residual dizziness can still be provoked
by unaccustomed movements and disorienting situations
[2,3]. Autonomic symptoms can also be induced by anxiety
arousal [4–6]. Both illness- and anxiety-provoked symptoms
have the potential to create a vicious cycle of prolonged
symptomatology and distress, as symptoms can be augmen-
ted by anxiety and, in turn, fuel further anxiety [5–8].
Indeed, high levels of anxiety are often reported among those
who experience vertigo [9–11], and elevated levels of
anxiety and distress have been found in people with
Ménière's disease [12–14]. It would be helpful to be able
to identify modifiable factors that are associated with anxiety
in order to limit the exacerbation of this vicious cycle.
Cognitive–behavioral approaches to chronic illness
suggest that cognitions about illness and its consequences
are important in how people with chronic illness respond
emotionally to their illness [15,16]. Therefore, if the
cognitions that contribute to anxiety in Ménière's disease
112 S.E. Kirby, L. Yardley / Journal of Psychosomatic Research 66 (2009) 111–118
can be identified, this should assist with the identification of
the forms of support and therapy that are most likely to
reduce anxiety in people with Ménière's disease. This study
considers the relevance of three groups of cognitions found
to be related to anxiety among other chronic illnesses—
illness perceptions, dizziness-related fears and beliefs, and
intolerance of uncertainty—to Ménière's disease. Anxiety is
likely to be related partly to realistic negative cognitions;
however, in chronic illness, anxiety is also often related to
excessive and catastrophic concerns, which may be amen-
able to modification.
Illness perceptions [17,18] have been found to play a
significant role in relation to a variety of outcomes, including
anxiety [19]. Chronically ill people experience more
psychological distress if they: have a strong illness identity
(i.e., attribute many symptoms to the illness), have a stronger
emotional response to illness, feel that they do not under-
stand their illness well, and believe that their illness has
serious consequences, will last a long time, and cannot be
easily controlled [20–22].
These perceptions of illness may be common in
Ménière's disease. A strong illness identity can develop if
symptoms of anxiety arousal and residual dizziness are
attributed to active disease. Moreover, some people with the
disease may have to make significant lifestyle changes,
including changing or giving up work or certain social or
leisure activities, or becoming unable to drive or travel.
Therefore, people may well view the disease as having
serious consequences, depending on the extent to which it
has impacted on their family and finances, and social and
occupational areas of life. The disease is incurable, and
treatment options are limited, as little is known about what
causes the disease. Therefore, people with Ménière's disease
may correctly expect their illness to be long-lasting, and may
also believe that they do not understand their illness very
well and that the symptoms cannot be easily controlled.
Dizziness-related fears and beliefs have also been found
to contribute to anxiety. In Ménière's disease, severe vertigo
attacks, which are unpleasant and frightening, are experi-
enced and result in a sense of loss of control and
helplessness. As noted above, milder symptoms of residual
or movement-provoked dizziness can also be experienced
between attacks. When people with Ménière's disease
experience any dizziness, they may interpret this catastro-
phically, misinterpreting the symptoms as the beginning of a
severe attack. Dizziness may also lead to fear that they will
be in physical danger (as attacks carry a risk of injury from
stumbling or falling) or a fear of embarrassment about
having an attack in public or letting people down [23,24].
Negative beliefs about the consequences of vertigo have
been shown to be more disabling than the symptoms
themselves, leading to high levels of disability and handicap
[8,25]. If people with Ménière's disease believe that
movement-provoked dizziness may develop into a severe
attack, they may also believe that movement is therefore bad
for them and should be avoided. This belief that physical
activity may be harmful and the subsequent avoidance of
physical activity have also been reported among people with
other chronic symptoms [15,26].
Thirdly, intolerance of uncertainty has been found to be
relevant to anxiety. Many chronic illnesses result in
increased levels of uncertainty with regard to the occurrence
or severity of symptoms, prognosis, or effectiveness of
treatment. Uncertainty has been well noted anecdotally in
Ménière's disease and chronic vertigo [12,27,28], as attacks
can occur unexpectedly, impacting on every area of life.
There may be individual differences in how people tolerate
these uncertainties and adapt their lives to accept and
incorporate their presence and consequences. Dugas et al.
[29] described someone who is intolerant of uncertainty as
having “an excessive tendency to find uncertain situations
stressful and upsetting, to believe that unexpected events are
negative and should be avoided, and to think that being
uncertain about the future is unfair” (p. 58). Intolerance of
uncertainty has been reported to lead to inaccurate appraisals
of threat [29,30] and to result in greater use of vigilance and
avoidance behaviors [31]. If people with Ménière's disease
believe that the unpredictable nature of their illness is
stressful, is unfair, and reflects badly on their character (e.g.,
making them appear to be disorganized or to underperform),
they may respond anxiously to all uncertain situations. They
may also try to avoid situations in which unexpected attacks
may occur. This may also contribute to anxiety as, due to the
nature of the disease, any situation could potentially be
appraised as uncertain.
The purposes of this study were, firstly, to investigate
whether illness perceptions, dizziness-related fears and
beliefs, and intolerance of uncertainty are associated with
clinical levels of anxiety, and, secondly, to identify what
combination of cognitions predicts the maintenance of
anxiety over time. Our multivariate analyses were designed
to examine and control for the effects of symptom severity, in
order to isolate the additional effects of these cognitions.
This study was nested within a randomized controlled
trial (RCT) of vestibular rehabilitation (VR) or symptom
control (SC) therapy presented in the form of self-manage-
ment booklets for people with Ménière's disease [32]. VR
involves stimulating the balance system using a series of
head movements, causing movement-provoked dizziness.
The balance system gradually habituates to these move-
ments, leading to a gradual reduction in provoked dizziness
[2]. SC therapy involves the use of applied relaxation,
controlled breathing, and stress management strategies; the
rationale is that since arousal and stress may aggravate
symptoms of dizziness, reducing stress can improve
adjustment and relieve symptoms [3]. By combining an
observational study with this RCT, we were able to examine
whether the longitudinal predictors of anxiety differed in
those undertaking different self-management programs.
It was hypothesized that, in line with previous research on
illness perceptions, anxiety would be associated with: the
belief that the illness has serious consequences, belief in a
 S.E. Kirby, L. Yardley / Journal of Psychosomatic Research 66 (2009) 111–118
chronic timeline, low perceived control, less understanding
of the illness, and greater emotional response. Greater levels
of anxiety were also hypothesized to be associated with
negative beliefs about dizziness and with greater intolerance
of uncertainty. Finally, it was hypothesized that these
associations would be moderated by the intervention
group. As the VR intervention requires the deliberate
provocation of unpleasant symptoms, stronger associations
were hypothesized to occur within the VR intervention group
than within the SC or the control group.
Method
Participants and procedure
Participants were 358 members of the Ménière's Society
who had current dizziness symptoms but reported no acute
attack in the previous 6 weeks. They were randomized to
receive a self-management booklet on VR or SC, or were
assigned to a waiting list control group [32]. Questionnaire
measures for this study were sent with the baseline and
3-month follow-up measures for the RCT.
Measures
Anxiety
Anxiety was assessed by the anxiety subscale of the
Hospital Anxiety and Depression Scale (HADS) [33]. The
HADS was chosen because it does not include somatic
symptoms of anxiety that are analogous with secondary
symptoms of dizziness. Anxiety scores at baseline and on
follow-up were dichotomized for analysis, with participants
being classified as having clinical levels of anxiety if they
scored ≥8 [34].
Illness perceptions
Illness perceptions were measured by eight of the nine
subscales of the Revised Illness Perception Questionnaire
(IPQ-R) [17]. The “timeline acute/chronic” subscale assesses
how long respondents expect the illness to last, and the
“timeline cyclical” subscale asks respondents whether the
illness fluctuates or is unpredictable. The “consequences”
subscale measures respondents' expectations of the effects of
the illness. The “personal control” subscale measures
respondents' belief in personal control over the illness,
whereas the “treatment control” subscale measures belief in
the effectiveness of treatments. The “illness coherence”
subscale assesses the extent to which respondents believe
that they understand their illness. The “emotional represen-
tations” subscale measures the presence of emotional
responses to the illness (e.g., depression, anger, worry,
anxiety, and fear). The “causal” dimension asks respondents
what may have caused their illness. Factor analysis (principal
components analysis with varimax rotation) was used to
identify any meaningful clusters of perceived causes that
could be used as causal beliefs subscales. Only one clear
113
factor, which related to the belief that Ménière's disease was
caused by a psychological state (e.g., stress, worry, or
personality), emerged and corresponded to the “psychologi-
cal attributions” factor identified by Moss-Morris et al. [17].
Items loading over 0.5 on this factor were summed to create a
subscale with good internal consistency (Cronbach's α=.84).
Beliefs about dizziness
Three of the four subscales of the Dizziness Beliefs Scale
[24] were used to measure the extent to which participants
believed that dizziness would result in negative conse-
quences. The “physical danger” subscale assesses the belief
that dizziness will result in being physically harmed. The
“social incompetence” subscale measures beliefs about the
social embarrassment of becoming dizzy in public and being
unable to behave normally. The “severe attack” subscale
measures concern that dizziness will develop into a severe
attack of vertigo. The “serious illness” subscale, which
measures the belief that the dizziness is a sign of an
underlying disease, was not used in this study because
participants knew that Ménière's disease was the cause of
their dizziness.
The extent to which participants believed that their
symptoms could be made worse by physical activity was
measured using the “physical activity” subscale of the Fear–
Avoidance Beliefs Questionnaire (FABQ) [26]. The FABQ
was originally designed for people with low back pain, and
so the “physical activity” subscale was adapted for the
purposes of this study by replacing references to the word
“pain” with the word “vertigo” and by removing references
to participants' backs. The internal reliability for the adapted
scale was acceptable (α=.79).
Intolerance of uncertainty
Intolerance of uncertainty was measured using the
Intolerance of Uncertainty Scale (IUS) [30]. The IUS
assesses the emotional and behavioral consequences of
uncertainty for respondents, their expectations that future
events should be predictable, and attempts to control
future events.
Demographic and illness characteristics
Single items were used to assess the length of time (in
months) since symptoms began, gender, and age. Vertigo
was assessed using the long version of the Vertigo Symptom
Scale (VSS) [6]. The “vertigo severity” subscale measures
the frequency and severity of symptoms of vestibular origin,
such as vertigo, dizziness, and imbalance. The “autonomic/
somatic symptoms” subscale measures autonomic symptoms
that are secondary to vestibular dysfunction and symptoms
of somatic anxiety and anxiety arousal. Hearing loss was
assessed using five questions from the Hearing Disability
Questionnaire [35] that assessed subjective severity of
hearing impairment. Tinnitus and fullness in the ear were
assessed using the Tinnitus Severity Index and the Aural
Pressure Index [36,37].
114 S.E. Kirby, L. Yardley / Journal of Psychosomatic Research 66 (2009) 111–118

Table 1
Preliminary ANOVA results showing baseline variables associated with anxiety at baseline and anxiety at 3 months postintervention
Anxiety at baseline Anxiety postintervention
a
F Cohen's d Fb Cohen's d
Demographic and illness characteristics
Gender 1.83 0.14 4.51 0.25
Age 0.37 −0.06 1.03 −0.11
Illness duration 0.27 −0.06 0.97 0.13
VSS: vertigo severity 5.54 ⁎ 0.25 5.06 ⁎ 0.23
VSS: autonomic/somatic symptoms 52.37 ⁎⁎⁎ 0.78 47.24 ⁎⁎⁎ 0.72
Tinnitus 0.89 0.10 0.00 0.01
Fullness in the ear 6.09 ⁎⁎ 0.26 9.44 ⁎⁎ 0.34
Hearing disability 5.36 ⁎ 0.25 4.88 ⁎ 0.22
Psychological variables
IPQ-R: timeline acute/chronic 0.03 0.02 1.51 0.15
IPQ-R: timeline cyclical 0.22 0.05 1.00 0.10
IPQ-R: consequences 20.04 ⁎⁎⁎ 0.48 16.70 ⁎⁎⁎ 0.43
IPQ-R: personal control 3.37 −0.19 2.60 −0.17
IPQ-R: treatment control 5.81 ⁎ −0.26 8.13 ⁎⁎ −0.31
IPQ-R: illness coherence 18.53 ⁎⁎⁎ −0.46 21.29 ⁎⁎⁎ −0.49
IPQ-R: emotional representations 93.40 ⁎⁎⁎ 1.03 51.76 ⁎⁎⁎ 0.77
IPQ-R: psychological attributions 22.54 ⁎⁎⁎ 0.51 8.98 ⁎⁎ 0.33
Intolerance of uncertainty 85.89 ⁎⁎⁎ 1.01 69.89 ⁎⁎⁎ 0.88
FABQ: physical 4.60 ⁎ 0.23 8.76 ⁎⁎ 0.31
Dizziness beliefs: physical danger 31.22 ⁎⁎⁎ 0.60 21.27 ⁎⁎⁎ 0.50
Dizziness beliefs: social incompetence 27.67 ⁎⁎⁎ 0.56 32.99 ⁎⁎⁎ 0.61
Dizziness beliefs: severe attack 7.02 ⁎⁎ 0.28 21.54 ⁎⁎⁎ 0.50
a
df(1,356), except for tinnitus (1,355) and IPQ-R: psychological attributions (1,353).
b
df(1,342), except for tinnitus (1,341) and IPQ-R: psychological attributions (1,339).
⁎ Pb.05.
⁎⁎ Pb.01.
⁎⁎⁎ Pb.001.

Statistical analyses entered into two hierarchical logistic regressions, with

Initially, analysis of variance (ANOVA) was used to
identify variables related to anxiety (nonclinical vs. clinical)
at baseline. Baseline anxiety was entered into the analysis as
a fixed factor, with each of the baseline variables being
entered in turn as dependent variables. We then used
ANOVA to determine whether the same baseline variables
predicted anxiety on follow-up, and whether intervention
group (VR vs. SC vs. control group) affected this relation-
ship. For these analyses, ANOVA were repeated, but baseline
anxiety was replaced by anxiety on follow-up, and treatment
group was added as a second fixed factor. No interactions
were found in these analyses, indicating that intervention
group did not influence the relationship between baseline
variables and anxiety on follow-up; therefore, data for the
intervention groups were pooled for our final analyses.
These initial analyses were intended to minimize Type 2
error (overlooking variables related to anxiety), and so our
focus was principally on the effect sizes of each variable,
rather than on their statistical significance. To determine
which variables were associated with anxiety while
controlling for Type 1 error (i.e., minimising the likelihood
that relationships were identified as significant by chance),
all baseline variables identified in the ANOVA (shown in
Table 1) as potentially significantly related to anxiety were
anxiety at baseline and anxiety on follow-up as the
dependent variables. The logistic regression for anxiety on
follow-up controlled for baseline levels of anxiety by
entering baseline anxiety on the first step of the regression,
thus allowing us to identify predictors of change in anxiety
from baseline [38]. In both regressions, demographic and
illness characteristics were entered together as covariates to
control for the effects of these variables. The cognitions
were lastly entered together on the final step. All statistical
analyses were carried out using the Statistical Package for
the Social Sciences, version 14.0, for windows.
Results
Participant characteristics
Of the 358 participants, 246 were female (68.7%) and 112
were male (31.3%). The age range was 28–90 years. The
length of time since the symptoms began ranged from 18 to
660 months. Ten participants dropped out before the follow-
up assessment (five from the VR group, four from the SC
group, and one from the control group), leaving 114
participants in the VR group, 115 in the SC group, and
119 in the control group.
 S.E. Kirby, L. Yardley / Journal of Psychosomatic Research 66 (2009) 111–118 115

Following the clinical cutoff points recommended for the
HADS [33], at baseline, 56.2% of participants had at least
mild clinical levels of anxiety, and 27.4% met the criteria for
moderate to severe clinical levels of anxiety. At 3-month
follow-up, 48.1% had at least mild clinical levels of anxiety,
and 24.9% had moderate to severe clinical levels of anxiety.
develop into a severe attack of vertigo. The beliefs that
treatment would not be effective in controlling their illness
and that physical activity could make symptoms worse also
had small to moderate associations with anxiety.
Predictors of anxiety at baseline and on follow-up

Bivariate analyses
Bivariate analyses of the associations between baseline
variables and anxiety at baseline and on follow-up are
reported in Table 1. None of the baseline variables had
different patterns of association with anxiety on follow-up
in the three intervention groups (i.e., there were no
significant interactions with the intervention group), and
so pooled analyses for the whole sample are presented. In
general, a similar pattern of associations was found with
anxiety at baseline and anxiety on follow-up. Of the illness
characteristics, higher levels of autonomic/somatic symp-
toms were strongly associated with clinical levels of
anxiety, and anxiety was also higher among those who
reported worse symptoms of vertigo, fullness in the ear, and
hearing disability.
Among the cognitions, the variables most strongly
associated with anxiety were intolerance of uncertainty and
emotional responses to the illness. Participants who were
clinically anxious also had stronger beliefs that dizziness
could result in them losing control and being physically
harmed, embarrassed, or unable to fulfill social roles. Having
a poor understanding of the illness and believing that it had
more severe consequences were moderately associated with
higher levels of anxiety. Small to moderate associations were
found between anxiety and the belief that the illness was
caused by psychological factors and that dizziness would
The results of the logistic regression indicated that 8 of the
14 variables that had been identified by ANOVA as related to
anxiety independently contributed to the regression equation
predicting baseline levels of clinical anxiety (see Table 2).
Clinical levels of baseline anxiety were most strongly
associated with reporting greater autonomic/somatic symp-
toms; severity of vertigo, fullness in the ear, and hearing
disability were no longer related to anxiety after controlling
for autonomic/somatic symptoms. However, after illness
severity had been controlled for, baseline anxiety was found
to be strongly related to being more intolerant of uncertainty
and having a greater emotional response to illness. Clinical
levels of anxiety were also associated with having stronger
beliefs that the illness was caused by psychological factors
and that dizziness could be made worse by physical activity
and would develop into a severe attack of vertigo. Higher
levels of anxiety were also related to beliefs that their illness
had greater consequences and that treatment would not be
effective in controlling their illness.
After baseline anxiety had been controlled for, anxiety on
follow-up was found to be no longer related to the severity of
vertigo, hearing loss, or tinnitus, and was also found to be no
longer related to many of the baseline psychological
measures that were significant in the bivariate correlations
(i.e., perceived consequences, treatment control, emotional
representations, psychological attributions, fear–avoidance,
and belief that symptoms might herald a severe attack).

Table 2
Logistic regression results for anxiety at baseline and anxiety at 3 months postintervention (only significant predictors are shown)
B S.E. Wald statistic Odds ratio 95% confidence interval
a
Predictors of baseline anxiety (n=354)
VSS: autonomic/somatic symptoms 0.08 .02 21.28 ⁎⁎⁎ 1.08 1.05–1.12
IPQ-R: consequences −0.10 .04 5.75 ⁎ 0.90 0.83–0.98
IPQ-R: treatment control −0.11 .05 4.52 ⁎ 0.90 0.82–0.99
IPQ-R: emotional representations 0.19 .04 19.92 ⁎⁎⁎ 1.21 1.11–1.31
IPQ-R: psychological attributions 0.09 .03 8.89 ⁎⁎ 1.09 1.03–1.16
Intolerance of uncertainty 0.05 .01 20.54 ⁎⁎⁎ 1.05 1.03–1.07
FABQ: physical −0.09 .03 10.00 ⁎⁎ 0.92 0.87–0.97
Dizziness beliefs: severe attack −0.14 .06 6.36 ⁎⁎ 0.87 0.78–0.97
Predictors of postintervention anxiety (n=345) b
Baseline anxiety 1.95 .32 37.16 ⁎⁎⁎ 7.05 3.76–13.22
VSS: autonomic/somatic symptoms 0.04 .02 5.85 ⁎ 1.04 1.01–1.08
IPQ-R: illness coherence −0.06 .03 3.96 ⁎ 0.94 0.88–1.00
Intolerance of uncertainty 0.02 .01 4.79 ⁎ 1.02 1.00–1.04
a
Model χ2=168.22, Pb.001; Nagelkerke R2=.51.
b
Model χ2=150.82, Pb.001; Nagelkerke R2=.47.
⁎ Pb.05.
⁎⁎ Pb.01.
⁎⁎⁎ Pb.001.
116 S.E. Kirby, L. Yardley / Journal of Psychosomatic Research 66 (2009) 111–118
However, maintenance of anxiety was predicted by three
baseline variables (see Table 2). These were autonomic/
somatic symptoms, greater intolerance of uncertainty, and
reporting less understanding of the illness.
Discussion
The purpose of this study was to identify cognitions
associated with anxiety, while examining and controlling for
the effects of symptom severity, in order to isolate the
additional effects of cognitions. At baseline, anxiety was
related to the severity of all symptoms of Ménière's disease,
except for tinnitus, but was most closely related to
autonomic/somatic symptoms. The strength of this correla-
tion is undoubtedly due, in part, to the fact that autonomic
and somatic symptoms are an intrinsic part of anxiety.
However, they can also be provoked by vestibular disorder. It
seems likely that, in this study, autonomic/somatic symptoms
were partly related to the severity of Ménière's disease, since
the other symptoms of Ménière's disease were no longer
related to anxiety after controlling for the severity of
autonomic/somatic symptoms.
After symptom severity had been controlled for, most
of the hypothesized relationships between anxiety and
cognitions were confirmed on cross-sectional analyses.
Anxiety was associated with the belief that the illness has
serious consequences, negative beliefs about the con-
sequences of dizziness, perceived lack of understanding of
the illness, a stronger emotional response to it, and
greater intolerance of uncertainty. The causal direction of
associations cannot be determined from cross-sectional
correlations; consequently, it is not possible to be certain
whether high anxiety levels caused or resulted from these
beliefs and attitudes.
After baseline anxiety had been controlled for, three
baseline variables were found to predict the maintenance of
anxiety on follow-up, although it should be noted that the
size of these effects was small. Since the variance that these
variables shared with anxiety at baseline was partialled out,
greater significance could be attached to their potential
causal role in maintaining anxiety. Moreover, these long-
itudinal relationships were found in all three intervention
groups, and the strength of the relationships was not affected
by the interventions.
After baseline anxiety, the next strongest predictor of
persisting anxiety on follow-up were autonomic/somatic
symptoms. Given the conceptual overlap between auto-
nomic/somatic symptoms and anxiety (as measured by the
HADS), it is not surprising that they were strongly
associated. Nevertheless, it was essential to include auto-
nomic/somatic symptoms in order to control for illness
severity when measuring the effects of the psychological
variables. Of more interest, therefore, is the finding that
intolerance of uncertainty predicted persisting anxiety after
controlling for baseline anxiety and autonomic/somatic
symptoms. This provides, for the first time, an indication
that the strong association with anxiety observed in the cross-
sectional analyses at baseline (and in another study [39]) may
reflect a causal relationship, whereby the predisposition to
react negatively to uncertainty may contribute to anxiety. In
addition, a perceived lack of comprehension of the illness at
baseline predicted persisting anxiety, suggesting that anxiety
is maintained not only by the sense that symptoms are
unpredictable but also by the sense that they are inexplicable.
The findings of this study cannot be generalized to all
people with Ménière's disease, as the RCT was limited to
participants from the Ménière's Society who had current
dizziness but were not experiencing frequent spontaneous
attacks of acute vertigo. Members of the Ménière's Society
may not be representative of the general medical population
of people with Ménière's disease. For example, members
may have wanted to join the society as a result of higher
levels of anxiety than nonmembers. Therefore, these findings
need to be replicated in a sample comprising members who
have not joined a self-help group. A further limitation of this
study is that we were only able to analyse and report
associations with one aspect of the distress caused by
Ménière's disease. It is probable that other key aspects of
distress, such as depression and handicap, are related to
different patterns of symptoms and cognitions [39]. Most
importantly, while longitudinal prediction of changes in
anxiety provides a stronger evidence of possible causality
than can be inferred from cross-sectional associations, it
cannot confirm a causal relationship. In order to do this, it
would be necessary to show that the outcome of an
intervention that was successful in reducing anxiety was
mediated by a reduction in autonomic/somatic symptoms
and intolerance of uncertainty.
About half of the participants in our RCT had possible
clinical levels of anxiety at baseline. This observation is
consistent with the findings of Savastano et al. [40], who
identified distressed and nondistressed subgroups, and
suggests that whereas some people with Ménière's disease
are able to successfully adjust to having the disease, others
may need support to achieve this. In the RCT in which this
study was embedded [32], VR resulted in a reduction in
symptoms (assessed by a scale that measured both vertigo
and autonomic/somatic symptoms) and a decrease in anxiety
(measured by the HADS). Since VR requires patients to
deliberately and repeatedly provoke dizziness (in order to
stimulate neurological adaptation), undertaking VR teaches
patients that residual symptoms are tolerable, and partly
predictable and controllable, and that it is not necessary to
avoid activity. It has therefore been suggested that VR can
function as a form of cognitive–behavioral therapy, inter-
rupting the vicious cycle of symptoms and anxiety about
symptoms [3,32,41]. Indeed, in the trial associated with this
study, VR also resulted in a reduction in negative beliefs
about dizziness. Nevertheless, benefits obtained using the
self-help booklets were modest, and further research is
needed to identify additional therapy components that might
improve outcomes.
 S.E. Kirby, L. Yardley / Journal of Psychosomatic Research 66 (2009) 111–118
The cognitions found to be relevant to anxiety in this
study are consistent with results found among populations
with chronic pain [21], multiple sclerosis [22], and dizziness
[24,42], and suggest that there may be a pattern on how
people perceive and think about chronic illness that is related
to poor adjustment and increased distress.
Emotions, bodily symptoms, cognitions, and behaviors
seem to become linked in a strong and unhelpful way, and it
may be necessary for cognitive–behavioral therapy to
address all of these components of the illness experience.
However, this study has identified intolerance of uncertainty
as a reaction that may be particularly important to address in
therapy for Ménière's disease. Action and contingency plans
might be useful coping tools. However, McCracken and
Eccleston [43] suggest that interventions that focus on the
acceptance of, rather than on coping with, chronic illness may
be more beneficial in improving adjustment. As uncertainty
cannot be avoided in Ménière's disease, support could be
focused on helping people with Ménière's disease to accept
that, at times, they may not be able to do certain things. A
controlled trial is needed to test whether anxiety can be
reduced by successfully treating intolerance of uncertainty.
Acknowledgments
This study was funded by the Ménière's Society, UK.
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