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Christine Kormash

Christine was diagnosed with Meniere’s Disease in Sept 05 after years of symptoms at age 19. She had unsuccessful endolymphatic sac decompression surgery Nov 05, unsuccessful series of gentamicin injections Jan 06. Successful Vestibular Nerve Section surgery May 06 (viral menigitis following surgery).

Cognitive and Psychological Effects of Meniere’s Disease

Introduction
It is no surprise that patients with vestibular disorders present with a very high prevalence of psychological distress. The difficulties patients face in getting an accurate diagnosis, and the unpredictability of diseases, especially Meniere’s disease, are just a few of the factors that play into the high co-morbidity of psychological issues patients are succumbed to. As professionals, our focus is often on attempting to eliminate the most distressing of symptoms, which is usually vertigo. And while this is crucial in treating patients afflicted with vestibular dysfunctions, often times we direct so much of our attention to trying to rid the patient of the devastating physical symptoms, that we forget the extreme impact Meniere’s has on a patient’s life outside of the office or clinic in which we see them.

It is important that when treating patients with such a disease, we focus not only on the physical aspects of the disease, but also on helping the patient to cope with the psychological, cognitive, and social distress they face as a result of their affliction.

Psychological Effects
With a disease as unpredictable and as potentially devastating as Meniere’s disease, it would be difficult to find a patient whose life is not, essentially, turned upside down because of the disorder. The vertigo and balance problems experienced by patients can severely limit their physical activity and that alone can result in a feeling of isolation. Add to this that a majority of patients also experience hearing loss and it becomes very understandable why patients with Meniere’s disease often suffer from a strong feeling of being isolated, which often results in a high incidence of depression.

One study found that as many as two-thirds of Meniere’s patients report feelings of depression or anxiety (Huy, 2005). As Huy (2005) found, “the unpredictability of the attacks, the fear of recurrence, and all the ignorance surrounding prognosis and treatment could easily account for anxiety, agoraphobia, depression, avoidance behavior, and other troubling mood states” (p. 1).

Depending on the severity of the disease and occurrence of vertigo attacks, many patients stop working either because they are physically unable to continue performing their jobs, or often because they are forced to. The lack of understanding of this disease in the general public makes it difficult for others to fully comprehend the disease, and often times peoples’ ignorance results in those who suffer from Meniere’s being treated as a burden or even a liability. Many patients, therefore, are forced to work at home, retire completely, or even file for disability.

In addition, hearing loss greatly plays into this as well. Most employers expect their employees to be able to hear and understand everything that goes on, and if one loses their hearing, often the employer tends to feel that their performance will suffer. This only contributes to the patient’s feelings of isolation, and loss of their independence.

In severe cases, those who suffer from Meniere’s disease may also become agoraphobic, and stray away from going out to perform normal, everyday activities, because of their fear of having an episode in public. Bronstein (2002) found that “fears of fainting, falling,inability to cope with dangerous activities, such as crossing the road and concerns about behaving abnormally in public were prevalent, up to 80%” in a random group of patients suffering from vertigo (p. 2).

Studies by Jacobson and Calder (2000) also confirm these findings. They found that those patients suffering from bilateral vestibular losses reported a variety of problems they now suffer from as a result, including “a sense of frustration with their problem, a fear of leaving home alone, a fear that others would interpret their unsteadiness of gait to represent a state of intoxication, and restrictions in their ability to walk by themselves or to travel for business or leisure” (p. 80).

In general, patients report an extreme loss of independence, and in some cases, even a loss of identity. Those suffering from Meniere’s often report a strong sense of frustration in no longer being able to do things for themselves, in having to rely on others for help with everyday things, and in having to reschedule their lives to work around the disease.

One patient reports, there is a major loss of self worth, value and confidence. Also there is a loss of independence - relying on others to do things for you. If people lose the ability to drive a car, that makes dependence on others even greater. If you can’t talk on the phone, somebody else has to call in your prescription.

Isolation and loneliness is a big issue for me. I can’t understand anybody but one-on-one. So group situations are impossible. I am no longer able to participate in groups, only spectate. I hate it. (Mason, personal communication, October 28, 2006).

The preceding studies and self-reported difficulties faced by those with Meniere’s disease are a true testimony to the problems these patients face as a result of the disease. It is not surprising at all that there is such a high incidence of psychological distress in these patients, who are forced to live with the unpredictability of the disease every day of their lives.

Physicians and other health professionals who work with patients plagued with Meniere’s disease need to keep all of these factors in mind when helping to treat the patient.

Cognitive Effects:
In the past decade or so, a lot of research has gone into determining if vestibular dysfunction can result in cognitive deficits. Previous studies suggest that vestibular damage causes problems in the areas of spatial navigation. However, more recent studies have shown that those suffering from unilateral or bilateral vestibular dysfunctions may be affected cognitively in more ways than spatial navigation.

A study by Smith, Zheng, Horri and Darlington(2005), suggests that a number of other cognitive processes are affected by vestibular damage, including memory, mental arithmetic, attention, and reaction time. The study showed that while patients were performing increasingly more difficult balancing tasks, their performance on reaction time tests and other mental tasks worsened. This leads researchers to believe “the process of monitoring orientation can make substantial demands on cognition in a vestibular deficient patient and that this may lead to poorer performance in a cognitive task” (p. 4).

Many patients with vestibular disorders report extreme difficulty in remembering even simple things, such as words used everyday. A patient with bilateral Meniere’s disease reports,

“Now I can’t remember people’s names, or words that I use every day. I drive down the street and suddenly can’t recognize where I am. I take that road every day and am unable to discern if I’ve missed my exit or it is still yet to come. I have absolutely no sense of direction, so getting lost is an ordinary daily occurrence.” (Mason, personal communication, October 28, 2006).

In a lecture presented at a Vestibular Disorders Association onference, Dr. Kenneth Erickson noted that neuropsychological exams of those with vestibular disorders found a number of cognitive deficits. Patients have a much harder time handling sequences, which results in mixing up letters or words, and problems following a conversation or the order of events in a story. The patients also exhibited a much more difficult time in paying attention to two processes at the same time, and a significantly decreased mental stamina.

As found in the study by Smith et al, Erickson also discussed the high incidence of memory problems in patients with vestibular dysfunctions. Erickson discussed the “reduced channel capacity” vestibular patients have, and the extreme sequencing difficulties many patients present with. He mentioned that “it’s exceedingly similar to a kind of problem seen in early Alzheimer’s diseases. It seems to indicate a loss of a kind of time setting or time tag” (p. 4).

Discussion
As easily seen from the above studies and personal testimonies, vestibular disorders like Meniere’s disease affect more than an individual’s balance. Although not life-threatening, diseases like Meniere’s are most certainly life-altering for those who are afflicted by them.

There is an array of psychological and cognitive problems that result from Meniere’s, and physicians and other health professionals that work with these patients need to keep all factors in mind. With regards to the cognitive deficits faced by those with vestibular dysfunctions, cognitive and vestibular rehabilitation therapy may help with some of the cognitive symptoms.

Smith et al also suggest vestibular rehabilitation therapists try to have patients perform minor cognitive tasks while performing various balance tasks, as this may help improve the patient’s ability to use their divided attention and thus improve overall.

As for physicians, audiologists, and other professionals, there is not a whole lot we can physically do to ‘fix’ the cognitive and psychological distress these patients experience. Yet, providing just nonjudgmental, empathetic listening can build a great bond and trust between the patient and professional. This alone can help to put the patient at ease and have a great trust for the doctor or other professional they are working with, therefore making it more likely for the patient to be honest about what is going on.

If the professional listens with empathy and without judgment, it is much more likely that the patient will feel at ease with them, and have a say in their treatment course.

Although we, as professionals, cannot ‘cure’ Meniere’s disease, giving the patient our support and encouragement can greatly improve their outlook on life with this disease,and help to improve their psychological well-being.

References
Bronstein, A. M. (2002). Visual and psychological aspects of vestibular disease.
Current Opinion in Neurology, 15, 1–3. Retrieved September 29, 2006, from http://www.co-neurology.com
Erickson, K. (2003). Cognitive Aspects of Vestibular Disorders.
Vestibular Disorders Association Conference, 1–9.
Retrieved October 25, 2006, from http://www.backgroundfacts.com/menieres/cogdis.htm
Huy, P. T. (2005). What Should a Primitive Surgeon Know About Meniere’s Patients?
Otology & Neurotology, 27, 1–3.

Jacobson, G. P., & Calder, J. H. (2000). Self-Perceived Balance Disability/Handicap
in the Presence of Bilateral Peripheral Vestibular System Impairment.
Journal of the American Academy of Audiology, 11, 76–83.
Smith, P. F., Zheng, Y., Horii, A., & Darlington, C. L. (2005).
Does vestibular damage cause cognitive dysfunction in humans?
Journal of Vestibular Research, 15, 1–9.
Retrieved September 22, 2006, from http://www.jvr-web.org

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