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Serotonin Reuptake Inhibitors for Dizziness With Psychiatric Symptoms
Jeffrey P. Staab, MD, MS;
Michael J. Ruckenstein, MD;
David Solomon, MD, PhD;
Neil T. Shepard, PhD
Arch Otolaryngol Head Neck Surg. 2002;128:554-560.
ABSTRACT
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Objective To investigate the efficacy and tolerability of selective serotonin
reuptake inhibitors (SSRIs) for the treatment of patients with dizziness and
major or minor psychiatric symptoms, with or without neurotologic illnesses.
Design Review of 60 consecutive cases of patients with dizziness who were treated
with an SSRI for at least 20 weeks during the 30-month period from July 1998
to December 2000.
Setting Tertiary care, multidisciplinary referral center.
Patients Sixty men and women, aged 13 to 81 years, with (1) psychogenic dizziness,
(2) dizziness due to a neurotologic condition, as well as significant psychiatric
symptoms, or (3) idiopathic dizziness.
Interventions Open-label treatment with an SSRI titrated to 1 of 3 end points: optimal
clinical benefit, intolerable adverse effects, or no therapeutic response.
Main Outcome Measure Change in dizziness and psychiatric symptoms measured by the 7-point,
clinician-rated, Clinical Global Impressions-Improvement Scale.
Results Thirty-eight (63%) of 60 patients in the intent-to-treat sample and
32 (84%) of 38 patients who completed treatment improved substantially. The
response rates did not differ between patients with major psychiatric disorders
and those with lesser psychiatric symptoms. Patients whose only diagnosis
was a psychiatric disorder and those with coexisting peripheral vestibular
conditions or migraine headaches fared better than patients with central nervous
system deficits. Before being treated with an SSRI, two thirds of the study
patients took meclizine hydrochloride and/or benzodiazepines, with minimal
benefit.
Conclusions Treatment with SSRIs relieved dizziness in patients with major or minor
psychiatric symptoms, including those with peripheral vestibular conditions
and migraine headaches. Patients fared far better with SSRI treatment than
with treatment with vestibular suppressants or benzodiazepines.
INTRODUCTION
PATIENTS WITH dizziness often experience psychiatric symptoms, such
as anxiety, panic attacks, phobic behaviors, and depression.1-11
Psychiatric disorders may coexist with neurotologic illnesses, or they may
be the sole cause of patients' complaints.1-2
Several terms have been used to describe dizziness with psychiatric or behavioral
symptoms, including psychogenic dizziness,3
phobic postural vertigo,4-5 space
phobia,6 space-motion discomfort, and space-motion
phobia.7 Most patients with dizziness and psychiatric
symptoms suffer from anxiety or depressive disorders, whether or not they
have coexisting neurotologic conditions.3, 5, 7-11
However, only limited anecdotal data exist on the medical treatment of these
patients,4 almost none of which incorporates
the substantial advances from the last decade in the pharmacotherapy of anxiety
and depression.12-13 Clinical
experience suggests that the medications most often prescribed for these patients,
including vestibular suppressants and benzodiazepines, provide only transient
or incomplete relief of symptoms.1
Over the last 10 years, the group of antidepressants known as selective
serotonin reuptake inhibitors (SSRIs) has supplanted tricyclic antidepressants,
monoamine oxidase inhibitors, and benzodiazepines as first-line therapy for
most anxiety and depressive disorders.12-13
Five SSRIs—fluoxetine hydrochloride (Prozac, Sarafem), sertraline hydrochloride
(Zoloft), paroxetine hydrochloride (Paxil), fluvoxamine maleate (Luvox), and
citalopram hydrobromide (Celexa)—have been approved by the Food and
Drug Administration for the treatment of at least 1 anxiety or mood disorder.
None of these agents is consistently superior to the others, but all have
advantages over earlier antidepressants and benzodiazepines, including better
tolerability, ease of prescribing, far greater safety in overdose, no need
for monitoring of serum levels, and fewer complications in the medically ill.12-13 For patients with anxiety disorders,
treatment with SSRIs can be discontinued more successfully than treatment
with benzodiazepines, and SSRIs have no addiction liability.
Despite these advantages, there were several concerns about prescribing
SSRIs for patients with dizziness. Nausea is one of the most common adverse
effects of all 5 SSRIs. It occurs at least transiently in about 20% of patients
and is a leading cause of medication discontinuation. Dizziness is reported
in up to 8% of patients taking an SSRI.14 Other
adverse effects, such as physical fatigue and mental sluggishness, might mimic
symptoms that accompany chronic dizziness. An SSRI discontinuation syndrome
has been reported after abrupt withdrawal from the use of these medications,
with dizziness a prominent symptom.15 Nevertheless,
SSRIs offered the same potential advantages for neurotologic patients with
dizziness and psychiatric symptoms as they did for patients with psychiatric
disorders alone. In July 1998, we began to prescribe SSRIs regularly for patients
with dizziness and psychiatric symptoms, including those with and without
comorbid neurotologic illnesses. The goals of this effort were to achieve
better clinical outcomes than those of existing treatments and to evaluate
the efficacy and tolerability of SSRI therapy for this challenging patient
population.
This report covers 30 months of experience with SSRIs. We hypothesized
that patients with major psychiatric disorders would have a more favorable
outcome than those with lesser psychiatric symptoms, because their established
psychiatric illnesses would be targeted specifically by the SSRIs. Preliminary
findings showed substantial clinical benefit across a wide range of psychiatric
symptom severity.16 We also hypothesized that
patients with coexisting neurotologic and psychiatric conditions would benefit
from treatment with SSRIs.
PATIENTS AND METHODS
Data for this report were abstracted from a research database containing
anonymous information on 110 consecutive patients who underwent a formal psychiatric
examination as part of a multidisciplinary, clinical evaluation for dizziness
at an urban, university-based, tertiary care, neurotology referral center
from July 1998 through December 2000. The database includes patient demographics,
presenting symptoms, duration of illness, medical and psychiatric diagnoses,
treatment histories prior to referral, therapies prescribed by the authors,
and ratings of clinical outcomes. The research database contains no unique
identifying information on any patient and is maintained separately from all
medical records. Therefore, the institutional review board at the University
of Pennsylvania School of Medicine, Philadelphia, classified this study as
exempt from human subjects review.
PATIENT SELECTION
All patients in this study underwent a thorough neurotologic examination
as well as balance function tests and neuroimaging, if clinically indicated.
Patients were referred for psychiatric evaluation if their neurotologic examination
revealed 1 of the 3 following clinical conditions: (1) psychogenic dizziness,3 characterized by vague, persistent sensations of dizziness,
subjective imbalance, lightheadedness, fullness in the head, or detachment
from the environment that were worse in open spaces (eg, warehouses and churches)
or active visual surroundings (eg, busy malls); (2) dizziness due to a neurotologic
condition, as well as significant psychiatric symptoms (eg, Meniere disease
with depression or benign paroxysmal positional vertigo with anxiety); and
(3) idiopathic dizziness, defined as atypical complaints not consistent with
a central or peripheral vestibular deficit but no overt psychiatric symptoms.
The psychiatric evaluation closely followed the Structured
Clinical Interview for Axis I DSM-IV Disorders, Research Version, Patient
Edition (SCID-I/P),17 an instrument
that is widely accepted as the diagnostic standard in psychiatric clinical
research.
We treated 60 of the 110 patients with an SSRI after their multidisciplinary
evaluation. The remaining 50 patients were seen for 1-time consultations (n
= 20), had diagnoses that required other therapies (n = 18), declined treatment
with an SSRI (n = 6), or were unavailable for follow-up (n = 6). To be included
in this study, patients must have remained in treatment until they reached
1 of 3 clinical end points: (1) optimal clinical benefit, (2) intolerable
adverse effects (defined as persistent adverse effects that prevented patients
from continuing to take their medication), or (3) lack of clinical response
(defined as the absence of any noticeable improvement [see rating scale in
the "Outcome Measure" section] in patients who had taken an SSRI for at least
20 weeks and had reached a dose equivalent to 150 mg/d of sertraline hydrochloride).
MEDICATION DOSING
The SSRIs were prescribed in open-label fashion after patients were
informed of the clinical indications, common adverse effects, and anticipated
course of treatment. The regimens were started at the lowest available doses
because of the concern that adverse effects would lead to premature discontinuation.
In 1998, sertraline was available in the lowest-strength tablets relative
to the other SSRIs, so it was used most frequently (n = 40). Later, the other
SSRIs were marketed in equivalent low-dose tablets or elixirs, but they were
prescribed less often (fluoxetine [n = 11], paroxetine [n = 13], and citalopram
[n = 5]). Fluvoxamine, the most sedating SSRI, was not used. Patients followed
1 of the 2 dosing schedules shown in Figure
1, depending on their tolerance for the starting dose (equivalent
to 12.5 mg/d of sertraline hydrochloride). In 2 cases, the best final dose
was an intermediate titration step (37.5 mg of sertraline hydrochloride in
one case and 125 mg in the other). Five patients were taking an SSRI at the
time of referral. The dosage of their medication was adjusted to the optimal
clinical benefit. The dosages of all other psychotropic medications were tapered
gradually. The use of vestibular suppressants and other otologic agents was
minimized for patients with active neurotologic conditions and discontinued
for all others. No other treatments (eg, psychological or behavioral therapies)
were used during the first 20 weeks of SSRI therapy.
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Figure 1. The selective serotonin reuptake
inhibitor (SSRI) dose titration schedule, showing sertraline hydrochloride
as an example, emphasizes a "start low, go slow" approach for patients with
dizziness. Fifty milligrams was the modal daily dose of sertraline hydrochloride
(range, 25-150 mg/d). Equivalent doses are listed for other SSRIs.
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OUTCOME MEASURE
Treatment outcomes were measured with the Clinical Global Impressions-Improvement
(CGI-I) Scale,18 a clinician-rated instrument
that is used widely in psychiatric research to score overall changes in patients'
symptoms: 1, very much improved; 2, much improved; 3, minimally improved;
4, no change; 5, minimally worse; 6, much worse; and 7, very much worse. In
clinical trials, the CGI-I scale often is used as a dichotomous measure to
separate patients with a positive treatment response (score of 1 or 2) from
those with no clear benefit (score  3). This approach sets a more rigorous
standard for a positive outcome (definite improvement) and presents the results
in a clinically relevant manner (percentage of individuals who benefit, rather
than group means). The CGI-I scale was used dichotomously in this study. Scores
were based on the change in severity of both dizziness and psychiatric symptoms
from the initial evaluation to 20 weeks after the initiation of an SSRI therapy.
We treated 28 patients for at least 1 year and rated them a second time, comparing
their clinical status at 12 months with that at 20 weeks.
DIAGNOSTIC CATEGORIES
Patients were divided into 2 groups by psychiatric diagnoses: major
psychiatric disorders and minor psychiatric conditions (Table 1). The major disorders are well-known anxiety and depressive
disorders, such as panic disorder and major depression. The minor conditions
are less familiar to those outside the mental health professions. Undifferentiated
somatoform disorder is a condition in which patients have a persistent physical
symptom out of proportion to objective medical findings.19
This diagnosis was given in cases involving chronic dizziness but no active
neurotologic illness and no other psychological symptoms (eg, no significant
worry, dysphoria, changes in daily routines, or avoidance of situations associated
with dizziness). The patient with specific phobia had dizziness and phobic
avoidance limited to driving situations only. Individuals with anxiety disorder,
not otherwise specified, had chronic or recurrent dizziness as well as mild
to moderate levels of worry, episodic anxiety, and/or phobic avoidance that
fell short of a major anxiety disorder. These minor psychiatric diagnoses
closely resemble published descriptions of monosymptomatic phobic postural
vertigo5 and space-motion discomfort/phobia.7 The 2 patients with mal de debarquement were demoralized
by their symptoms but did not have a psychiatric disorder.
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Table 1. Psychiatric and Medical Diagnoses of 60 Patients Treated With
SSRIs*
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Thirty-two patients had medical conditions that were at least partially
responsible for their dizziness, based on their presenting histories, physical
examination findings, and/or laboratory test results (Table 1). In 7 cases, the diagnoses were based on history alone.
Three patients had past episodes of benign paroxysmal positional vertigo,20 while 3 others had previous bouts of vestibular neuronitis.20 One patient had undergone surgery during childhood
for an unknown "tumor in the right ear." Patients diagnosed as having Meniere
disease met the classic criteria for this diagnosis, ie, unilateral tinnitus,
a history of recurrent episodes of vertigo, and unilateral hearing loss documented
on audiometric assessment.21 Those with migraine
experienced unilateral, throbbing headaches with nausea, photophobia, and/or
sonophobia, as well as episodic dizziness22
as confirmed by headache logs or collateral information from family members.
Other diagnoses were based on consultation with appropriate medical specialists.
Three patients had clinical evidence of autonomic dysregulation (eg, dizziness
exacerbated by exercise, orthostatic intolerance, or past episodes of vasovagal
syncope).
DATA ANALYSIS
To test the first hypothesis, differences in patient demographics and
medical comorbidity between the major and minor psychiatric groups were examined.
Then, average medication doses and treatment outcomes were compared. Fisher
exact or  2 tests were used for categorical data (sex, race,
medical comorbidity, and treatment response); t tests
were used for other parameters. All tests were 2-tailed, with statistical
significance set at P<.05. Both intent-to-treat
and completer analyses were performed. The intent-to-treat analysis included
all patients, comparing those with positive (CGI-I  2) and those with negative
(CGI-I >2 or medication intolerant) outcomes. The completer analyses excluded
patients who could not tolerate SSRIs and compared those with a positive outcome
(CGI-I 2) with those who received no benefit from a full medication trial
(CGI-I >2).
The second hypothesis was examined using the same statistical approaches.
Patient demographics and treatment outcomes were compared between patients
with and without medical illnesses, and then outcomes were analyzed within
the medically ill cohort. Medical diagnoses were grouped into 4 categories
for statistical analysis: peripheral vestibular deficits, central nervous
system illnesses, cardiovascular conditions, and other diagnoses. There was
insufficient power for a 2 x 2 x 2 analysis (psychiatric diagnosis
by medical condition by outcome).
RESULTS
Demographic characteristics of the study patients are shown in Table 2. The groups with and without major
psychiatric disorders did not differ significantly in age, sex, race, presence
of medical comorbidity, or duration of dizziness, which exceeded 4 years on
average. The clinical outcomes of the 2 groups are compared in Table 3. Mean and modal medication doses and dose ranges are listed
in Table 4 for patients with a
positive treatment response. There were no differences between the psychiatric
groups in SSRI efficacy, tolerability, mean or modal medication doses, or
dose ranges. In the intent-to-treat analysis, 38 (63%) of 60 patients tolerated
their medication well and were rated much or very much improved on the CGI-I
scale at 20 weeks. Among those who completed treatment, 38 (84%) of 45 responded
well (CGI-I 2).
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Table 2. Demographic Characteristics of Dizzy Patients With and Without
Major Psychiatric Illnesses
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Table 3. Response to Treatment With SSRIs* in 60 Dizzy Patients With
and Without Major Psychiatric Illness
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Table 4. SSRI Dosing in 38 Dizzy Patients With and Without Major Psychiatric
Illnesses*
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Twenty-eight patients with a positive outcome at 20 weeks were followed
up for 12 months or more (23 with major psychiatric disorders and 5 with minor
conditions). Twenty-six (93%) enjoyed continued success throughout the year.
One patient with a long history of major depression, panic disorder, and bilateral
Meniere disease was hospitalized with an acute exacerbation of her psychiatric
symptoms. The other patient experienced worsening depressive symptoms while
taking cyclophosphamide for a rheumatologic condition.
The length of time that patients were ill affected the extent of their
response to SSRI therapy. When the population was divided at the median duration
of illness (33.5 months), the positive response rate did not differ significantly
between patients who had been ill for 3 to 31 months (16/30, 53%) and those
who had been ill for 36 to 336 months (22/30, 73%) (21 = 4.45; P<.10). However, positive responders
who had been dizzy for the shorter period of time were more likely to achieve
a CGI-I score of 1 (very much improved) rather than 2 (much improved) after
20 weeks. Thirteen (81%) of 16 positive responders with a short duration of
illness had a score of 1, compared with 8 (36%) of 22 who had been ill for
36 months or more (21 = 10.2; P<.001).
Patients with medical illnesses were older than those without (45.1
± 16.5 vs 36.8 ± 12.9 years; P<.03),
but there were no other differences in demographic variables or duration of
illness. Furthermore, there were no significant differences in SSRI efficacy,
tolerability, or average daily medication dose between the 32 patients with
medical illnesses and the 28 patients without medical illnesses. However, Table 5 shows that response rates and tolerability
were not uniform across all medical conditions. The intent-to-treat analysis
demonstrated that patients with peripheral vestibular deficits, migraine headaches,
and autonomic symptoms responded well to treatment with SSRIs, while those
with central nervous system illnesses fared quite poorly. The small groups
of patients with cardiac dysrhythmias and mal de debarquement also had negative
outcomes.
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Table 5. Response to Treatment With SSRIs* in 32 Dizzy Patients With
Psychiatric Symptoms and Medical Illness
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The dosages of all other psychotropic medications were tapered in each
case in which the patient responded to treatment with an SSRI, with the exception
of 5 cases involving individuals with severe anxiety disorders who responded
best when a benzodiazepine was used in conjunction with an SSRI. Patients
without active neurotologic conditions successfully discontinued all otologic
therapy. Patients with histories of benign paroxysmal positional vertigo and
vestibular neuronitis were treated with SSRIs alone, while those with Meniere
disease, autoimmune ear disease, and migraine headaches were maintained on
a regimen of medications typically used for those disorders.
Fifteen patients (25%) could not tolerate treatment with an SSRI, including
4 who tried taking 2 different SSRIs, without success. Intolerable adverse
effects were sedation or fatigue (n = 5), sexual adverse effects (n = 4),
dulled mentation (n = 3), insomnia (n = 2), or nausea (n = 1). Another 5 patients
did not tolerate their first SSRI treatment but were able to take a second
medication successfully. A few patients experienced mild symptoms of the SSRI
discontinuation syndrome during brief periods of medication noncompliance.
At least 1 medication for dizziness was prescribed to 56 (93%) of the
60 patients before they were referred to us (Figure 2). Fifty (83%) of the 60 patients had taken meclizine hydrochloride
and/or benzodiazepines. Three patients, all with active vestibular illnesses,
reported that meclizine temporarily reduced their symptoms during periods
of acute vertigo. The others reported no benefit or worsening of symptoms
due to sedation. No patient achieved sustained improvement in either dizziness
or psychiatric symptoms with the use of benzodiazepines. The most common response
was a partial symptom reduction for several days to weeks. Sedation or cognitive
impairment limited attempts to increase the doses. One of the 2 patients with
Meniere disease reported moderate improvement with the use of diuretics, including
acetazolamide sodium. Treatment with corticosteroids, antihistamines, and
buspirone hydrochloride provided no relief for any patient. Fourteen patients
had taken an SSRI before they were evaluated by us, but their courses of treatment
were too short to obtain clinical benefit. Ten (71%) of the 14 patients had
excellent therapeutic outcomes in the present study. Tricyclic antidepressants
were prescribed at migraine or insomnia doses, which were too low to be effective
for psychiatric symptoms.
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Figure 2. Medications taken by study patients
before their referral to us provided only limited or inconsistent relief from
dizziness and psychiatric symptoms. Migraine prophylactic agents included ß-blockers,
calcium channel blockers, and divalproex sodium. Tricyclic antidepressants
are listed separately.
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COMMENT
The results of the present study indicate that SSRI therapy can alleviate
symptoms of dizziness in patients with major or minor anxiety disorders and
major depression, whether these psychiatric conditions are the sole causes
of patients' complaints or coexist with certain medical illnesses. Treatment
with SSRIs also may be helpful for patients who experience chronic sensations
of disequilibrium alone (ie, undifferentiated somatoform dizziness). Approximately
two thirds of all patients who took an SSRI had a positive response, but those
with psychiatric disorders alone, as well as those with psychiatric symptoms
accompanied by peripheral vestibular deficits or migraine headaches, had the
best outcomes. Patients with central nervous system illnesses, such as traumatic
brain injury or stroke, fared poorly. Treatment with SSRIs was effective in
patients with many years of disability, although individuals with a shorter
duration of illness (<3 years) had a more robust response than those who
had been ill for a longer time. The initial data on long-term outcomes were
encouraging. Nearly all patients who were followed up for 12 months or more
enjoyed sustained benefits. Finally, the patient population in this study
was similar to those described in investigations of psychogenic dizziness,3 phobic postural vertigo,4-5
and space-motion phobia,7 suggesting that SSRI
therapy may benefit patients with those syndromes.
The study was not designed to compare treatment with SSRIs directly
with any other treatment for dizziness, but the high percentage of patients
who obtained little benefit from the use of meclizine, benzodiazepines, and
other medications indicates that SSRI therapy may offer significant advantages
over these treatments for patients with dizziness and major or minor psychiatric
symptoms.
The positive results of this investigation are tempered somewhat by
the fact that 1 in 4 patients could not take an SSRI, mostly because of somnolence,
physical fatigue, and mental sluggishness. These adverse effects occurred
at higher rates than in double-blind, placebo-controlled trials of SSRI therapy
for uncomplicated anxiety and depressive disorders,23-24
suggesting that patients with dizziness may be particularly intolerant of
adverse reactions that mimic the nagging symptoms that often accompany chronic
disequilibrium. In contrast, gastrointestinal adverse effects were managed
successfully with the slow titration schedules shown in Figure 1, and sexual adverse effects occurred at rates similar to
those observed in other patient populations.25
To our knowledge, this is the first investigation of the efficacy and
tolerability of SSRI therapy for patients with dizziness accompanied by major
or minor psychiatric symptoms. It introduces an encouraging new therapeutic
approach for this difficult clinical problem. However, the study has several
limitations, including an unblinded design and lack of a control group. Furthermore,
the small amount of long-term data does not provide adequate information about
the optimal length of treatment. These shortcomings are partially mitigated
by the fact that our study comprised a consecutive case series and that the
number of subjects was fairly large for an uncontrolled pharmacological study.
A standardized clinical protocol was used for the neurotologic evaluations,
and widely accepted clinical research tools were used for the psychiatric
examinations and outcome measures. Retrospective bias was minimized by encoding
clinical data into the research database in a prospective manner. Nevertheless,
controlled trials are needed to confirm our findings . Future pharmacological
research should include a broader selection of neurotologic and psychiatric
outcome measures and investigate long-term treatment responses.
AUTHOR INFORMATION
Accepted for publication October 2, 2001.
This study was presented in part at the 153rd Annual Meeting of the
American Psychiatric Association, Chicago, Ill, May 17, 2000.
Corresponding author: Jeffrey P. Staab, MD, MS, Department of Psychiatry,
Hospital of the University of Pennsylvania, Founders Pavilion, F11.015, 3400
Spruce St, Philadelphia, PA 19104 (e-mail: jeffrey.staab{at}uphs.upenn.edu).
From the Departments of Psychiatry (Dr Staab), Otorhinolaryngology–Head
and Neck Surgery (Drs Staab, Ruckenstein, Solomon, and Shepard), and Neurology
(Dr Solomon) and the Balance Center (Drs Staab, Ruckenstein, Solomon, and
Shepard), University of Pennsylvania Health System, Philadelphia. Dr Staab
receives research funding from Pfizer Inc and GlaxoSmithKline, and is a consultant
to Eli Lilly and Company and Forest Laboratories, Inc.
REFERENCES
| |
1. Staab JP. Diagnosis and treatment of psychologic symptoms and psychiatric disorders
in patients with dizziness and imbalance. Otolaryngol Clin North Am. 2000;33:617-633.
FULL TEXT
|
ISI
| PUBMED
2. Yardley L. Overview of psychological effects of chronic dizziness and balance
disorders. Otolaryngol Clin North Am. 2000;33:603-616.
FULL TEXT
|
ISI
| PUBMED
3. Simpson RB, Nedzelski JM, Barber HO, Thomas MR. Psychiatric diagnoses in patients with psychogenic dizziness or severe
tinnitus. J Otolaryngol. 1988;17:325-330.
ISI
| PUBMED
4. Brandt T, Huppert D, Dieterich M. Phobic postural vertigo: a first follow-up. J Neurol. 1994;241:191-195.
FULL TEXT
|
ISI
| PUBMED
5. Kapfhammer HP, Mayer C, Hock U, Huppert D, Dieterich M, Brandt T. Course of illness in phobic postural vertigo. Acta Neurol Scand. 1997;95:23-28.
ISI
| PUBMED
6. Marks JM. Space "phobia": a pseudo-agoraphobic syndrome. J Neurol Neurosurg Psychiatry. 1981;48:729-735.
FREE FULL TEXT
7. Jacob RG, Furman JM, Durrant JD, Turner SM. Panic, agoraphobia, and vestibular dysfunction. Am J Psychiatry. 1996;153:503-512.
FREE FULL TEXT
8. Sullivan M, Clark MR, Katon WJ, et al. Psychiatric and otologic diagnoses in patients complaining of dizziness. Arch Intern Med. 1993;153:1479-1484.
FREE FULL TEXT
9. Stein MB, Asmundson GJG, Ireland D, Walker JR. Panic disorder in patients attending a clinic for vestibular disorders. Am J Psychiatry. 1994;151:1697-1700.
FREE FULL TEXT
10. McKenna L, Hallam RS, Hinchcliffe R. The prevalence of psychological disturbance in neuro-otology outpatients. Clin Otolaryngol. 1991;16:452-456.
ISI
| PUBMED
11. Clark DB, Hirsch BE, Smith MG, Furman JM, Jacob RG. Panic in otolaryngology patients presenting with dizziness or hearing
loss. Am J Psychiatry. 1994;151:1223-1225.
FREE FULL TEXT
12. Zohar J, Westenberg HG. Anxiety disorders: a review of tricyclic antidepressants and selective
serotonin reuptake inhibitors. Acta Psychiatr Scand Suppl. 2000;403:39-49.
PUBMED
13. Hirschfield RM. Efficacy of SSRIs and newer antidepressants in severe depression: comparison
with TCAs. J Clin Psychiatry. 1999;60:326-335.
ISI
| PUBMED
14. Goldstein BJ, Goodnick PJ. Selective serotonin reuptake inhibitors in the treatment of affective
disorders: III, tolerability, safety, and pharmacoeconomics. J Psychopharmacol. 1998;12(suppl B):S55-S87.
15. Schatzberg AF, Haddad P, Kaplan EM, et al. Serotonin reuptake inhibitor discontinuation syndrome: a hypothetical
definition: Discontinuation Consensus Panel. J Clin Psychiatry. 1997;58(suppl 7):5-10.
16. Staab JP, Ruckenstein MJ, Solomon D, Shepard NT. An open trial of selective serotonin reuptake inhibitors in patients
with dizziness and major or minor psychiatric symptoms. New research program presented at: 153rd Annual Meeting of the American
Psychiatric Association; May 17, 2000; Chicago, Ill.
17. First MB, Spitzer RL, Gibbon M, Williams JBW. Structured Clinical Interview for Axis I DSM-IV Disorders,
Research Version, Patient Edition (SCID-I/P). New York: Biometrics Research, New York State Psychiatric Institute;
1994.
18. Guy W. ECDEU Assessment Manual for Psychopharmacology, Revised. Rockville, Md: US Dept of Health, Education, and Welfare; 1976. Publication
(ADM) 76-338.
19. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition. Washington, DC: American Psychiatric Association; 1994.
20. El-Kashlan HK, Telian SA. Diagnosis and initiating treatment for peripheral system disorders:
imbalance and dizziness with normal hearing. Otolaryngol Clin North Am. 2000;33:563-577.
FULL TEXT
|
ISI
| PUBMED
21. Committee on Hearing and Equilibrium. Ménière's Disease: Criteria for Diagnosis
and Evaluation of Therapy for Reporting. Vol 5. Alexandria, Va: American Academy of Otolaryngology–Head
and Neck Surgery Foundation Inc; July 1985:6-7.
22. Harker LA. Migraine-associated vertigo. In: Baloh RW, Halmagyi GM, eds. Disorders of the
Vestibular System. New York, NY: Oxford University Press; 1996:407-417.
23. Pohl RB, Wolkow RM, Clary CM. Sertraline in the treatment of panic disorder: a double-blind multicenter
trial. Am J Psychiatry. 1998;155:1189-1195.
FREE FULL TEXT
24. Thase ME, Fava M, Halbreich U, et al. A placebo-controlled, randomized clinical trial comparing sertraline
and imipramine for the treatment of dysthymia. Arch Gen Psychiatry. 1996;53:777-784.
FREE FULL TEXT
25. Montejo-Gonzalez AL, Llorca G, Izquierdo JA, et al. SSRI-induced sexual dysfunction: fluoxetine, paroxetine, sertraline,
and fluvoxamine in a prospective, multicenter, and descriptive clinical study
of 344 patients. J Sex Marital Ther. 1997;23:176-194.
ISI
| PUBMED
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