Associations between affect and dizziness symptoms: Ecological Momentary Assessment study in functional dizziness

Associations between affect and dizziness symptoms: Ecological Momentary Assessment study in functional dizziness | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Associations between affect and dizziness symptoms: Ecological Momentary Assessment study in functional dizziness Kazuaki Hashimoto, Takeaki Takeuchi, Kaho Tanobe, Noriko Takeda, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4453398/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract An association between dizziness symptoms and psychological factors has been hypothesized, but evaluating this through questionnaires alone risks recall bias. We aimed to clarify this relationship using the EMA method to reduce bias. Participants comprised 30 patients (16 with persistent postural perceptual dizziness (PPPD), 14 with the others) aged 20–74 years with functional dizziness symptoms. Participants were sent survey forms at random times for 10 days, 890 hierarchical data were obtained. Survey forms were included the Subjective Dizziness Symptoms (SDS) evaluated as medical condition and the Positive and Negative Affect Schedule assessed as affects. Level 1 model revealed: Positive affect (PA) had a negative fixed effect on SDS in both groups, but the group-mean centering of PA was significant only in the others group. Level 2 model revealed: Negative affect (NA) had a significant fixed effect in both groups; however, the interaction between PA and NA was significant only in the others group. A simple slope analysis of the others group revealed that, in participants with higher NA, reduced momentary SDS was associated with higher PA. Functional dizziness symptoms were more severe when PA was low and NA high. Treatment for functional dizziness pathology could begin with PA. Biological sciences/Psychology Health sciences/Medical research Health sciences/Neurology Affect Ecological Momentary Assessment Persistent Postural Perceptual Dizziness Somatic Symptoms Disorder Figures Figure 1 Introduction Although the frequency of dizziness in primary care is approximately 5%, it is a frequent symptom that most people experience at least once in their lives [ 1 , 2 ]. However, reports suggest that the cause of dizziness cannot be identified in up to 80% of cases [ 3 ]. A constant state of some functional dizziness is referred to as persistent postural perceptual dizziness (PPPD). Although the exact prevalence of PPPD is unknown, it has been reported to be the second most common disorder in dizziness clinics, with a frequency of approximately 15% [ 4 , 5 ]. According to the prevailing hypothesis, dizziness symptoms in PPPD originate from psychological disorders that gradually become fixed [ 6 ]. Functional dizziness causes dysfunction of the hippocampus and insular cortex, which have important links to psychiatric symptoms [ 6 ]. Psychiatric symptoms such as anxiety [ 7 ] and depression [ 8 ] are highly associated with dizziness and are frequent comorbidities [ 9 ]. Furthermore, some aspects of PPPD are similar to the psychiatric definition of somatic symptom disorders [ 10 , 11 ]. A neurophysiological mechanism called central sensitization, which is associated with severe somatic symptomatology, may be related to dizziness symptoms in PPPD [ 12 ]. Psychological disorders are often influenced by cumulative daily affectional loads. Affects are divided into Positive and Negative, and each is associated with psychological concerns, such as anxiety and depression [ 13 – 15 ]. In a previous study, higher Positive affect was associated with lower functional somatic symptoms [ 16 ]. One study showed that there is a stronger association between stress and health outcomes [ 17 ] and stronger somatic symptoms [ 18 ] when Negative affect is higher. Questionnaires are the most commonly used method for assessing psychological factors. However, questionnaires have limited usefulness because patients responded by recalling their own past states [ 19 ]. This drawback can be overcome by utilizing ecological momentary assessment (EMA), a method of instantaneous condition assessment that can be used in daily life. To the best of our knowledge, no study has examined the relationship between symptoms and psychological factors using EMA in patients with functional dizziness. Therefore, this study aimed to clarify the relationship between symptoms and affect in functional dizziness and the characteristics of PPPD. Methods Participants This study applied a longitudinal observational study design. Subjects were recruited from patients who regularly attended the Department of Psychosomatic Medicine at an urban university hospital. The recruitment period was from September 2021 to March 2024. Inclusion criteria were as follows: (1) between the ages of 20 and 74 years; (2) able to understand the purpose and process of the study and sign an informed consent form; (3) have had chronic dizziness symptoms lasting for more than 3 months; (4) able to respond immediately using a digital device. Exclusion criteria included diagnosis of: (1) schizophrenia spectrum disorder or other psychotic disorders; (2) dementia (such as Alzheimer’s dementia, vascular dementia, Parkinson’s disease dementia, and Lewy body dementia); (3) neurodevelopmental disorders (such as autism spectrum disorder, attention deficit/hyperactivity disorder, communication disabilities); (4) dissociative disorders; and (5) patients who could not be accurately assessed for any reason. A previous study [ 6 ] was referenced for the diagnosis of PPPD; diagnosis was made by a physician specializing in psychosomatic medicine. In total, 65 patients met the study criteria. Of the eligible patients, 31 agreed to participate in the study; one dropped out of the study, resulting in a final sample of 30 participants. Questionnaires The participants completed a cross-sectional assessment of their symptoms before participating in this study. First, participants were assessed for the intensity and characteristics of their subjective dizziness symptoms (SDS) using a single question that was assessed on an 11-point scale (0: mini, 10: max) to the question, “What is your perceived level of dizziness symptoms now?”. Next, they completed the Dizziness Handicap Inventory (DHI) [ 20 ] and the Niigata PPPD Questionnaire (NPQ) [ 21 ]. The DHI comprises 25 questions regarding the impairment of living functions caused by dizziness. The scores range from 0 to 100 points, with a score of 46 points or higher considered severe. The reliability and validity of the Japanese version of the DHI have been verified [ 22 ]. The NPQ evaluates the severity of PPPD and consists of three sub-items: upright posture/walking, movement, and visual stimulation scores. Each item is rated on a four-question Likert scale ranging from 0 to 6, with higher scores indicating a more severe disease [ 21 ]. We assessed comorbid psychological conditions in participants using the Hospital Anxiety and Depression Scales (HADS) [ 23 ]. The anxiety and depression scales are scored from 0 to 21 points, and each scale has been used as a clinical psychiatric index in general practice [ 24 ]. The Japanese version was confirmed reliable and valid [ 25 ]. In the EMA, participants were sent four survey forms per day at random times between 8:00 am and 8:00 pm for 10 consecutive days, beginning the day after entry. The survey forms included affect assessment items by SDS and the Positive and Negative Affect Schedule (PANAS) [ 13 ]. The PANAS consists of two scales, Positive and Negative, each of which is assessed using 10 questions. Higher scores on both items indicate stronger affect. To ensure immediacy, participants had to respond within 30 minutes of receiving the survey forms. Informed consent was obtained before the participants responded to the questionnaire, and they were provided with the option to stop the survey at any point. Participants were compensated with a prepaid card worth 1,000 yen when the response rate was less than 50%, 3,000 yen when the response rate was 50% or higher, or 6,000 yen when the response rate was 75% or higher. Data analysis The background factors of the PPPD and the others groups were compared using Fisher's test or the Mann–Whitney U test. By evaluating the correlation between the SDS and DHI using Pearson’s product–rate correlation coefficient, we confirmed that the SDS accurately reflected dizziness symptoms. We examined the associations between each group using a hierarchical linear model. In level 1 of this analysis, the objective variable was set to SDS, and the explanatory variables were Positive affect and the group mean centering of Positive affect. In level 2 of the analysis, models estimating the interaction between Positive and Negative affect were examined to evaluate the impact of Negative affect. When the estimated model showed an interaction, we performed a simple main effects analysis. IBM SPSS Statistics version 29 (IBM, Armonk, NY, USA) was used for statistical analyses. The significance level was set at less than 5%. Results The valid response rate was 74.2% (n = 890), and there was a significant strong positive association between SDS and DHI (correlation coefficient: 0.75, 95%; confidence interval: 0.53-0.87, p<0.001). The PPPD group consisted of 16 patients and the others group consisted of 14 patients. There were no clear differences in the demographic data between the two groups. By contrast, the PPPD group had significantly higher DHI, HADS depression, and NPQ scores than the others group. Next, the number of within-class correlations for each variable was calculated, and statistical significance confirmed that the data were hierarchical. The estimated models for the PPPD and others groups are shown in Tables 2 and 3. In the level 1 model for both groups, Positive affect had a negative fixed effect on SDS, but the group-mean centering of Positive affect was significant only in the others group. In the level 2 model estimating the interaction of Negative affect, Negative affect had a significant fixed effect in both groups; the interaction between Positive and Negative affect was significant only in the others group. As shown in Figure 1, a simple slope analysis revealed that the slope was significant only for those with higher Negative affect (1SD below the mean), indicating that reduced momentary SDS was associated with higher Positive affect in participants with higher Negative affect. However, the estimates for another slope (1SD above the mean) were not significant. Discussion In this study, functional dizziness was classified into two groups, PPPD and others, and the relationship between affect and symptoms was evaluated in each group using EMA. The results showed that high Positive affect may reduce the intensity of dizziness symptoms, whereas Negative affect may exacerbate the symptoms. In addition, the others group showed that Positive affect may decrease dizziness symptoms more when Negative affect is high, but this effect was not observed in the PPPD group. Positive and Negative affect are considered to represent two different emotional state dimensions, rather than two opposite poles of the same dimension [ 13 ], with Positive affect occupying a more relevant position in mental and physical health than Negative affect [ 26 ]. Psychological interventions that enhance Positive affect have been reported to be useful in treating somatic symptom disorders [ 27 ]. Psychological interventions that enhance Positive affect, which is a common comorbidity in PPPD, are also useful for depression and anxiety [ 6 ], which are common comorbidities in PPPD [ 28 – 30 ]. Considering the conceptual similarity of functional dizziness to somatic symptomatology and the fact that higher Positive affect was associated with lower dizziness symptoms in the present study under everyday conditions, we suggest that Positive affect may be a starting point for interventions in the treatment of functional dizziness. According to previous studies, vestibular rehabilitation was effective for dizziness symptoms in PPPD, while psychological status was not sufficiently improved [ 31 , 32 ]. Therefore, as a psychological intervention for PPPD, a combination of vestibular rehabilitation and cognitive behavioral therapy has been conducted [ 33 ]. Some cognitive behavioral therapies align well with positive psychology [ 34 ], and a previous study has reported that focusing on improving Positive affect may enhance the effects of cognitive-behavioral therapy [ 35 ]. In other words, combining vestibular rehabilitation with a cognitive behavioral therapy program that enhances Positive affect may have a more robust therapeutic effect. Negative affect is associated with dizziness symptoms associated with depression [ 8 ], which narrows the range of thought, action, and attention compared to Positive affect [ 36 ]. In addition, high Negative affect is associated with neuroticism in personality traits [ 37 ], and neuroticism is a characteristic personality trait of functional dizziness [ 38 ]. The fact that high Negative affect was associated with the intensity of dizziness symptoms in the present study further supports the results of previous studies. Negative affect was an influencing factor in the association between Positive affect and dizziness symptoms only in patients with functional dizziness other than PPPD in the present study. Psychological influences are added to the pathology that produces dizziness in PPPD, and the hypothesis of gradual symptom fixation has been proposed [ 6 ]. Thus, the others group may have included patients with pre-PPPD, and the results of this study can be interpreted as partial support for this possibility. Furthermore, our results support the report of a previous study [ 39 ] that antidepressants can be expected to have some benefit for functional dizziness, but the evidence is not sufficient for PPPD. However, comorbidity of psychiatric disorders such as depression are common in PPPD [ 9 ]. Considering that Negative and Positive affect are associated with the development and treatment of psychiatric disorders, therapeutic interventions for affect may be clinically important in a variety of functional dizziness conditions, including PPPD. Strengths and limitations This study is the first to directly demonstrate a previously unexplored relationship between functional dizziness and affect in daily life. However, there are some limitations to the interpretation of the results. First, because this was a single university hospital specializing in psychosomatic medicine, the sample size was small. In addition, the fact that patients who had difficulty completing questionnaires using digital devices in their daily lives were not recruited and that only patients attending a university hospital were recruited may have influenced the results. Second, this study did not necessarily recruit patients who were being treated for the first time; therefore, the effects of treatment history, treatment details, illness duration, and comorbidities cannot be ruled out. Owing to these limitations, the results of this study cannot be completely generalized; however, these issues will be resolved in the future by controlling for AI-based big data. Conclusions Using the EMA technique, we investigated the relationship between functional dizziness and affect in daily life. Functional dizziness symptoms were more severe when Positive affect was low. In patients with functional dizziness without PPPD, the association between Positive affect and symptoms was influenced by high Negative affect. Interventions for Positive and Negative affect may be the starting point for the treatment of functional dizziness. Declarations Acknowledgements This work was supported by a JSPS Grant-in-Aid for Scientific Research 21K13736. Author contributions KH designed the study protocol and wrote the manuscript. TT, KT, NT, and AK collected, analyzed, and discussed the interpretation of the data. MH designed the study and discussed the interpretation of the data. All authors reviewed the manuscript. Ethics Committee Approval This study was approved by the Toho University Medical Center Omori Hospital Ethics Committee, approval number: M23235 21095, with due consideration to the Helsinki Declaration, patient anonymity, and ethics. Written informed consent was obtained from all the participants prior to their enrollment in this study. Availability of data and material The datasets generated and analyzed during the current study are not publicly available because it was not permitted by the ethics committee, but are available from the corresponding author on reasonable request. Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article. 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Participant’s Characteristics with functional dizziness (n=30) Persistent Postural Perceptual Dizziness (n=16) The Others (n=14) P value Sex 0.99 Male 2 (12.5%) 2 (14.3%) Female 14 (87.5%) 12 (85.7%) Age (years±SD) 41.8 ± 12.1 43.3 ± 15.6 0.76 Habit Smoking 3 (18.8%) 1 (7.1%) 0.60 Drinking 3 (18.8%) 1 (7.1%) 0.60 Education (year) 14.0 [12.0-16.0] 12.0 [12.0-14.0] 0.18 Marriage 6 (37.5%) 6 (42.9%) 0.99 Medical therapy Antidepressant 11 (78.6%) 10 (71.4%) 0.99 Anxiolytics or Sleep medication 12 (75.0%) 7 (50.0%) 0.26 Subjective dizziness 5.8 ± 1.6 3.4 ± 1.7 <0.001 Questionnaire DHI 52.8 ± 11.6 34.4 ± 16.0 <0.01 NPQ 44.4 ± 9.9 18.5 ± 6.3 <0.001 HADS Anxiety 8.4 ± 3.1 6.1 ± 3.2 0.06 HADS Depression 10.2 ± 4.4 5.9 ± 4.9 <0.05 DHI: Dizziness Handicap Inventory，NPQ: Niigata PPPD Questionnaire， HADS: Hospital Anxiety and Depression Scale. Values are given as mean (±standard deviation) or median (inter quartile range). Table 2. A hierarchical linear model of the relationship between Subjective Dizziness Symptoms and Affect in the PPPD group (n=468) Independent variable Level 1 Level 2 coefficient Standard error Confidence Interval t value p-value coefficient Standard error Confidence Interval t value p-value 95% under 95% upper 95% under 95% upper Intercept 7.02 1.81 3.13 10.90 3.87 <0.01 4.43 0.45 3.47 5.39 9.88 <0.001 Positive -0.15 0.04 -0.23 -0.07 -4.07 <0.01 -0.16 0.03 -0.22 -0.10 -5.60 <0.001 Positive_gm 0.04 0.08 -0.14 0.22 0.46 0.65 0.02 0.06 -0.105 0.15 0.39 0.70 Negative 0.19 0.03 0.13 0.24 6.53 <0.001 Positive*Negative -0.001 0.003 -0.008 0.007 -0.15 0.88 gm: Grand-mean Centering, *: Interaction. Table 3. A hierarchical linear model of the relationship between Subjective Dizziness Symptoms and Affect in the others group (n=422) Independent variable Level 1 Level 2 coefficient Standard error Confidence Interval t value p-value coefficient Standard error Confidence Interval t value p-value 95% under 95% upper 95% under 95% upper Intercept 0.85 0.92 -1.15 10.90 0.92 0.37 2.75 0.44 1.80 3.71 6.28 <0.001 Positive -0.08 0.03 -0.15 -0.07 -2.66 <0.05 -0.09 0.02 -0.14 -0.04 -3.75 <0.01 Positive_gm 0.18 0.04 0.10 0.20 5.04 <0.001 0.09 0.04 -0.01 0.18 2.09 0.06 Negative 0.17 0.02 0.14 0.20 11.53 <0.01 Positive*Negative -0.005 0.001 -0.007 -0.002 -4.15 <0.001 gm: Grand-mean Centering, *: Interaction. Additional Declarations No competing interests reported. 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However, reports suggest that the cause of dizziness cannot be identified in up to 80% of cases [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. A constant state of some functional dizziness is referred to as persistent postural perceptual dizziness (PPPD). Although the exact prevalence of PPPD is unknown, it has been reported to be the second most common disorder in dizziness clinics, with a frequency of approximately 15% [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. According to the prevailing hypothesis, dizziness symptoms in PPPD originate from psychological disorders that gradually become fixed [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Functional dizziness causes dysfunction of the hippocampus and insular cortex, which have important links to psychiatric symptoms [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Psychiatric symptoms such as anxiety [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] and depression [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] are highly associated with dizziness and are frequent comorbidities [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Furthermore, some aspects of PPPD are similar to the psychiatric definition of somatic symptom disorders [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. A neurophysiological mechanism called central sensitization, which is associated with severe somatic symptomatology, may be related to dizziness symptoms in PPPD [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePsychological disorders are often influenced by cumulative daily affectional loads. Affects are divided into Positive and Negative, and each is associated with psychological concerns, such as anxiety and depression [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In a previous study, higher Positive affect was associated with lower functional somatic symptoms [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. One study showed that there is a stronger association between stress and health outcomes [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] and stronger somatic symptoms [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] when Negative affect is higher.\u003c/p\u003e \u003cp\u003eQuestionnaires are the most commonly used method for assessing psychological factors. However, questionnaires have limited usefulness because patients responded by recalling their own past states [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This drawback can be overcome by utilizing ecological momentary assessment (EMA), a method of instantaneous condition assessment that can be used in daily life. To the best of our knowledge, no study has examined the relationship between symptoms and psychological factors using EMA in patients with functional dizziness. Therefore, this study aimed to clarify the relationship between symptoms and affect in functional dizziness and the characteristics of PPPD.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThis study applied a longitudinal observational study design. Subjects were recruited from patients who regularly attended the Department of Psychosomatic Medicine at an urban university hospital. The recruitment period was from September 2021 to March 2024. Inclusion criteria were as follows: (1) between the ages of 20 and 74 years; (2) able to understand the purpose and process of the study and sign an informed consent form; (3) have had chronic dizziness symptoms lasting for more than 3 months; (4) able to respond immediately using a digital device. Exclusion criteria included diagnosis of: (1) schizophrenia spectrum disorder or other psychotic disorders; (2) dementia (such as Alzheimer\u0026rsquo;s dementia, vascular dementia, Parkinson\u0026rsquo;s disease dementia, and Lewy body dementia); (3) neurodevelopmental disorders (such as autism spectrum disorder, attention deficit/hyperactivity disorder, communication disabilities); (4) dissociative disorders; and (5) patients who could not be accurately assessed for any reason. A previous study [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] was referenced for the diagnosis of PPPD; diagnosis was made by a physician specializing in psychosomatic medicine. In total, 65 patients met the study criteria. Of the eligible patients, 31 agreed to participate in the study; one dropped out of the study, resulting in a final sample of 30 participants.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eQuestionnaires\u003c/h2\u003e \u003cp\u003eThe participants completed a cross-sectional assessment of their symptoms before participating in this study. First, participants were assessed for the intensity and characteristics of their subjective dizziness symptoms (SDS) using a single question that was assessed on an 11-point scale (0: mini, 10: max) to the question, \u0026ldquo;What is your perceived level of dizziness symptoms now?\u0026rdquo;. Next, they completed the Dizziness Handicap Inventory (DHI) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] and the Niigata PPPD Questionnaire (NPQ) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The DHI comprises 25 questions regarding the impairment of living functions caused by dizziness. The scores range from 0 to 100 points, with a score of 46 points or higher considered severe. The reliability and validity of the Japanese version of the DHI have been verified [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The NPQ evaluates the severity of PPPD and consists of three sub-items: upright posture/walking, movement, and visual stimulation scores. Each item is rated on a four-question Likert scale ranging from 0 to 6, with higher scores indicating a more severe disease [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe assessed comorbid psychological conditions in participants using the Hospital Anxiety and Depression Scales (HADS) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The anxiety and depression scales are scored from 0 to 21 points, and each scale has been used as a clinical psychiatric index in general practice [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The Japanese version was confirmed reliable and valid [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the EMA, participants were sent four survey forms per day at random times between 8:00 am and 8:00 pm for 10 consecutive days, beginning the day after entry. The survey forms included affect assessment items by SDS and the Positive and Negative Affect Schedule (PANAS) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The PANAS consists of two scales, Positive and Negative, each of which is assessed using 10 questions. Higher scores on both items indicate stronger affect. To ensure immediacy, participants had to respond within 30 minutes of receiving the survey forms. Informed consent was obtained before the participants responded to the questionnaire, and they were provided with the option to stop the survey at any point. Participants were compensated with a prepaid card worth 1,000 yen when the response rate was less than 50%, 3,000 yen when the response rate was 50% or higher, or 6,000 yen when the response rate was 75% or higher.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe background factors of the PPPD and the others groups were compared using Fisher's test or the Mann\u0026ndash;Whitney U test. By evaluating the correlation between the SDS and DHI using Pearson\u0026rsquo;s product\u0026ndash;rate correlation coefficient, we confirmed that the SDS accurately reflected dizziness symptoms. We examined the associations between each group using a hierarchical linear model. In level 1 of this analysis, the objective variable was set to SDS, and the explanatory variables were Positive affect and the group mean centering of Positive affect. In level 2 of the analysis, models estimating the interaction between Positive and Negative affect were examined to evaluate the impact of Negative affect. When the estimated model showed an interaction, we performed a simple main effects analysis. IBM SPSS Statistics version 29 (IBM, Armonk, NY, USA) was used for statistical analyses. The significance level was set at less than 5%.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe valid response rate was 74.2% (n = 890), and there was a significant strong positive association between SDS and DHI (correlation coefficient: 0.75, 95%; confidence interval: 0.53-0.87, p\u0026lt;0.001).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe PPPD group consisted of 16 patients and the others group consisted of 14 patients. There were no clear differences in the demographic data between the two groups. By contrast, the PPPD group had significantly higher DHI, HADS depression, and NPQ scores than the others group.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNext, the number of within-class correlations for each variable was calculated, and statistical significance confirmed that the data were hierarchical. The estimated models for the PPPD and others groups are shown in Tables 2 and 3. In the level 1 model for both groups, Positive affect had a negative fixed effect on SDS, but the group-mean centering of Positive affect was significant only in the others group. In the level 2 model estimating the interaction of Negative affect, Negative affect had a significant fixed effect in both groups; the interaction between Positive and Negative affect was significant only in the others group.\u003c/p\u003e\n\u003cp\u003eAs shown in Figure 1, a simple slope analysis revealed that the slope was significant only for those with higher Negative affect (1SD below the mean), indicating that reduced momentary SDS was associated with higher Positive affect in participants with higher Negative affect. However, the estimates for another slope (1SD above the mean) were not significant.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, functional dizziness was classified into two groups, PPPD and others, and the relationship between affect and symptoms was evaluated in each group using EMA. The results showed that high Positive affect may reduce the intensity of dizziness symptoms, whereas Negative affect may exacerbate the symptoms. In addition, the others group showed that Positive affect may decrease dizziness symptoms more when Negative affect is high, but this effect was not observed in the PPPD group. Positive and Negative affect are considered to represent two different emotional state dimensions, rather than two opposite poles of the same dimension [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], with Positive affect occupying a more relevant position in mental and physical health than Negative affect [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Psychological interventions that enhance Positive affect have been reported to be useful in treating somatic symptom disorders [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Psychological interventions that enhance Positive affect, which is a common comorbidity in PPPD, are also useful for depression and anxiety [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], which are common comorbidities in PPPD [\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Considering the conceptual similarity of functional dizziness to somatic symptomatology and the fact that higher Positive affect was associated with lower dizziness symptoms in the present study under everyday conditions, we suggest that Positive affect may be a starting point for interventions in the treatment of functional dizziness.\u003c/p\u003e \u003cp\u003eAccording to previous studies, vestibular rehabilitation was effective for dizziness symptoms in PPPD, while psychological status was not sufficiently improved [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Therefore, as a psychological intervention for PPPD, a combination of vestibular rehabilitation and cognitive behavioral therapy has been conducted [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Some cognitive behavioral therapies align well with positive psychology [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], and a previous study has reported that focusing on improving Positive affect may enhance the effects of cognitive-behavioral therapy [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. In other words, combining vestibular rehabilitation with a cognitive behavioral therapy program that enhances Positive affect may have a more robust therapeutic effect.\u003c/p\u003e \u003cp\u003eNegative affect is associated with dizziness symptoms associated with depression [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], which narrows the range of thought, action, and attention compared to Positive affect [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. In addition, high Negative affect is associated with neuroticism in personality traits [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], and neuroticism is a characteristic personality trait of functional dizziness [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. The fact that high Negative affect was associated with the intensity of dizziness symptoms in the present study further supports the results of previous studies.\u003c/p\u003e \u003cp\u003eNegative affect was an influencing factor in the association between Positive affect and dizziness symptoms only in patients with functional dizziness other than PPPD in the present study. Psychological influences are added to the pathology that produces dizziness in PPPD, and the hypothesis of gradual symptom fixation has been proposed [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Thus, the others group may have included patients with pre-PPPD, and the results of this study can be interpreted as partial support for this possibility. Furthermore, our results support the report of a previous study [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] that antidepressants can be expected to have some benefit for functional dizziness, but the evidence is not sufficient for PPPD. However, comorbidity of psychiatric disorders such as depression are common in PPPD [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Considering that Negative and Positive affect are associated with the development and treatment of psychiatric disorders, therapeutic interventions for affect may be clinically important in a variety of functional dizziness conditions, including PPPD.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThis study is the first to directly demonstrate a previously unexplored relationship between functional dizziness and affect in daily life. However, there are some limitations to the interpretation of the results. First, because this was a single university hospital specializing in psychosomatic medicine, the sample size was small. In addition, the fact that patients who had difficulty completing questionnaires using digital devices in their daily lives were not recruited and that only patients attending a university hospital were recruited may have influenced the results. Second, this study did not necessarily recruit patients who were being treated for the first time; therefore, the effects of treatment history, treatment details, illness duration, and comorbidities cannot be ruled out. Owing to these limitations, the results of this study cannot be completely generalized; however, these issues will be resolved in the future by controlling for AI-based big data.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eUsing the EMA technique, we investigated the relationship between functional dizziness and affect in daily life. Functional dizziness symptoms were more severe when Positive affect was low. In patients with functional dizziness without PPPD, the association between Positive affect and symptoms was influenced by high Negative affect. Interventions for Positive and Negative affect may be the starting point for the treatment of functional dizziness.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by a JSPS Grant-in-Aid for Scientific Research 21K13736.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthor contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKH designed the study protocol and wrote the manuscript. TT, KT, NT, and AK collected, analyzed, and discussed the interpretation of the data. MH designed the study and discussed the interpretation of the data. All authors reviewed the manuscript. \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics Committee Approval\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Toho University Medical Center Omori Hospital Ethics Committee, approval number: M23235 21095, with due consideration to the Helsinki Declaration, patient anonymity, and ethics. Written informed consent was obtained from all the participants prior to their enrollment in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and material\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available because it was not permitted by the ethics committee, but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConflict of interest\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have stated explicitly that there are no conflicts of interest in connection with this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePost, R. E. \u0026amp; Dickerson, L. M. Dizziness: A diagnostic approach. Am. Fam. 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Rev. 3, CD015188 (2023). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/14651858.CD015188.pub2\u003c/span\u003e\u003cspan address=\"10.1002/14651858.CD015188.pub2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"558\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\"\u003e\n \u003cp\u003eTable 1. Participant\u0026rsquo;s Characteristics with functional dizziness (n=30)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.904847396768403%\"\u003e\n \u003cp\u003ePersistent Postural Perceptual Dizziness\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n=16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28725314183124%\"\u003e\n \u003cp\u003e\u0026nbsp;The Others (n=14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.8491921005386%\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.8491921005386%\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003e\u0026nbsp; Male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.904847396768403%\"\u003e\n \u003cp\u003e2 (12.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28725314183124%\"\u003e\n \u003cp\u003e2 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003e\u0026nbsp; Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.904847396768403%\"\u003e\n \u003cp\u003e14 (87.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28725314183124%\"\u003e\n \u003cp\u003e12 (85.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003eAge (years\u0026plusmn;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.904847396768403%\"\u003e\n \u003cp\u003e41.8 \u0026plusmn; 12.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28725314183124%\"\u003e\n \u003cp\u003e43.3 \u0026plusmn; 15.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.8491921005386%\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003eHabit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003e\u0026nbsp; Smoking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.904847396768403%\"\u003e\n \u003cp\u003e3 (18.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28725314183124%\"\u003e\n \u003cp\u003e1 (7.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.8491921005386%\"\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003e\u0026nbsp; Drinking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.904847396768403%\"\u003e\n \u003cp\u003e3 (18.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28725314183124%\"\u003e\n \u003cp\u003e1 (7.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.8491921005386%\"\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003eEducation (year)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.904847396768403%\"\u003e\n \u003cp\u003e14.0 [12.0-16.0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28725314183124%\"\u003e\n \u003cp\u003e12.0 [12.0-14.0]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.8491921005386%\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003eMarriage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.904847396768403%\"\u003e\n \u003cp\u003e6 (37.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28725314183124%\"\u003e\n \u003cp\u003e6 (42.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.8491921005386%\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003eMedical therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003e\u0026nbsp; Antidepressant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.904847396768403%\"\u003e\n \u003cp\u003e11 (78.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28725314183124%\"\u003e\n \u003cp\u003e10 (71.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.8491921005386%\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003eAnxiolytics or Sleep medication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.904847396768403%\"\u003e\n \u003cp\u003e12 (75.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28725314183124%\"\u003e\n \u003cp\u003e7 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.8491921005386%\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003eSubjective dizziness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.904847396768403%\"\u003e\n \u003cp\u003e5.8 \u0026plusmn; 1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28725314183124%\"\u003e\n \u003cp\u003e3.4 \u0026plusmn; 1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.8491921005386%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003eQuestionnaire\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.904847396768403%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28725314183124%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.8491921005386%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003e\u0026nbsp; DHI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.904847396768403%\"\u003e\n \u003cp\u003e52.8 \u0026plusmn; 11.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28725314183124%\"\u003e\n \u003cp\u003e34.4 \u0026plusmn; 16.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.8491921005386%\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003e\u0026nbsp; NPQ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.904847396768403%\"\u003e\n \u003cp\u003e44.4 \u0026plusmn; 9.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28725314183124%\"\u003e\n \u003cp\u003e18.5 \u0026plusmn; 6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.8491921005386%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003e\u0026nbsp; HADS Anxiety\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.904847396768403%\"\u003e\n \u003cp\u003e8.4 \u0026plusmn; 3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28725314183124%\"\u003e\n \u003cp\u003e6.1 \u0026plusmn; 3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.8491921005386%\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.95870736086176%\"\u003e\n \u003cp\u003e\u0026nbsp; HADS Depression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.904847396768403%\"\u003e\n \u003cp\u003e10.2 \u0026plusmn; 4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.28725314183124%\"\u003e\n \u003cp\u003e5.9 \u0026plusmn; 4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.8491921005386%\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"4\"\u003e\n \u003cp\u003eDHI:\u0026nbsp;Dizziness Handicap Inventory，NPQ: Niigata PPPD Questionnaire，\u003c/p\u003e\n \u003cp\u003eHADS: Hospital Anxiety and Depression Scale.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eValues are given as mean (\u0026plusmn;standard deviation) or median (inter quartile range).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"869\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"13\" valign=\"top\"\u003e\n \u003cp\u003eTable 2. A hierarchical linear model of the relationship between Subjective Dizziness Symptoms and Affect in the PPPD group (n=468)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.189873417721518%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eIndependent variable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.31185270425777%\" colspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003eLevel 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.49827387802071%\" colspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003eLevel 2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.737127371273713%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ecoefficient\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.29810298102981%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eStandard\u003c/p\u003e\n \u003cp\u003eerror\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.872628726287262%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eConfidence Interval\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.368563685636857%\" rowspan=\"2\"\u003e\n \u003cp\u003et value\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.368563685636857%\" rowspan=\"2\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.872628726287262%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ecoefficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.29810298102981%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eStandard\u003c/p\u003e\n \u003cp\u003eerror\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.092140921409214%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eConfidence Interval\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.368563685636857%\" rowspan=\"2\"\u003e\n \u003cp\u003et value\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.723577235772358%\" rowspan=\"2\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"23.737373737373737%\" valign=\"top\"\u003e\n \u003cp\u003e95% under\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.737373737373737%\" valign=\"top\"\u003e\n \u003cp\u003e95% upper\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.737373737373737%\"\u003e\n \u003cp\u003e95% under\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.78787878787879%\" valign=\"top\"\u003e\n \u003cp\u003e95% upper\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.189873417721518%\" valign=\"top\"\u003e\n \u003cp\u003eIntercept\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.817031070195627%\" valign=\"top\"\u003e\n \u003cp\u003e7.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.745684695051784%\" valign=\"top\"\u003e\n \u003cp\u003e1.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\" valign=\"top\"\u003e\n \u003cp\u003e3.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\" valign=\"top\"\u003e\n \u003cp\u003e10.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\"\u003e\n \u003cp\u003e3.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.93210586881473%\" valign=\"top\"\u003e\n \u003cp\u003e4.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.745684695051784%\" valign=\"top\"\u003e\n \u003cp\u003e0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\" valign=\"top\"\u003e\n \u003cp\u003e3.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.5592635212888375%\" valign=\"top\"\u003e\n \u003cp\u003e5.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\" valign=\"top\"\u003e\n \u003cp\u003e9.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.5592635212888375%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.189873417721518%\" valign=\"top\"\u003e\n \u003cp\u003ePositive\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.817031070195627%\" valign=\"top\"\u003e\n \u003cp\u003e-0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.745684695051784%\" valign=\"top\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\" valign=\"top\"\u003e\n \u003cp\u003e-0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\" valign=\"top\"\u003e\n \u003cp\u003e-0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\"\u003e\n \u003cp\u003e-4.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.93210586881473%\" valign=\"top\"\u003e\n \u003cp\u003e-0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.745684695051784%\" valign=\"top\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\" valign=\"top\"\u003e\n \u003cp\u003e-0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.5592635212888375%\" valign=\"top\"\u003e\n \u003cp\u003e-0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\" valign=\"top\"\u003e\n \u003cp\u003e-5.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.5592635212888375%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.189873417721518%\" valign=\"top\"\u003e\n \u003cp\u003ePositive_gm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.817031070195627%\" valign=\"top\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.745684695051784%\" valign=\"top\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\" valign=\"top\"\u003e\n \u003cp\u003e-0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\" valign=\"top\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\" valign=\"top\"\u003e\n \u003cp\u003e0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\" valign=\"top\"\u003e\n \u003cp\u003e0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.93210586881473%\" valign=\"top\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.745684695051784%\" valign=\"top\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\" valign=\"top\"\u003e\n \u003cp\u003e-0.105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.5592635212888375%\" valign=\"top\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\" valign=\"top\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.5592635212888375%\"\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.189873417721518%\" valign=\"top\"\u003e\n \u003cp\u003eNegative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.817031070195627%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.745684695051784%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.93210586881473%\" valign=\"top\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.745684695051784%\" valign=\"top\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\" valign=\"top\"\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.5592635212888375%\" valign=\"top\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\" valign=\"top\"\u003e\n \u003cp\u003e6.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.5592635212888375%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.189873417721518%\" valign=\"top\"\u003e\n \u003cp\u003ePositive*Negative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.817031070195627%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.745684695051784%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.93210586881473%\" valign=\"top\"\u003e\n \u003cp\u003e-0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.745684695051784%\" valign=\"top\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\" valign=\"top\"\u003e\n \u003cp\u003e-0.008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.5592635212888375%\" valign=\"top\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.408515535097814%\" valign=\"top\"\u003e\n \u003cp\u003e-0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.5592635212888375%\" valign=\"top\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"13\" valign=\"top\"\u003e\n \u003cp\u003egm: Grand-mean Centering, *: Interaction. \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"879\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"13\" valign=\"top\"\u003e\n \u003cp\u003eTable 3. A hierarchical linear model of the relationship between Subjective Dizziness Symptoms and Affect in the others group (n=422)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.034168564920273%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eIndependent variable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.888382687927106%\" colspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003eLevel 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"44.07744874715262%\" colspan=\"6\" valign=\"top\"\u003e\n \u003cp\u003eLevel 2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.600536193029491%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ecoefficient\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.847184986595174%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eStandard\u003c/p\u003e\n \u003cp\u003eerror\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.600536193029491%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eConfidence Interval\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.3002680965147455%\" rowspan=\"2\"\u003e\n \u003cp\u003et value\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.640750670241287%\" rowspan=\"2\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.734584450402144%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ecoefficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.187667560321715%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eStandard\u003c/p\u003e\n \u003cp\u003eerror\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.14745308310992%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eConfidence Interval\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.3002680965147455%\" rowspan=\"2\"\u003e\n \u003cp\u003et value\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.640750670241287%\" rowspan=\"2\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.596153846153847%\" valign=\"top\"\u003e\n \u003cp\u003e95% under\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.596153846153847%\" valign=\"top\"\u003e\n \u003cp\u003e95% upper\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.403846153846153%\"\u003e\n \u003cp\u003e95% under\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"27.403846153846153%\" valign=\"top\"\u003e\n \u003cp\u003e95% upper\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.017064846416382%\" valign=\"top\"\u003e\n \u003cp\u003eIntercept\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.693970420932878%\" valign=\"top\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.508532423208191%\" valign=\"top\"\u003e\n \u003cp\u003e0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.346985210466439%\" valign=\"top\"\u003e\n \u003cp\u003e-1.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.346985210466439%\" valign=\"top\"\u003e\n \u003cp\u003e10.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.346985210466439%\" valign=\"top\"\u003e\n \u003cp\u003e0.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.484641638225256%\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.80773606370876%\" valign=\"top\"\u003e\n \u003cp\u003e2.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.646188850967008%\" valign=\"top\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.484641638225256%\" valign=\"top\"\u003e\n \u003cp\u003e1.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.484641638225256%\" valign=\"top\"\u003e\n \u003cp\u003e3.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.346985210466439%\" valign=\"top\"\u003e\n \u003cp\u003e6.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.484641638225256%\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.017064846416382%\" valign=\"top\"\u003e\n \u003cp\u003ePositive\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.693970420932878%\" valign=\"top\"\u003e\n \u003cp\u003e-0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.508532423208191%\" valign=\"top\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.346985210466439%\" valign=\"top\"\u003e\n \u003cp\u003e-0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.346985210466439%\" valign=\"top\"\u003e\n \u003cp\u003e-0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.346985210466439%\" valign=\"top\"\u003e\n \u003cp\u003e-2.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.484641638225256%\"\u003e\n \u003cp\u003e\u0026lt;0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.80773606370876%\" valign=\"top\"\u003e\n \u003cp\u003e-0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.646188850967008%\" valign=\"top\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.484641638225256%\" valign=\"top\"\u003e\n \u003cp\u003e-0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.484641638225256%\" valign=\"top\"\u003e\n \u003cp\u003e-0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.346985210466439%\" valign=\"top\"\u003e\n \u003cp\u003e-3.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.484641638225256%\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.017064846416382%\" valign=\"top\"\u003e\n \u003cp\u003ePositive_gm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.693970420932878%\" valign=\"top\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.508532423208191%\" valign=\"top\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.346985210466439%\" valign=\"top\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.346985210466439%\" valign=\"top\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.346985210466439%\" valign=\"top\"\u003e\n \u003cp\u003e5.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.484641638225256%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.80773606370876%\" valign=\"top\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.646188850967008%\" valign=\"top\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.484641638225256%\" valign=\"top\"\u003e\n \u003cp\u003e-0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.484641638225256%\" valign=\"top\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.346985210466439%\" valign=\"top\"\u003e\n \u003cp\u003e2.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.484641638225256%\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.017064846416382%\" valign=\"top\"\u003e\n \u003cp\u003eNegative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.693970420932878%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.508532423208191%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.346985210466439%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.346985210466439%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.346985210466439%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.484641638225256%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.80773606370876%\" valign=\"top\"\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.646188850967008%\" valign=\"top\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.484641638225256%\" valign=\"top\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.484641638225256%\" valign=\"top\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.346985210466439%\" valign=\"top\"\u003e\n \u003cp\u003e11.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.484641638225256%\"\u003e\n \u003cp\u003e\u0026lt;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.017064846416382%\" valign=\"top\"\u003e\n \u003cp\u003ePositive*Negative\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.693970420932878%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.508532423208191%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.346985210466439%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.346985210466439%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.346985210466439%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.484641638225256%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.80773606370876%\" valign=\"top\"\u003e\n \u003cp\u003e-0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.646188850967008%\" valign=\"top\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.484641638225256%\" valign=\"top\"\u003e\n \u003cp\u003e-0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.484641638225256%\" valign=\"top\"\u003e\n \u003cp\u003e-0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.346985210466439%\" valign=\"top\"\u003e\n \u003cp\u003e-4.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.484641638225256%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"13\" valign=\"top\"\u003e\n \u003cp\u003egm: Grand-mean Centering, *: Interaction.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Affect, Ecological Momentary Assessment, Persistent Postural Perceptual Dizziness, Somatic Symptoms Disorder","lastPublishedDoi":"10.21203/rs.3.rs-4453398/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4453398/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAn association between dizziness symptoms and psychological factors has been hypothesized, but evaluating this through questionnaires alone risks recall bias. We aimed to clarify this relationship using the EMA method to reduce bias. Participants comprised 30 patients (16 with persistent postural perceptual dizziness (PPPD), 14 with the others) aged 20\u0026ndash;74 years with functional dizziness symptoms. Participants were sent survey forms at random times for 10 days, 890 hierarchical data were obtained. Survey forms were included the Subjective Dizziness Symptoms (SDS) evaluated as medical condition and the Positive and Negative Affect Schedule assessed as affects. Level 1 model revealed: Positive affect (PA) had a negative fixed effect on SDS in both groups, but the group-mean centering of PA was significant only in the others group. Level 2 model revealed: Negative affect (NA) had a significant fixed effect in both groups; however, the interaction between PA and NA was significant only in the others group. A simple slope analysis of the others group revealed that, in participants with higher NA, reduced momentary SDS was associated with higher PA. Functional dizziness symptoms were more severe when PA was low and NA high. Treatment for functional dizziness pathology could begin with PA.\u003c/p\u003e","manuscriptTitle":"Associations between affect and dizziness symptoms: Ecological Momentary Assessment study in functional dizziness","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-07 19:00:43","doi":"10.21203/rs.3.rs-4453398/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d8eb854b-795e-40f6-889e-3a72ce89addf","owner":[],"postedDate":"June 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":32704662,"name":"Biological sciences/Psychology"},{"id":32704663,"name":"Health sciences/Medical research"},{"id":32704664,"name":"Health sciences/Neurology"}],"tags":[],"updatedAt":"2025-01-08T05:23:16+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-07 19:00:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4453398","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4453398","identity":"rs-4453398","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}