Does BPPV affect the psychological state of patients?  

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Hoda Abd-Elhamid, Ahmed El Abedein, Ahmed Abd El Moniam Ragab, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5485840/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Benign paroxysmal positional vertigo (BPPV) is recognized as one of the most prevalent peripheral vestibular disorders, with a one-year prevalence rate of 1.6% and a lifetime prevalence rate of 2.4%. Objective to assess the prevalence of anxiety and depression in BPPV patients. Methods This study comprised 385 participants with BPPV and 385 normal controls. all participants subjected to full history taking, basic audiological evaluation, videonystagmography, Arabic version of Dizziness handicap inventory and Arabic version of Hospital anxiety and depression scale. Results There were insignificant differences between patients and controls regarding their sex and age distribution. In this study 227 (59%) of patients have anxiety and 117 (30.4%) of patients have depression. There was no statistically significant difference between patients and controls regarding anxiety and depression before BPPV attack. There was a statistically significant increase in anxiety and depression in patients during the attack than before the attack and after treatment. There was a significant correlation between the score of anxiety and depression with the duration of the BPPV course, number of attacks and DHI score, also depression score showed positive correlation with anxiety score. The severity of DHI was significantly correlated with anxiety and depression. Conclusion The current study revealed a high prevalence of anxiety and depression in BPPV group which was significantly correlated with duration of disease, recurrence of attacks and DHI score. Anxiety and depression should be treated concurrently with BPPV to improve the outcome of treatment and quality of life. Anxiety Benign Paroxysmal Positional Vertigo Depression Dizzy Patients Risk Factors Figures Figure 1 INTRODUCTION Approximately 15% to over 20% of adults experience Dizziness, including vertigo each year. Vestibular vertigo represents about 25% of these cases. Prevalence tends to increase with age and is two to three times more in women than men ( 1 ). Benign paroxysmal positional vertigo (BPPV) is the most prevalent disorder affecting the vestibular system ( 2 ), exhibiting a lifetime prevalence of 2.4% ( 3 ).Dizziness related to head movements may be caused by BPPV ,vestibular migraine and central lesions. BPPV is characterized by episodes of rotational vertigo, triggered by changes in head position relative to gravity. Spontaneous recovery occurs in about 20% of cases within a month and in about 50% within 3 months ( 4 ). Vertigo and dizziness symptoms play a substantial role in the overall burden of disease and significantly impact daily activities and quality of life. ( 5 ) Many patients suffering from vertigo may experience secondary psychiatric disorders. ( 6 ). Yeo et al. ( 7 ) revealed that patients with BPPV are at increased risk of developing anxiety disorders in comparison with controls. The fear of sudden and unpredictable vertigo can adversely affects patients, increasing their anxiety levels regardless of any previous experiences with this condition ( 8 ). Most of the previous studies on the association between BPPV, anxiety and depression didn't include control group and didn't study the relation between anxiety, depression and recurrence of BPPV. The objective of this study was therefore to investigate the prevalence of anxiety and depression in a BPPV group and to correlate the prevalence of anxiety and depression with recurrence of the attacks. Patients and Methods This case control study was conducted on 770 participants who were assessed in the audio vestibular medicine clinic, Menoufia university hospital, El-Menoufia governorate, Egypt (patients were referred from many centers all over the governorate and neighbouring governorates), during the period from September 2023 to October 2024. Participants in this study were divided into 2 groups: study group, consisted of 385 subjects of BPPV patients and control group, consist of 385 normal subjects selected from the relatives of the patients. Inclusion criteria: Subjects diagnosed as BPPV according to British society of audiology guidelines ( 9 ) with the exclusion of patients with psychiatric disorders or cognitive dysfunction, patients with vertigo due to causes other than the BPPV and any medical condition that may interfere with the psychological state. All patients included in the current study were subjected to: 1. full history taking including a complete description of the dizziness complaint regarding: character, frequency of the attack, number of the attacks, severity of the attack, duration of the attack, duration of the disease, precipitating and relieving factors, as well as any accompanying symptoms. 2. office test (positioning and gait tests). 3. Videonystagmography VNG model, interacoustic (micromedical). The following tests were done (spontaneous and gaze testing, occulomotor testing, positioning & positional test and caloric test) testing and interpretation were done according to British society of audiology guidelines ( 9 ). 4. Arabic version of dizziness handicap inventory (DHI): which consists of 25 items to assess the self-perceived handicap level due to dizziness. It was graded as: mild disorder score between (0–30), moderate disorder score between (31–60) and severe disorder score between (61–100) ( 10 ). 5. Arabic version of hospital anxiety and depression scale (HADS): was used to screen for anxiety and depression in medical outpatient settings, it consists of 14 items on a 4-points scale (0–3): 7 items assess anxiety with cut-off point 8.5 and 7 items assess depression with cut of point 9.5.The score of each subscale is the sum of the 7 items ranging (0–21), the total score is the sum of 14 items. ( 11 ). Statistical analysis The results were tabulated and statistically analyzed using SPSS V.25 (IBM Corporation, 1 Orchard Rd, Armonk, NY 10504, USA) and Microsoft Excel 2019 (Microsoft Corporation, One Microsoft Way Redmond, WA 98052 − 6399, USA). The Kolmogorov- Smirnov was used to verify the normality of the distribution of variables. The mean and standard deviation were used for quantitative data analysis, the frequency and relative percentage were used for qualitative data analysis. The Chi-square test was applied to compare the qualitative categorical data between the two groups. Fischer exact test for 2 x 2 tables when expected cell count of more than 25% of cases was less than 5. An independent t-test which is a parametric test was used to compare between the normally distributed variables. Mann-Whitney test which is a non-parametric test was used for comparison between the abnormal distributed variables in the two groups. P value < 0.05 was considered statistically significant. RESULTS There was no statistically significant difference between patients and controls regarding their sex and age distribution ( Table 1). This study consisted of 385 BPPV patients: 384 patients were diagnosed with posterior canal BPPV, 1 patient was diagnosed with lateral canal BPPV. The mean duration of the attacks was 1.49±0.49 months, 380 (98%) patients suffer from severe attacks and 5 (2%) patients had moderate attacks. According to Arabic version of DHI, 340 (88.3%) patients had severe handicap, 44 (11.6%) patients had moderate handicap, and 1 (0.1%) patient had mild handicap, the total mean score was 59±9.2 during attack, 0.00±0.00 after attack. The mean duration of BPPV was 9.26±3.78 months, 377 (97.9%) patients diagnosed with canalithiasis and 8 (2.1%) patients diagnosed with cupulolithiasis. (Table 2) shows comparison between the studied groups regarding prevalence and score of anxiety and depression before the attacks of BPPV. There was no statistically significant difference between patients and controls regarding anxiety and depression (prevalence and score) before BPPV attack. (Table 3) shows anxiety and depression before, during the attack and after treatment among BPPV patients. There was a statistically significant increase in anxiety (score and prevalence) and depression (score and prevalence) in patients during the attack than before the attack and after treatment, there was no statistically significant difference in anxiety (score and prevalence), depression (score and prevalence) in patients before the attack and after treatment. (Table 4) shows the correlation between anxiety & depression scores during the attack and patients variables: age, clinical criteria of attacks and DHI. There was a positive significant correlation between anxiety score during the attack and duration of BPPV, number of attacks and DHI score. There was a positive significant correlation between depression score during attack and duration of BPPV, number of attacks, DHI score and anxiety score, while there was a negative significant correlation between depression score during the attack and age. (Figure 1) shows the correlation between DHI and anxiety & depression among studied patients. The severity of DHI was significantly correlated with anxiety (chi-square test, x 2 = 22.26, p-value < 0.01) and depression (chi-square test, x 2 = 7.09, P-value 0.020). (Table 5) shows anxiety and depression in relation to recurrence of BPPV attacks among the studied patients. There was no statistically significant difference between the scores and prevalence of anxiety and depression in patients with recurrent attacks and those with single attack (before the attack), however during the attack, there was a statistically significant increase in prevalence and score of anxiety and depression in patients with recurrent attacks than those with single attack. Also, after treatment of BPPV there was a statistically significant difference in anxiety and depression score in patients with recurrent attacks and those with single attack, while there was no statistically significant difference in prevalence of anxiety and depression in patients with recurrent attacks and those with single attack. Discussion Dizziness or vertigo represents one of the most frequently reported complaints in clinical medicine, 80% of cases ( 12 ), BPPV is among the most prevalent peripheral vestibular disorders 2.4% ( 3 ). BPPV is associated with depression ( 13 ), and other anxiety disorders ( 14 ). HADS: in the current study, HADS was used for assessment of anxiety and depression, HADS was developed to provide a reliable, valid & easy tool to identify anxiety & depression in medical patients ( 15 ). The current study showed a significant increase in anxiety and depression (score and prevalence) in BPPV patients during attack. Kim et al., ( 4 ) reported that patients diagnosed with BPPV showed a higher prevalence of psychiatric disorders as depression and generalized anxiety than in general population ( 16 ). In the current study, the prevalence of anxiety and depression during the attacks was 59% & 30% respectively also 1.5% & 0.5% of BPPV patient had anxiety and depression respectively after treatment, Omara et al., ( 17 ) revealed anxiety and depression in 29% and 7% of their patients respectively . This study showed that there was a statistically significant increase in anxiety & depression (score and prevalence) in patients with recurrent attacks than those with single attack. Our study was close to the study obtained by Wei et al., ( 18 ) who found that recurrent attacks of BPPV can cause chronic worry and aggravates the psychosomatic symptoms of anxiety. Additionally, Shu et al., ( 19 ) observed that anxiety and obsessive convulsive disorders were associated with a heightened risk of the first BPPV recurrence. Anxiety and depression were also reported in other episodic vertiginous conditions, Kim et al.,2023 ( 20 ) reported anxiety and depression in 49% and 32% respectively in vestibular migraine patients. Wei et al., ( 18 ) demonstrated that anxiety-depression status significantly reduces the patients’ satisfaction and increases the risk of recurrence in BPPV. Previous studies provide several possible explanations. First, anxiety and depression were correlated with a chronic low-grade inflammatory response. This could increase oxidative and nitrosative stress and aggravate vestibular degeneration, causing difficulties in relocation and reabsorption of the dislodged otoliths ( 18 ) ( 19 ). Second, anxiety leads to a neuroendocrine response dysfunction that can alter the blood flow of the inner ear and disrupt BPPV recovery. ( 19 ). Third, there was a link between the vestibular and emotional processing systems. Neurotransmitters and neuroanatomical regions responsible for the vestibular systems and emotional responses share similarities. Parabrachial nuclei provides interconnection between vestibular nuclei and brain regions involved in the response to fear and anxiety, both areas affect the autonomic system ( 21 ) ( 7 ). This makes it clear that it is mandatory to overcome anxiety and/or depression that result from BPPV to achieve complete recovery of the condition. The DHI has validated its role as an effective tool for recording the impacts of vestibular and/or balance disorders in the form of disability and handicaps ( 22 ). In the current study the severity of DHI was correlated to anxiety and depression score, Ketola et al., ( 16 ) reported that patients suffering from high psychological distress level tend to have increased (DHI) scores. These findings suggest that patients suffering from dizziness and high levels of psychological distress may report more vertigo symptoms, specifically those having both anxiety and depression. Feng and Zang, ( 23 ) declared that patients with comorbid anxiety or depression experienced more severe vertigo which adversely affected their somatic symptoms, emotional state, and social function. The present study showed that anxiety and depression score during the attacks has a significant positive correlation with duration of disease, number and severity of attacks and DHI score. increased duration, recurrence of disease and severity of DHI affect patients’ quality of life and daily activities so, increasing burden of disease while there was a negative significant correlation between depression score during attack and age. Finally, BPPV had a psychological impact on the patients, the current study revealed high level of anxiety & depression in BPPV patients during the attacks which was correlated to the severity of symptoms also recurrence of the attacks increase the psychological burden over the patients. It’s important to assess the prevalence of anxiety & depression in BPPV patients as the presence of anxiety & depression could aggravate vertigo itself, affect the quality of life, increase the recurrence of attacks and affect the outcome of treatment. These patients required special attention to treat anxiety & depression concurrently with BPPV. Patients move in viscous circuit as each of them can increase the prevalence of the other ( 18 ). The current study had some limitations: almost all the cases had posterior canal BPPV, only 1 case had lateral canal BPPV, no cases with anterior canal BPPV were involved in the study. The authors couldn’t compare between patients with canalithiasis and cupulolithiasis due to the very small number of cupulolithiasis cases. Also, simple screening questionnaires were used in the assessment of anxiety and depression. Further studies using diagnostic tools should be implemented in the diagnosis of psychological impact of dizziness. Conclusion A high prevalence of anxiety and depression in BPPV group in comparison to controls. The prevalence of anxiety and depression was significantly correlated with duration of disease, recurrence of attacks and DHI score. Anxiety and depression should be treated concurrently with BPPV to improve the outcome of treatment and quality of life. Declarations Ethical approval and consen t: a written informed consent was obtained from all the participants. The study plan was approved by the local ethical committee of faculty of medicine, Menoufia, Egypt under number of 9/2023 ENT 17. Funding: no funds were obtained. Author Contribution Contributor 1 Contributor 2 Contributor 3 Contributor 4Concepts √ √ Design √ √ Definition of intellectual content √ √ Literature search ✓ √ √Clinical studies √ √ √ √Experimental studies Data analysis √ Statistical analysis √ √Manuscript preparation √ √ ✓ ✓Manuscript editing √ √ √ ✓Manuscript review √ √ √ √Guarantor √ √ √ √ References Iljazi A, Ashina H, Lipton RB, Chaudhry B, Al-Khazali HM, Naples JG et al (2020) Dizziness and vertigo during the prodromal phase and headache phase of migraine: a systematic review and meta-analysis. Cephalalgia. 2020;40(10):1095–103 Agrawal Y, Ward BK, Minor LB (2013) Vestibular dysfunction: prevalence, impact and need for targeted treatment. J Vestib Res Equilib Orientat 23(3):113 Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T et al (2017) Clinical practice guideline: benign paroxysmal positional vertigo (update). Otolaryngol Neck Surg 156(3suppl):S1–47 Kim HJ, Lee JO, Choi JY, Kim JS (2020) Etiologic distribution of dizziness and vertigo in a referral-based dizziness clinic in South Korea. J Neurol 267(8):2252–2259 Kaplan GG, Windsor JW (2021) The four epidemiological stages in the global evolution of inflammatory bowel disease. Nat Rev Gastroenterol Hepatol 18(1):56–66 Habs M, Strobl R, Grill E, Dieterich M, Becker-Bense S (2020) Primary or secondary chronic functional dizziness: does it make a difference? A DizzyReg study in 356 patients. J Neurol 267:212–222 Yeo BSY, Toh EMS, Lim NE, Lee RS, Ho RCM, Tam WWS et al (2024) Association of Benign Paroxysmal Positional Vertigo with Depression and Anxiety—A Systematic Review and Meta-Analysis. Laryngoscope 134(2):526–534 Özdilek A, Dikmen PY, Acar E, Aksoy EA, Korkut N (2019) Determination of anxiety, health anxiety and somatosensory amplification levels in individuals with benign paroxysmal positional vertigo. J Int Adv Otol 15(3):436 BSA. Recommended Procedure: (2015) Vestibular assessment - eye movement recordings. Br Soc Audiol 38(11):1–43 Alsanosi AA (2012) Adaptation of the dizziness handicap inventory for use in the Arab population. Neurosci J 17(2):139–144 Moaty AS, Talaat HS, Mehrez MG (2021) Prevalence of anxiety and depression in dizzy patients using Arabic hospital anxiety and depression scale. Menoufia Med J 34(2):420–426 Parnes LS, Agrawal SK, Atlas J (2003) Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ 169(7):681–693 Hagr A (2009) Comorbid psychiatric conditions of benign paroxysmal positional vertigo. Int J Health Sci (Qassim) 3(1):23 Monzani D, Casolari L, Guidetti G, Rigatelli M (2001) Psychological distress and disability in patients with vertigo. J Psychosom Res 50(6):319–323 Angstskala HD Hospital Anxiety and Depression Scale (HADS-D).(2005) Schmerzdokumentation der Prax Klassif Stadieneinteilung, Schmerzfragebögen. 89:89 Ketola S, Havia M, Appelberg B, Kentala E (2007) Depressive symptoms underestimated in vertiginous patients. Otolaryngol Neck Surg. 2007;137(2):312–5 Omara A, Basiouny EM, Shabrawy M, El, Shafei RR, El (2022) The correlation between anxiety, depression, and vertigo: a cross-sectional study. Egypt J Otolaryngol 38(1):143 Wei W, Sayyid ZN, Ma X, Wang T, Dong Y (2018) Presence of anxiety and depression symptoms affects the first time treatment efficacy and recurrence of benign paroxysmal positional vertigo. Front Neurol 9:178 Shu Y, Liao N, Fang F, Shi Q, Yan N, Hu Y (2023) The relationship between psychological conditions and recurrence of benign paroxysmal positional vertigo: a retrospective cohort study. BMC Neurol 23(1):137 Kim T, Su WH, Lee, Yoon Heo (2024) Prevalence and contributing factors of anxiety and depression in patients with vestibular migraine. ENT J 103(5):305–312 Balaban CD, Thayer JF (2001) Neurological bases for balance–anxiety links. J Anxiety Disord 15(1–2):53–79 Jacobson GP, Newman CW (1990) The development of the dizziness handicap inventory. Arch Otolaryngol neck Surg 116(4):424–427 Feng S, Zang J (2023) The effect of accompanying anxiety and depression on patients with different vestibular syndromes. Front Aging Neurosci 15:1208392 Tables Table 1. Demographic characteristics of studied participants (n=770) Variable Patients (n=385) Controls (n=385) Test of significance p-value No. % No. % Sex Male Female 169 216 43.9 56.1 173 212 44.9 55.1 χ2=0.08 0.772 Age (Years) Mean ±SD Range 37.94 ±11.49 18-62 37.98 ±11.51 18-62 t=0.05 0.960 SD: Standard deviation, χ2: Chi-squared test, t: Student t test, p-value: probability value. Table (2): Comparison between patients and controls regarding anxiety and depression before attack (n=770) Variable Patients=385 Controls=385 Test of significance p-value No. % No. % - Anxiety prevalence 0 0 0 0 --- --- -Anxiety score Mean ±SD Range 0.46 ±0.56 0-2 0.43 ±0.53 0-2 U=0.35 0.723 (NS) -Depression prevalence 0 0 0 0 --- --- -Depression score Mean ±SD Range 0.19 ±0.44 0-2 0.18 ±0.42 0-2 U=0.22 0.825 (NS) NS: Non-significant, SD: Standard deviation, U: Mann-Whitney U test Table 3. Anxiety and depression before, during the attack and after treatment among BPPV patients (n=385). Variable Before attack During attack After treatment p-value Post Hoc test No. % No. % No. % Anxiety prevalence 0 0 227 59 5 1.3 <0.001* P1<0.001* P2<0.001* P3=0.063 score (Mean ±SD) 0.45 ±0.56 9.24 ±2.03 0.57 ±1.24 <0.001* P1<0.001* P2<0.001* P3=0.432 Depression prevalence 0 0 117 30.4 2 0.5 <0.001* P1<0.001* P2<0.001* P3=0.500 Depression score (Mean ±SD) 0.19 ±0.44 7.17 ±2.81 0.28 ±0.95 <0.001* P1<0.001* P2<0.001* P3=0.269 *: Statistically significant, SD: Standard deviation P1: P-value between before attack and during attack P2: P-value between during attack and after treatment P3: P-value between before attack and after treatment Table 4. Correlation between anxiety & depression scores during the attack and age, clinical criteria of attacks and DHI. Variable Anxiety score Depression score r p-value r p-value Age (Years) -0.033 0.513 -0.133 0.027* Duration of Disease (Months) 0.822 <0.001* 0.695 <0.001* Severity of attack 0.001 0.982 -0.028 0.583 Duration of attack (Minutes) 0.013 0.799 0.011 0.833 Number of attacks 0.973 <0.001* 0.734 <0.001* DHI 0.615 <0.001* 0.641 <0.001* Anxiety score --- --- 0.744 <0.001* *: Statistically significant, DHI: Dizziness handicap inventory, r: Correlation coefficient Table 5. Anxiety and depression in relation to recurrence among studied patients (n=385). Variable Single attack (n=56) Recurrent (n=329) Test of significance p-value No. % No. % Before attack - Anxiety prevalence 0 0 0 0 --- --- - Anxiety score Mean ±SD 0.39 ±0.53 0.47 ±0.57 U=0.87 0.387 - Depression prevalence 0 0 0 0 --- --- - Depression score Mean ±SD 0.09 ±0.29 0.21 ±0.46 U=1.79 0.073 During attack - Anxiety prevalence 0 0 227 69 χ2=94.15 <0.001* - Anxiety score Mean ±SD 6.38 ±0.68 9.74 ±1.76 t=14.09 <0.001* - Depression prevalence 0 0 117 35.6 χ2=28.61 <0.001* - Depression score Mean ±SD 3.80 ±1.85 7.77 ±2.53 U=9.22 <0.001* After treatment - Anxiety prevalence 0 0 5 1.5 FE 1.000 - Anxiety score Mean ±SD 0.09 ±0.29 0.66 ±1.32 U=4.34 <0.001* - Depression prevalence 0 0 2 0.6 FE 1.000 - Depression score Mean ±SD 0.07 ±0.26 0.32 ±1.01 U=2.32 0.020* SD: Standard deviation, U: Mann-Whitney U test, FE: Fisher exact test, p-value: probability value. * significant Additional Declarations No competing interests reported. Supplementary Files Supplementarydata.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 17 Apr, 2025 Reviews received at journal 17 Apr, 2025 Reviewers agreed at journal 15 Apr, 2025 Reviewers agreed at journal 15 Apr, 2025 Reviewers invited by journal 14 Apr, 2025 Submission checks completed at journal 24 Mar, 2025 First submitted to journal 22 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5485840","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":443096454,"identity":"5edbd2ea-de47-4438-af71-9565f56cbbdd","order_by":0,"name":"Hoda Abd-Elhamid","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIiWNgGAWjYBACAzBiYGZgYzjY+ADI4uEjWgs/4+HDIBYPG9FaJJuPpUmARAhqMWdv3vi5oMZa3uDYGbPKrzl2MmwMzA8f3cCjxbLnWLH0jGPphhvOnDG7LbstGegwNmPjHHwOu5FjIM3Ddphxww2gFsltzEAtPGzSBLQY/+b5d9h+w/03ZsWS2+qJ0mImzdt2OHFmw7E0xo/bDhOh5cyxMmvevvTkfobDh6UZtx3nYWMm5JfjzZtv83yztm0DRuXHn9uq7fnZmx8+xqcFBTDzgElilYMA4w9SVI+CUTAKRsGIAQAJ90sxh7xb7QAAAABJRU5ErkJggg==","orcid":"","institution":"Menoufia University","correspondingAuthor":true,"prefix":"","firstName":"Hoda","middleName":"","lastName":"Abd-Elhamid","suffix":""},{"id":443096455,"identity":"1d0d3d70-f8ee-4d2a-a3b3-b691b657afd0","order_by":1,"name":"Ahmed El Abedein","email":"","orcid":"","institution":"Menoufia University","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"El","lastName":"Abedein","suffix":""},{"id":443096457,"identity":"7488a7db-dc51-450d-b98b-07203817e2c0","order_by":2,"name":"Ahmed Abd El Moniam Ragab","email":"","orcid":"","institution":"Menoufia University","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"Abd El Moniam","lastName":"Ragab","suffix":""},{"id":443096459,"identity":"bb562020-aeec-4e8f-8a6c-ede6799436ca","order_by":3,"name":"Asmaa Salah Mokhtar","email":"","orcid":"","institution":"Menoufia University","correspondingAuthor":false,"prefix":"","firstName":"Asmaa","middleName":"Salah","lastName":"Mokhtar","suffix":""}],"badges":[],"createdAt":"2024-11-19 19:08:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5485840/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5485840/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":80786579,"identity":"a2d48a8f-2d46-4f16-83a0-1c6ec8e8f0d2","added_by":"auto","created_at":"2025-04-17 06:01:16","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":111711,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRelation between dizziness handicapping, anxiety and depression among studied patients\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5485840/v1/466c03db05e908d0c0a897af.jpeg"},{"id":80786912,"identity":"5cf54929-6d02-4eb6-97f2-14a90a4c11aa","added_by":"auto","created_at":"2025-04-17 06:02:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1075835,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5485840/v1/8877da8e-1da7-4af5-8ed0-dac0b8f0981e.pdf"},{"id":80785249,"identity":"9876b733-39f2-4bcd-8ca4-78c057dd0702","added_by":"auto","created_at":"2025-04-17 05:40:27","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":27039,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarydata.docx","url":"https://assets-eu.researchsquare.com/files/rs-5485840/v1/eb619b078fccd313b8fc7528.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Does BPPV affect the psychological state of patients? ","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eApproximately 15% to over 20% of adults experience Dizziness, including vertigo each year. Vestibular vertigo represents about 25% of these cases. Prevalence tends to increase with age and is two to three times more in women than men (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBenign paroxysmal positional vertigo (BPPV) is the most prevalent disorder affecting the vestibular system (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), exhibiting a lifetime prevalence of 2.4% (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).Dizziness related to head movements may be caused by BPPV ,vestibular migraine and central lesions. BPPV is characterized by episodes of rotational vertigo, triggered by changes in head position relative to gravity. Spontaneous recovery occurs in about 20% of cases within a month and in about 50% within 3 months (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eVertigo and dizziness symptoms play a substantial role in the overall burden of disease and significantly impact daily activities and quality of life. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) Many patients suffering from vertigo may experience secondary psychiatric disorders. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Yeo et al. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) revealed that patients with BPPV are at increased risk of developing anxiety disorders in comparison with controls. The fear of sudden and unpredictable vertigo can adversely affects patients, increasing their anxiety levels regardless of any previous experiences with this condition (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMost of the previous studies on the association between BPPV, anxiety and depression didn't include control group and didn't study the relation between anxiety, depression and recurrence of BPPV. The objective of this study was therefore to investigate the prevalence of anxiety and depression in a BPPV group and to correlate the prevalence of anxiety and depression with recurrence of the attacks.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cp\u003eThis case control study was conducted on 770 participants who were assessed in the audio vestibular medicine clinic, Menoufia university hospital, El-Menoufia governorate, Egypt (patients were referred from many centers all over the governorate and neighbouring governorates), during the period from September 2023 to October 2024. Participants in this study were divided into 2 groups: study group, consisted of 385 subjects of BPPV patients and control group, consist of 385 normal subjects selected from the relatives of the patients.\u003c/p\u003e \u003cp\u003eInclusion criteria: Subjects diagnosed as BPPV according to British society of audiology guidelines (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) with the exclusion of patients with psychiatric disorders or cognitive dysfunction, patients with vertigo due to causes other than the BPPV and any medical condition that may interfere with the psychological state.\u003c/p\u003e \u003cp\u003eAll patients included in the current study were subjected to: 1. full history taking including a complete description of the dizziness complaint regarding: character, frequency of the attack, number of the attacks, severity of the attack, duration of the attack, duration of the disease, precipitating and relieving factors, as well as any accompanying symptoms. 2. office test (positioning and gait tests). 3. Videonystagmography VNG model, interacoustic (micromedical). The following tests were done (spontaneous and gaze testing, occulomotor testing, positioning \u0026amp; positional test and caloric test) testing and interpretation were done according to British society of audiology guidelines (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). 4. Arabic version of dizziness handicap inventory (DHI): which consists of 25 items to assess the self-perceived handicap level due to dizziness. It was graded as: mild disorder score between (0\u0026ndash;30), moderate disorder score between (31\u0026ndash;60) and severe disorder score between (61\u0026ndash;100) (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). 5. Arabic version of hospital anxiety and depression scale (HADS): was used to screen for anxiety and depression in medical outpatient settings, it consists of 14 items on a 4-points scale (0\u0026ndash;3): 7 items assess anxiety with cut-off point 8.5 and 7 items assess depression with cut of point 9.5.The score of each subscale is the sum of the 7 items ranging (0\u0026ndash;21), the total score is the sum of 14 items. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe results were tabulated and statistically analyzed using SPSS V.25 (IBM Corporation, 1 Orchard Rd, Armonk, NY 10504, USA) and Microsoft Excel 2019 (Microsoft Corporation, One Microsoft Way Redmond, WA 98052\u0026thinsp;\u0026minus;\u0026thinsp;6399, USA). The Kolmogorov- Smirnov was used to verify the normality of the distribution of variables. The mean and standard deviation were used for quantitative data analysis, the frequency and relative percentage were used for qualitative data analysis. The Chi-square test was applied to compare the qualitative categorical data between the two groups. Fischer exact test for 2 x 2 tables when expected cell count of more than 25% of cases was less than 5. An independent t-test which is a parametric test was used to compare between the normally distributed variables. Mann-Whitney test which is a non-parametric test was used for comparison between the abnormal distributed variables in the two groups. P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThere was no statistically significant difference between patients and controls regarding their sex and age distribution \u003cstrong\u003e(\u003c/strong\u003e\u003cstrong\u003eTable 1).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study consisted of 385 BPPV patients: 384 patients were diagnosed with posterior canal BPPV, 1 patient was diagnosed with lateral canal BPPV. The mean duration of the attacks was 1.49\u0026plusmn;0.49 months, 380 (98%) patients suffer from severe attacks and 5 (2%) patients had moderate attacks. According to Arabic version of DHI, 340 (88.3%) patients had severe handicap, 44 (11.6%) patients had moderate handicap, and 1 (0.1%) patient had mild handicap, the total mean score was 59\u0026plusmn;9.2 during attack, 0.00\u0026plusmn;0.00 after attack. The mean duration of BPPV was 9.26\u0026plusmn;3.78 months, 377 (97.9%) patients diagnosed with canalithiasis and 8 (2.1%) patients diagnosed with cupulolithiasis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(Table 2)\u003c/strong\u003e shows comparison between the studied groups regarding prevalence and score of anxiety and depression before the attacks of BPPV. There was no statistically significant difference between patients and controls regarding anxiety and depression (prevalence and score) before BPPV attack.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(Table 3)\u003c/strong\u003e shows anxiety and depression before, during the attack and after treatment among BPPV patients. There was a statistically significant increase in anxiety (score and prevalence) and depression (score and prevalence) in patients during the attack than before the attack and after treatment, there was no statistically significant difference in anxiety (score and prevalence), depression (score and prevalence) in patients before the attack and after treatment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(Table 4)\u003c/strong\u003e shows the correlation between anxiety \u0026amp; depression scores during the attack and patients variables: age, clinical criteria of attacks and DHI. There was a positive significant correlation between anxiety score during the attack and duration of BPPV, number of attacks and DHI score. There was a positive significant correlation between depression score during attack and duration of BPPV, number of attacks, DHI score and anxiety score, while there was a negative significant correlation between depression score during the attack and age.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(Figure 1)\u003c/strong\u003e shows the correlation between DHI and anxiety \u0026amp; depression among studied patients. The severity of DHI was significantly correlated with anxiety (chi-square test,\u0026nbsp; x\u003csup\u003e2\u003c/sup\u003e = 22.26, p-value \u0026lt; 0.01) and depression (chi-square test, x\u003csup\u003e2\u003c/sup\u003e = 7.09, P-value 0.020).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(Table 5)\u0026nbsp;\u003c/strong\u003eshows anxiety and depression in relation to recurrence of BPPV attacks among the studied patients. There was no statistically significant difference between the scores and prevalence of anxiety and depression in patients with recurrent attacks and those with single attack (before the attack), however during the attack, there was a statistically significant increase in prevalence and score of anxiety and depression in patients with recurrent attacks than those with single attack. Also, after treatment of BPPV there was a statistically significant difference in anxiety and depression score in patients with recurrent attacks and those with single attack, while there was no statistically significant difference in prevalence of anxiety and depression in patients with recurrent attacks and those with single attack.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDizziness or vertigo represents one of the most frequently reported complaints in clinical medicine, 80% of cases (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), BPPV is among the most prevalent peripheral vestibular disorders 2.4% (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). BPPV is associated with depression (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), and other anxiety disorders (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHADS: in the current study, HADS was used for assessment of anxiety and depression, HADS was developed to provide a reliable, valid \u0026amp; easy tool to identify anxiety \u0026amp; depression in medical patients (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe current study showed a significant increase in anxiety and depression (score and prevalence) in BPPV patients during attack. Kim et al., (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) reported that patients diagnosed with BPPV showed a higher prevalence of psychiatric disorders as depression and generalized anxiety than in general population (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the current study, the prevalence of anxiety and depression during the attacks was 59% \u0026amp; 30% respectively also 1.5% \u0026amp; 0.5% of BPPV patient had anxiety and depression respectively after treatment, Omara et al., (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) revealed anxiety and depression in 29% and 7% of their patients respectively .\u003c/p\u003e \u003cp\u003eThis study showed that there was a statistically significant increase in anxiety \u0026amp; depression (score and prevalence) in patients with recurrent attacks than those with single attack. Our study was close to the study obtained by Wei et al., (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) who found that recurrent attacks of BPPV can cause chronic worry and aggravates the psychosomatic symptoms of anxiety. Additionally, Shu et al., (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) observed that anxiety and obsessive convulsive disorders were associated with a heightened risk of the first BPPV recurrence. Anxiety and depression were also reported in other episodic vertiginous conditions, Kim et al.,2023 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) reported anxiety and depression in 49% and 32% respectively in vestibular migraine patients.\u003c/p\u003e \u003cp\u003eWei et al., (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) demonstrated that anxiety-depression status significantly reduces the patients\u0026rsquo; satisfaction and increases the risk of recurrence in BPPV. Previous studies provide several possible explanations. First, anxiety and depression were correlated with a chronic low-grade inflammatory response. This could increase oxidative and nitrosative stress and aggravate vestibular degeneration, causing difficulties in relocation and reabsorption of the dislodged otoliths (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Second, anxiety leads to a neuroendocrine response dysfunction that can alter the blood flow of the inner ear and disrupt BPPV recovery. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Third, there was a link between the vestibular and emotional processing systems. Neurotransmitters and neuroanatomical regions responsible for the vestibular systems and emotional responses share similarities. Parabrachial nuclei provides interconnection between vestibular nuclei and brain regions involved in the response to fear and anxiety, both areas affect the autonomic system (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). This makes it clear that it is mandatory to overcome anxiety and/or depression that result from BPPV to achieve complete recovery of the condition.\u003c/p\u003e \u003cp\u003eThe DHI has validated its role as an effective tool for recording the impacts of vestibular and/or balance disorders in the form of disability and handicaps (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). In the current study the severity of DHI was correlated to anxiety and depression score, Ketola et al., (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) reported that patients suffering from high psychological distress level tend to have increased (DHI) scores. These findings suggest that patients suffering from dizziness and high levels of psychological distress may report more vertigo symptoms, specifically those having both anxiety and depression. Feng and Zang, (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) declared that patients with comorbid anxiety or depression experienced more severe vertigo which adversely affected their somatic symptoms, emotional state, and social function.\u003c/p\u003e \u003cp\u003eThe present study showed that anxiety and depression score during the attacks has a significant positive correlation with duration of disease, number and severity of attacks and DHI score. increased duration, recurrence of disease and severity of DHI affect patients\u0026rsquo; quality of life and daily activities so, increasing burden of disease while there was a negative significant correlation between depression score during attack and age.\u003c/p\u003e \u003cp\u003eFinally, BPPV had a psychological impact on the patients, the current study revealed high level of anxiety \u0026amp; depression in BPPV patients during the attacks which was correlated to the severity of symptoms also recurrence of the attacks increase the psychological burden over the patients. It\u0026rsquo;s important to assess the prevalence of anxiety \u0026amp; depression in BPPV patients as the presence of anxiety \u0026amp; depression could aggravate vertigo itself, affect the quality of life, increase the recurrence of attacks and affect the outcome of treatment. These patients required special attention to treat anxiety \u0026amp; depression concurrently with BPPV. Patients move in viscous circuit as each of them can increase the prevalence of the other (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe current study had some limitations: almost all the cases had posterior canal BPPV, only 1 case had lateral canal BPPV, no cases with anterior canal BPPV were involved in the study. The authors couldn\u0026rsquo;t compare between patients with canalithiasis and cupulolithiasis due to the very small number of cupulolithiasis cases. Also, simple screening questionnaires were used in the assessment of anxiety and depression.\u003c/p\u003e \u003cp\u003eFurther studies using diagnostic tools should be implemented in the diagnosis of psychological impact of dizziness.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eA high prevalence of anxiety and depression in BPPV group in comparison to controls. The prevalence of anxiety and depression was significantly correlated with duration of disease, recurrence of attacks and DHI score. Anxiety and depression should be treated concurrently with BPPV to improve the outcome of treatment and quality of life.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consen\u003c/strong\u003et: a written informed consent was obtained from all the participants. The study plan was approved by the local ethical committee of faculty of medicine, Menoufia, Egypt under number of 9/2023 ENT 17.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e no funds were obtained.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eContributor 1 Contributor 2 Contributor 3 Contributor 4Concepts \u0026radic; \u0026radic; Design \u0026radic; \u0026radic; Definition of intellectual content \u0026radic; \u0026radic; Literature search ✓ \u0026radic; \u0026radic;Clinical studies \u0026radic; \u0026radic; \u0026radic; \u0026radic;Experimental studies Data analysis \u0026radic; Statistical analysis \u0026radic; \u0026radic;Manuscript preparation \u0026radic; \u0026radic; ✓ ✓Manuscript editing \u0026radic; \u0026radic; \u0026radic; ✓Manuscript review \u0026radic; \u0026radic; \u0026radic; \u0026radic;Guarantor \u0026radic; \u0026radic; \u0026radic; \u0026radic;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eIljazi A, Ashina H, Lipton RB, Chaudhry B, Al-Khazali HM, Naples JG et al (2020) Dizziness and vertigo during the prodromal phase and headache phase of migraine: a systematic review and meta-analysis. Cephalalgia. 2020;40(10):1095\u0026ndash;103\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgrawal Y, Ward BK, Minor LB (2013) Vestibular dysfunction: prevalence, impact and need for targeted treatment. J Vestib Res Equilib Orientat 23(3):113\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T et al (2017) Clinical practice guideline: benign paroxysmal positional vertigo (update). Otolaryngol Neck Surg 156(3suppl):S1\u0026ndash;47\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim HJ, Lee JO, Choi JY, Kim JS (2020) Etiologic distribution of dizziness and vertigo in a referral-based dizziness clinic in South Korea. J Neurol 267(8):2252\u0026ndash;2259\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaplan GG, Windsor JW (2021) The four epidemiological stages in the global evolution of inflammatory bowel disease. 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Recommended Procedure: (2015) Vestibular assessment - eye movement recordings. Br Soc Audiol 38(11):1\u0026ndash;43\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlsanosi AA (2012) Adaptation of the dizziness handicap inventory for use in the Arab population. Neurosci J 17(2):139\u0026ndash;144\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoaty AS, Talaat HS, Mehrez MG (2021) Prevalence of anxiety and depression in dizzy patients using Arabic hospital anxiety and depression scale. Menoufia Med J 34(2):420\u0026ndash;426\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eParnes LS, Agrawal SK, Atlas J (2003) Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ 169(7):681\u0026ndash;693\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHagr A (2009) Comorbid psychiatric conditions of benign paroxysmal positional vertigo. 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Egypt J Otolaryngol 38(1):143\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWei W, Sayyid ZN, Ma X, Wang T, Dong Y (2018) Presence of anxiety and depression symptoms affects the first time treatment efficacy and recurrence of benign paroxysmal positional vertigo. Front Neurol 9:178\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShu Y, Liao N, Fang F, Shi Q, Yan N, Hu Y (2023) The relationship between psychological conditions and recurrence of benign paroxysmal positional vertigo: a retrospective cohort study. BMC Neurol 23(1):137\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim T, Su WH, Lee, Yoon Heo (2024) Prevalence and contributing factors of anxiety and depression in patients with vestibular migraine. ENT J 103(5):305\u0026ndash;312\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBalaban CD, Thayer JF (2001) Neurological bases for balance\u0026ndash;anxiety links. J Anxiety Disord 15(1\u0026ndash;2):53\u0026ndash;79\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJacobson GP, Newman CW (1990) The development of the dizziness handicap inventory. Arch Otolaryngol neck Surg 116(4):424\u0026ndash;427\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeng S, Zang J (2023) The effect of accompanying anxiety and depression on patients with different vestibular syndromes. Front Aging Neurosci 15:1208392\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eDemographic characteristics of studied participants (n=770)\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"621\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatients (n=385)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 147px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControls (n=385)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTest of significance\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMale\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFemale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e169\u003c/p\u003e\n \u003cp\u003e216\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e43.9\u003c/p\u003e\n \u003cp\u003e56.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e173\u003c/p\u003e\n \u003cp\u003e212\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e44.9\u003c/p\u003e\n \u003cp\u003e55.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e\u0026chi;2=0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003e0.772\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 139px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (Years)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMean \u0026plusmn;SD\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eRange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 147px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e37.94 \u0026plusmn;11.49\u003c/p\u003e\n \u003cp\u003e18-62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 147px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e37.98 \u0026plusmn;11.51\u003c/p\u003e\n \u003cp\u003e18-62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003et=0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.960\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eSD: Standard deviation, \u0026chi;2: Chi-squared test, t: Student t test, p-value: probability value.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable (2): Comparison between patients and controls regarding anxiety and depression before attack (n=770)\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"659\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatients=385\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eControls=385\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTest of significance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e- Anxiety prevalence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-Anxiety score\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMean \u0026plusmn;SD\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eRange\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.46 \u0026plusmn;0.56\u003c/p\u003e\n \u003cp\u003e0-2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.43 \u0026plusmn;0.53\u003c/p\u003e\n \u003cp\u003e0-2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eU=0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.723\u003c/p\u003e\n \u003cp\u003e(NS)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-Depression \u0026nbsp;prevalence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e---\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-Depression score\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMean \u0026plusmn;SD\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eRange\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.19 \u0026plusmn;0.44\u003c/p\u003e\n \u003cp\u003e0-2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.18 \u0026plusmn;0.42\u003c/p\u003e\n \u003cp\u003e0-2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eU=0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.825\u003c/p\u003e\n \u003cp\u003e(NS)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eNS: Non-significant, SD: Standard deviation, U: Mann-Whitney U test\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003eAnxiety and depression before, during the attack and after treatment among BPPV patients (n=385).\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"722\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBefore attack\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuring attack\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAfter treatment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePost Hoc\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnxiety\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eprevalence\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e227\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eP1\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eP2\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eP3=0.063\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 163px;\"\u003e\n \u003cul\u003e\n \u003cli\u003escore (Mean \u0026plusmn;SD)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.45 \u0026plusmn;0.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e9.24 \u0026plusmn;2.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.57 \u0026plusmn;1.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eP1\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eP2\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eP3=0.432\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDepression\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003eprevalence\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e117\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 64px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e30.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eP1\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eP2\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eP3=0.500\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 163px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDepression\u003c/strong\u003e\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003escore (Mean \u0026plusmn;SD)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.19 \u0026plusmn;0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7.17 \u0026plusmn;2.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.28 \u0026plusmn;0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eP1\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eP2\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eP3=0.269\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e*: Statistically significant, SD: Standard deviation\u003c/p\u003e\n\u003cp\u003eP1: P-value between before attack and during attack\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eP2: P-value between during attack and after treatment\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eP3: P-value between before attack and after treatment\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4.\u0026nbsp;\u003c/strong\u003eCorrelation between anxiety \u0026amp; depression scores during the attack and age, clinical criteria of attacks and DHI.\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"629\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 233px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnxiety score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 206px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDepression score\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e\u003cstrong\u003er\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e\u003cstrong\u003er\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (Years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e-0.033\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e0.513\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e-0.133\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.027*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of Disease (Months)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e0.822\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e0.695\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeverity of attack\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e0.982\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e-0.028\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.583\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration of attack (Minutes)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e0.013\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e0.799\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e0.011\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e0.833\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNumber of attacks\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e0.973\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e0.734\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDHI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e0.615\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e0.641\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 190px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnxiety score\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e---\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 111px;\"\u003e\n \u003cp\u003e0.744\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e*: Statistically significant, DHI: Dizziness handicap inventory, r: Correlation coefficient\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5.\u0026nbsp;\u003c/strong\u003eAnxiety and depression in relation to recurrence among studied patients (n=385).\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"584\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 157px;\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 139px;\"\u003e\n \u003cp\u003eSingle attack (n=56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 137px;\"\u003e\n \u003cp\u003eRecurrent (n=329)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 85px;\"\u003e\n \u003cp\u003eTest of significance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 66px;\"\u003e\n \u003cp\u003ep-value\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 584px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBefore attack\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e- Anxiety prevalence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e- Anxiety score\u003c/p\u003e\n \u003cp\u003eMean \u0026plusmn;SD\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.39 \u0026plusmn;0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.47 \u0026plusmn;0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eU=0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.387\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e- Depression prevalence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e---\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e- Depression score\u003c/p\u003e\n \u003cp\u003eMean \u0026plusmn;SD\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.09 \u0026plusmn;0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 137px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.21 \u0026plusmn;0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eU=1.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.073\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 584px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuring attack\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e- Anxiety prevalence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e227\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026chi;2=94.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e- Anxiety score\u003c/p\u003e\n \u003cp\u003eMean \u0026plusmn;SD\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6.38 \u0026plusmn;0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 137px;\"\u003e\n \u003cp\u003e9.74 \u0026plusmn;1.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003et=14.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e- Depression prevalence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e117\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e35.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026chi;2=28.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e- Depression score\u003c/p\u003e\n \u003cp\u003eMean \u0026plusmn;SD\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 139px;\"\u003e\n \u003cp\u003e3.80 \u0026plusmn;1.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 137px;\"\u003e\n \u003cp\u003e7.77 \u0026plusmn;2.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eU=9.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 584px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAfter treatment\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e- Anxiety prevalence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eFE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e- Anxiety score\u003c/p\u003e\n \u003cp\u003eMean \u0026plusmn;SD\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 139px;\"\u003e\n \u003cp\u003e0.09 \u0026plusmn;0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 137px;\"\u003e\n \u003cp\u003e0.66 \u0026plusmn;1.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eU=4.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e- Depression prevalence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 49px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eFE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 157px;\"\u003e\n \u003cp\u003e- Depression score\u003c/p\u003e\n \u003cp\u003eMean \u0026plusmn;SD\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 139px;\"\u003e\n \u003cp\u003e0.07 \u0026plusmn;0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 137px;\"\u003e\n \u003cp\u003e0.32 \u0026plusmn;1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eU=2.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.020*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eSD: Standard deviation, U: Mann-Whitney U test, FE: Fisher exact test, p-value: probability value. * significant\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-journal-of-otolaryngology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [The Egyptian Journal of Otolaryngology](https://ejo.springeropen.com/)","snPcode":"43163","submissionUrl":"https://submission.springernature.com/new-submission/43163/3","title":"The Egyptian Journal of Otolaryngology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Anxiety, Benign Paroxysmal Positional Vertigo, Depression, Dizzy Patients, Risk Factors","lastPublishedDoi":"10.21203/rs.3.rs-5485840/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5485840/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eBenign paroxysmal positional vertigo (BPPV) is recognized as one of the most prevalent peripheral vestibular disorders, with a one-year prevalence rate of 1.6% and a lifetime prevalence rate of 2.4%.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eto assess the prevalence of anxiety and depression in BPPV patients.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study comprised 385 participants with BPPV and 385 normal controls. all participants subjected to full history taking, basic audiological evaluation, videonystagmography, Arabic version of Dizziness handicap inventory and Arabic version of Hospital anxiety and depression scale.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThere were insignificant differences between patients and controls regarding their sex and age distribution. In this study 227 (59%) of patients have anxiety and 117 (30.4%) of patients have depression. There was no statistically significant difference between patients and controls regarding anxiety and depression before BPPV attack. There was a statistically significant increase in anxiety and depression in patients during the attack than before the attack and after treatment. There was a significant correlation between the score of anxiety and depression with the duration of the BPPV course, number of attacks and DHI score, also depression score showed positive correlation with anxiety score. The severity of DHI was significantly correlated with anxiety and depression.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe current study revealed a high prevalence of anxiety and depression in BPPV group which was significantly correlated with duration of disease, recurrence of attacks and DHI score. Anxiety and depression should be treated concurrently with BPPV to improve the outcome of treatment and quality of life.\u003c/p\u003e","manuscriptTitle":"Does BPPV affect the psychological state of patients? ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-17 05:32:22","doi":"10.21203/rs.3.rs-5485840/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-04-17T21:50:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-17T06:22:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"37707261098504236390431178609692121360","date":"2025-04-15T07:15:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"33213905232897432446811819652248670524","date":"2025-04-15T05:07:04+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-14T20:21:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-24T04:07:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"The Egyptian Journal of Otolaryngology","date":"2025-03-22T17:52:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-journal-of-otolaryngology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [The Egyptian Journal of Otolaryngology](https://ejo.springeropen.com/)","snPcode":"43163","submissionUrl":"https://submission.springernature.com/new-submission/43163/3","title":"The Egyptian Journal of Otolaryngology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9cb019ff-81f8-4670-a6a6-07abbf928ace","owner":[],"postedDate":"April 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-04-18T14:53:06+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-17 05:32:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5485840","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5485840","identity":"rs-5485840","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}