Abstract Background: The purpose of this paper was to estimate the test-retest agreement and to describe the discriminative validity of measures recorded from the Situational Characteristics Questionnaire-extended

This paper presents diagnostic criteria for persistent postural-perceptual dizziness (PPPD) to be included in the International Classification of Vestibular Disorders (ICVD). The term PPPD is new, but the disorder is not. Its diagnostic criteria were derived by expert consensus from an exhaustive review of 30 years of research on phobic postural vertigo, space-motion discomfort, visual vertigo, and chronic subjective dizziness. PPPD manifests with one or more symptoms of dizziness, unsteadiness, or non-spinning vertigo that are present on most days for three months or more and are exacerbated by upright posture, active or passive movement, and exposure to moving or complex visual stimuli. PPPD may be precipitated by conditions that disrupt balance or cause vertigo, unsteadiness, or dizziness, including peripheral or central vestibular disorders, other medical illnesses, or psychological distress. PPPD may be present alone or co-exist with other conditions. Possible subtypes await future identification and validation. The pathophysiologic processes underlying PPPD are not fully known. Emerging research suggests that it may arise from functional changes in postural control mechanisms, multi-sensory information processing, or cortical integration of spatial orientation and threat assessment. Thus, PPPD is classified as a chronic functional vestibular disorder. It is not a structural or psychiatric condition.

Research suggests that mothers interacting with disruptive children tend to experience greater negative affect (NA) and less parental confidence. Because children with externalizing disorders can be quite oppositional and rejecting, involvement in the parental role can lead to a sense of learned helplessness that can exacerbate anxious feelings. This study looked at whether high-social anxiety (SA) mothers were more likely to experience greater distress and negative self-appraisals of parenting performance than low-SA mothers, during an experimental interaction with an uncontrollable, deviant child. The experimental task had each parent interact with child confederates such that in one session a child behaved in a cooperative fashion and in a second session, a different child exhibited behaviors characteristic of externalizing disorders. Measures of distress and affect including self-ratings, observer mood ratings, heart rate, and blood pressure were obtained. Results indicated that high-SA parents experienced greater NA, regardless of child behavior, compared to low-SA parents. It appears that high-SA parents have a lower threshold for activated negative emotions such as anxiety, anger, and irritability and less positive interpersonal engagement. (Contains 3 tables and 27 references.) (JDM) Reproductions supplied by EDRS are the best that can be made from the original document. Parental Social Anxiety 1 RUNNING HEAD: PARENTAL SOCIAL ANXIETY Parental social anxiety during an experimental parent-child learned helplessness procedure Todd B. Kashdan, University at Buffalo Rolf G. Jacob, University of Pittsburgh William E. Pelham, University at Buffalo Alan R. Lang, Florida State University Richard J. Jennings, University of Pittsburgh Elizabeth M. Gnagy, University at Buffalo Jonathan D. Blumenthal, National Institute of Mental Health Poster presented at the 108th Annual Convention of the American Psychological Association, Washington, DC., August, 2000. Requests for reprints and correspondence concerning this article should be addressed to Todd B. Kashdan, University at Buffalo, Department of Psychology, Park Hall, Box 604110, Buffalo, NY 14260. Email: kashdanAacsu.buffalo.edu.

The comorbidity among balance disorders, anxiety disorders and migraine has been studied extensively from clinical and basic research perspectives. From a neurological perspective, the comorbid symptoms are viewed as the product of sensorimotor, interoceptive and cognitive adaptations that are produced by afferent interoceptive information processing, a vestibulo-parabrachial nucleus network, a cerebral cortical network (including the insula, orbitofrontal cortex, prefrontal cortex and anterior cingulate cortex), a raphe nuclear-vestibular network, a coeruleo-vestibular network and a raphe-locus coeruleus loop. As these pathways overlap extensively with pathways implicated in the generation, perception and regulation of emotions and affective states, the comorbid disorders and effective treatment modalities can be viewed within the contexts of neurological and psychopharmacological sites of action of current therapies.

Introduction. - Space and motion discomfort (SMD) refers to various symptoms that occur in environments with unreliable visual and kinesthetic information that do not permit adequate spatial orientation. Some studies have demonstrated that there is a stable and predictable relationship between vestibular dysfunction and anxiety disorders. Further, vestibular dysfunction can predispose or trigger the development of panic disorder with or without agoraphobia (PD/A) or reinforce phobic avoidance. It therefore seems clinically useful to develop and validate instruments for evaluating SMD in various populations. Measuring SMD could facilitate identification of individuals with PD/A who present comorbid vestibular dysfunction. Jacob et al. developed and validated such a questionnaire: the Situational characteristics questionnaire (SitQ). This questionnaire evaluates the presence of symptoms such as dizziness, vertigo, and instability under specific conditions. The SitQ comprises two subscales that measure SMD and one subscale (agoraphobia) that measures agoraphobic avoidance behaviours. The instrument has two sections. The first section is composed of the SMD-I and agoraphobia subscales, containing 19 and seven items, respectively. Each item consists of two contrasting descriptors of a specific situation or environment. The respondent is required to indicate to what extent the two described situations or environments cause discomfort. Each item includes a "criterion" descriptor for the situation (i.e., a descriptor that is presumed to engender SMD) and an alternative (non-criterion) descriptor. The second section comprises the SMD-II scale; this scale is composed of nine criterion situations, for which non-criterion situations are not supplied. The instrument takes approximately 20 minutes to complete.Objective. - The present study focuses on the validation of the French-language version of the SitQ: the questionnaire des caracteristiques situationnelles (QCS).Method. - The sample was composed of French Canadians recruited across Quebec from an anxiety disorders treatment clinic, general psychiatric care clinics, a community organization for individuals with anxiety disorders, advertisements in local newspapers, and ads posted in various public locations. The sample included 141 participants who met the criteria for lifetime PD/A. Participants reported current PD/A (n=73) or PD/A in remission (n=68). The control sample was recruited from undergraduate courses in various disciplines. Two hundred and thirty-five (n = 235) students completed the questionnaires. Data from 63 (26.8%) participants were excluded from the analyses due to failure to complete all of the research questionnaires.Results. - Analysis of the global descriptive data and the descriptive data for each dependent variable revealed that the data were independent of sociodemographic variables and respected the assumptions of normal distribution (skewness and kurtosis). Parametric tests were subsequently conducted. Using the combined data from the control and clinical groups, the internal consistency of the scales was analyzed using Cronbach's alpha. The SMD-I and SMD-II scales demonstrated good homogeneity. The results were comparable or superior to those obtained with the English-language version of the questionnaire. The agoraphobia scale demonstrated weaker internal consistency and corresponding weaker homogeneity. This result was consistent with that of the original version of the agoraphobia scale; this scale was eliminated for the subsequent analyses. Construct validity was analyzed via t-tests comparing clinical and control groups. Effect sizes were estimated using percentage of variance explained. The SMD-I scale demonstrated weak construct validity and was also eliminated from subsequent analyses. The SMD-II scale demonstrated good construct validity and provided an adequate measure of the theoretical construct of SMD. This scale permitted discrimination of participants according to the presence or absence of PD/A. It is therefore possible to identify participants with PD/A by their level of SMD. This result is comparable to that of Jacob et al.Conclusion. - The results of the present study are generally consistent with the results of the validation of the original version of the questionnaire. However, the SMD-I and agoraphobia scales in the French-language version of the measure did not achieve a level of significance sufficient to definitively establish validity. (C) L'Encephale, Paris, 2011.

OBJECTIVE:Previous research suggested that panic disorder with agoraphobia is associated with abnormalities on vestibular and balance function tests. The purpose of this study was to further examine psychiatric correlates of vestibular/balance dysfunction in patients with anxiety disorders and the specific nature of the correlated vestibular abnormalities. The psychiatric variables considered included anxiety disorder versus normal control status, panic disorder versus non-panic anxiety disorder diagnosis, presence or absence of comorbid fear of heights, and degree of space and motion discomfort (SMD). The role of anxiety responses to vestibular testing was also re-examined.METHODS:104 subjects were recruited: 29 psychiatrically normal individuals and 75 psychiatric patients with anxiety disorders. Anxiety patients were assigned to four subgroups depending on whether or not they had panic disorder and comorbid fear of heights. SMD and anxiety responses were measured by questionnaires. Subjects were examined for abnormal unilateral vestibular hypofunction on caloric testing indicative of peripheral vestibular dysfunction, asymmetric responses on rotational testing as an indicator of an ongoing vestibular imbalance and balance function using Equitest dynamic posturography as an indicator of balance control. Logistic regression was used to establish the association between the psychiatric variables and vestibular or balance test abnormalities.RESULTS:Rotational test results were not significantly related to any of the psychiatric variables. The presence of either panic attacks or fear of heights increased the probability of having caloric hypofunction in a non-additive fashion. SMD and anxiety responses were independently associated with abnormal balance. Among specific posturography conditions, the association with SMD was significant for a condition that involved the balance platform tilting codirectionally with body sway, suggesting an abnormal dependence on somatosensory cues in the control of balance.CONCLUSION:In patients with anxiety disorders, higher SMD is indicative of somatosensory dependence in the control of balance. The absence of both panic and fear of heights reduces the probability of having peripheral vestibular dysfunction. Future research should examine if vestibular rehabilitation can be of value for patients with anxiety disorders complicated by SMD.

Previous studies of vestibulo-ocular function in patients with anxiety disorders have suggested a higher prevalence of peripheral vestibular dysfunction compared to control populations, especially in panic disorder with agoraphobia. Also, our recent companion studies have indicated abnormalities in postural control in patients with anxiety disorders who report a high degree of space and motion discomfort. The aim of the present study was to assess the VOR, including the semicircular canal-ocular reflex, the otolith-ocular reflex, and semicircular canal-otolith interaction, in a well-defined group of patients with anxiety disorders. The study included 72 patients with anxiety disorders (age 30.6 +/- 10.6 yrs; 60 (83.3% F) and 29 psychiatrically normal controls (age 35.0 +/minus; 11.6 yrs; 24 (82.8% F). 25 patients had panic disorder; 47 patients had non-panic anxiety. Patients were further categorized based on the presence (45 of 72) or absence (27 of 72) of height phobia and the presence (27 of 72) or absence (45 of 72) of excessive space and motion discomfort (SMD). Sinusoidal and constant velocity earth-vertical axis rotation (EVAR) was used to assess the semicircular canal-ocular reflex. Constant velocity off-vertical axis rotation (OVAR) was used to assess both the otolith-ocular reflex and static semicircular canal-otolith interaction. Sinusoidal OVAR was used to assess dynamic semicircular canal-otolith interaction. The eye movement response to rotation was measured using bitemporal electro-oculography. Results showed a significantly higher VOR gain and a significantly shorter VOR time constant in anxiety patients. The effect of anxiety on VOR gain was significantly greater in patients without SMD as compared to those with SMD. Anxiety patients without height phobia had a larger OVAR modulation. We postulate that in patients with anxiety, there is increased vestibular sensitivity and impaired velocity storage. Excessive SMD and height phobia seem to have a mitigating effect on abnormal vestibular sensitivity, possibly via a down-weighting of central vestibular pathways.

Postural sensitivity to moving visual environments in patients with anxiety disorders was studied. We hypothesized that patients with anxiety disorders would have greater sway in response to a moving visual environment compared to healthy adults, especially if they have space and motion discomfort (SMD). Twenty-one patients with generalized anxiety without panic (NPA) and 38 patients with panic and agoraphobia (PAG) were compared to 22 healthy controls. SMD was evaluated in all subjects via questionnaire. Subjects stood on a force platform that was either fixed or rotating with the subject (i.e., sway referenced) during exposure to a sinusoidally moving visual surround. Center of pressure (COP) data were computed from force transducers in the platform as a measure of sway. Results showed that patients swayed significantly more in response to the moving visual scene compared to control subjects, with no differences between the NPA and PAG groups. SMD was a predictor of sway response in the patients: patients with high SMD swayed significantly more than both Controls and anxiety patients with low SMD. These results indicate that patients with anxiety disorders, particularly those with SMD, are more visually dependent for balance. This subgroup of patients may be amenable to treatment used for patients with balance disorders (i.e., vestibular rehabilitation) that focuses on sensory re-integration processes that address visual sensitivity.

BACKGROUND AND PURPOSE Acrophobia (fear of heights) may be related to a high degree of height vertigo caused by visual dependence in the maintenance of standing balance. The purpose of this case report is to describe the use of vestibular physical therapy intervention following behavioral therapy to reduce a patient's visual dependence and height vertigo. CASE DESCRIPTION Mr N was a 37-year-old man with agoraphobia (fear of open spaces) that included symptoms of height phobia. Exposure to heights triggered symptoms of dizziness. Intervention. Mr N underwent 8 sessions of behavioral therapy that involved exposure to heights using a head-mounted virtual reality device. Subsequently, he underwent 8 weeks of physical therapy for an individualized vestibular physical therapy exercise program. OUTCOMES After behavioral therapy, the patient demonstrated improvements on the behavioral avoidance test and the Illness Intrusiveness Rating Scale, but dizziness and body sway responses to moving visual scenes did not decrease. After physical therapy, his dizziness and sway responses decreased and his balance confidence increased. DISCUSSION Symptoms of acrophobia and sway responses to full-field visual motion appeared to respond to vestibular physical therapy administered after completion of a course of behavioral therapy. Vestibular physical therapy may have a role in the management of height phobia related to excessive height vertigo.

We investigated whether graphomotor organization during a digitized Clock Drawing Test (dCDT) would be associated with cognitive and/or brain structural differences detected with a tractography-derived structural connectome of the brain. 72 non-demented/non-depressed adults were categorized based on whether or not they used ‘anchor’ digits (i.e., 12, 3, 6, 9) before any other digits while completing dCDT instructions to “draw the face of a clock with all the numbers and set the hands to 10 after 11”. ‘Anchorers’ were compared to ‘non-anchorers’ across dCDT, additional cognitive measures and connectome-based metrics. In the context of grossly intact clock drawings, anchorers required fewer strokes to complete the dCDT and outperformed non-anchorers on executive functioning and learning/memory/recognition tasks. Anchorers had higher local efficiency for the left medial orbitofrontal and transverse temporal cortices as well as the right rostral anterior cingulate and superior frontal gyrus versus non-anchorers suggesting better regional integration within local networks involving these regions; select aspects of which correlated with cognition. Results also revealed that anchorers’ exhibited a higher degree of modular integration among heteromodal regions of the ventral visual processing stream versus non-anchorers. Thus, an easily observable graphomotor distinction was associated with 1) better performance in specific cognitive domains, 2) higher local efficiency suggesting better regional integration, and 3) more sophisticated modular integration involving the ventral (‘what’) visuospatial processing stream. Taken together, these results enhance our knowledge of the brain-behavior relationships underlying unprompted graphomotor organization during dCDT.

Dizziness is a common complaint that can result from abnormalities of the vestibular apparatus of the inner ear and of those portions of the central nervous system (CNS) that process information from the peripheral vestibular system and other senses, particularly vision and somatosensation. Recently, two CNS disorders, migraine and anxiety, have been recognised as being commonly associated with dizziness.1,2 These associations may be an expression of an aetiological relationship, for example, dizziness caused by migraine, or dizziness caused by anxiety; alternatively, migraine or anxiety may influence the presentation of a balance disorder. For example, chronic dizziness may become more disabling during the added stress of a migraine headache or panic attack. In addition, dizziness occurs comorbidly with both migraine headache and anxiety disorders.3,4 Finally, there is increased comorbidity between anxiety and migraine.5 Thus, it is not surprising that some patients with dizziness may suffer from a combination of a balance disorder, migraine, and an anxiety disorder, a symptom complex that we propose to name migraine−anxiety related dizziness (MARD) (fig 1). The general recognition of MARD may be limited because of the fragmented nature of our healthcare system, where specialists in one field, such as psychiatry or neurology, fail to recognise phenomena known to specialists in other fields, such as otoneurology. Figure 1 Venn diagram of the interfaces among migraine, anxiety, and balance disorders. The central sector, which denotes the three way interface, represents an hypothesised new ailment, migraine−anxiety related dizziness (MARD). This editorial will focus on the pathophysiology and clinical issues relating to MARD, including the interfaces among balance disorders, migraine, and anxiety. We use current epidemiological data and studies of pathogenesis to develop comorbidity models. These models serve as hypotheses that may lead to possible treatment options for many patients with dizziness, including those with MARD. …

BACKGROUND:Individuals who fail to show a decline in blood pressure (BP) when asleep or at night (labeled nocturnal nondippers) are at elevated risk for hypertension and associated target-organ damage.PURPOSE:We tested whether the well-established changes in BP exhibited in response to daily activities are also blunted in nocturnal nondippers.METHODS:Cross-sectional study of 41 women and 56 men, aged 27 to 71 years, residing in Benin, Nigeria, enrolled in a health survey of civil servants. Ambulatory 24-hr BP monitoring was performed with concurrent diary recordings of physical activity level, posture, location, state of mental activity, interpersonal interaction, and mood obtained during the waking hours.RESULTS:Nocturnal nondippers exhibited smaller cardiovascular responses to changes in posture (from lying to sitting or to standing, ps <.02), location (from home to work or to driving/riding in a car, ps <.02), mental activity (from relaxed to active, p =.02), and mood (from feeling mellow to feeling elated-happy, p =.05) than did dippers. Statistical controls for posture substantially reduced the effects of nondipping status on responses to other daily activities and mood. Lack of systolic BP responsiveness to postural changes during the day is a strong predictor of nondipping status.CONCLUSIONS:Nondipping at night appears to extend to decreased cardiovascular responses to changes in activities during daytime hours.

BACKGROUND:Migraine and vestibular symptoms are co-morbid. Migraine is increasingly recognized as a cause of benign, recurrent vertigo. Although the International Headache Society does not currently include the diagnosis of migrainous vertigo, specific criteria have been proposed and utilized in clinical trials.MATERIAL/METHODS:Seventeen adult migraineurs were separately screened for the diagnosis of migrainous vertigo using a standardized structured interview for migrainous vertigo (SIM-V) and a clinical evaluation by an experienced neurotologist. The SIM-V was administered by a nurse who read and recorded subject responses, obtaining no additional information for the diagnosis of migrainous vertigo. Comparison of diagnoses between clinician and SIM-V was made using Cohen's kappa reliability testing. Subjects were asked to return for a second interview by the same nurse using the SIM-V, at least 2 weeks after the initial assessment. Testing stability was evaluated by comparing diagnoses obtained with each SIM-V administration.RESULTS:Cohen's kappa demonstrated excellent test validity (kappa=0.75). Fourteen subjects returned for repeat testing, with excellent retest stability (kappa=0.85). The additional three subjects could not be relocated or were not interested in attending a retest appointment.CONCLUSIONS:The SIM-V is an easy-to-administer screening tool for the diagnosis of migrainous vertigo. Diagnostic comparison to a standard clinical assessment shows good test validity. Retest stability was also demonstrated. The SIM-V may be a useful screening tool for migraineurs with an additional complaint of dizziness.

ome researchers who have studied children with behavior problems have suggested that depressed mothers distort reports of deviance in their children, perhaps contributing to misdiagnoses; howSever, investigations studying mothers with current or past depression have not clearly indicated such a bias. Because some of this equivocation may be due to the confounding effects of the mother—child history, the present study examined maternal ratings of the standardized behavior of child confederates, thereby providing an objective standard from which bias could be determined. Maternal lifetime diagnoses of depression and contemporary reports of depressive symptomatology were also evaluated. Mothers of 4- to12-year-old sons with attention-deficit/hyperactivity disorder (ADHD) interacted with and rated boys in the same age range whose behavior was carefully scripted to represent either ADHD or the absence of any disorder. Forty-four of these mothers had a history of clinical depression, and the entire sample represented a range of depressive symptomatology. Analyses revealed no significant differences in ratings of the child confederates' behaviors as a function of maternal history of depression or current depressive symptomatology. These findings thus call into question at least some of the prior assertions of maternal bias in the reporting of behavior problems in children.

Objective.-To validate a brief tool for screening migraine.Background.-Migraine is a common, but underdiagnosed condition. Effective utilization of nonphysician personnel to reliably screen patients for migraine may improve identification of migraineurs for clinical treatment and research.Methods.-An 8-question Migraine Assessment Tool (based on International Headache Society criteria) was designed for administration by a nurse with no specialized headache training as a pre-assessment for the diagnosis of migraine for use in either a research or clinical environment. Acommunity sample of 80 adults (71 women, 9 men; mean age, 33.7 years; 80% white, 14% African American, 2.5% Asian American) with self-reported headache was recruited through advertisements. A headache specialist independently diagnosed subjects using clinical assessment, and a nurse who works in a balance disorder clinic used the Migraine Assessment Tool. Agreement between physician and nurse-administered Migraine Assessment Tool diagnoses was determined. Each subject returned in 2 to 4 weeks for a second assessment, administered by the same nurse. Agreement between the 2 diagnoses from the Migraine Assessment Tool was calculated.Results.-Comparison between diagnosis by the physician versus the Migraine Assessment Tool revealed a positive predictive value of 0.85; negative predictive value, 0.84; sensitivity, 0.89; specificity, 0.79; and observed agreement, 0.85. Cohen's kappa reliability measure was 0.69, indicating good test reliability. Interestingly, in 8 of the 12 cases of disagreement, the examiner diagnosing nonmigraine diagnosed analgesic overuse headache. Comparing diagnoses assigned by the 2 separate administrations of the Migraine Assessment Tool revealed a Cohen's kappa of 0.69. Notably, 9 of the 12 cases of nonagreement on the 2 assessments were due to subjects endorsing analgesic overuse in only 1 of the 2 testing sessions.Conclusions.-This study showed good reliability and stability of a new, brief, nurse-administered migraine questionnaire. In addition, the study also showed that consistency in self-reporting analgesic overuse within individuals with headache is poor. This suggests the need for repeat questioning about analgesic overuse on subsequent appointments to ensure absence of analgesic overuse headache.

This study investigated the relation between parental anxiety and family functioning. Parental anxiety and depression, child attention deficit hyperactivity disorder (ADHD), and oppositional defiant disorder (ODD) symptoms were all included as predictors of 3 measures of family functioning to examine the independent contributions of each. Using a self-report battery completed by 45 mother-father pairs, 3 family functioning factors were derived: Parental Warmth and Positive Involvement, Intrusiveness and Negative Discipline, and Social Distress. Multilevel modeling simultaneously estimated the unique contributions of parental and child symptoms on family functioning. Results indicated that parental anxiety was negatively associated with Parental Warmth and Positive Involvement, Intrusiveness and Negative Discipline, and Social Distress; parental depression was only negatively associated with Social Distress. Child ODD symptoms had independent associations with all outcomes; no relations were found with ADHD. Sex moderated the effects of parental anxiety on Parental Warmth and Positive Involvement such that only for mothers did greater anxiety lead to less Parental Warmth and Positive Involvement.

We examined hope as a potential resiliency factor for the daily strains of raising children with disruptive behavior disorders. In light of the motivational component of hope theory, initiating and sustaining effort toward goals (i.e., agency), we were interested in hope's relation to constructs addressing self-esteem, familial functioning, and stress. Two hundred, fifty-two parents of children with externalizing disorders completed self-report questionnaires. Significant associations were foundamong hope and parental and familial functioning indices (e.g., warm and nurturing parenting styles, cohesive and active family environment, adaptive coping strategies). Considering their conceptual overlap, we tested the unique predictive power of hope and optimistic attributions on indices of psychological functioning. Separate regressions indicated that hope significantly predicted psychological functioning beyond what was accounted for by social desirability, the severity of child symptoms, and optimistic attributions. Hope agency compared to hope pathways (i.e., perceived ability to generate strategies to obtain goals) accounted for the vast amount of variance in regression models. In contrast, optimistic attributions failed to predict any of the variables of interest. Treatment and prevention strategies are suggested with an integrated focus on both the disruptive behaviors of children and parental character traits.