Additional cognitive behavior therapy for persistent postural-perceptual dizziness: a meta-analysis

Zang, Jialin; Zheng, Mohan; Chu, Hongyuan; Yang, Xu

doi:10.1016/j.bjorl.2024.101393

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Brazilian Journal of Otorhinolaryngology

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Sumário

Review article • Braz. j. otorhinolaryngol. 90 (3) • 2024 • https://doi.org/10.1016/j.bjorl.2024.101393 copy

Additional cognitive behavior therapy for persistent postural-perceptual dizziness: a meta-analysis

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

To investigate whether additional Cognitive Behavior Therapy (CBT) combined with conventional therapy improves outcomes for patients with Persistent Postural-Perceptual Dizziness (PPPD) compared with conventional therapy alone.

Methods

Two reviewers independently searched PubMed, Embase, Web of Science, Cochrane Library, and ClinicalTrials.gov for relevant Randomized Controlled Trials (RCTs) examining CBT for PPPD which were conducted and published in English from January 2002 to November 2022. RCTs reporting any indicators for assessing corresponding symptoms of PPPD were included, such as Dizziness Handicap Inventory (DHI), Hamilton Anxiety Scale (HAMA), Hamilton Depression Scale (HAMD), Hospital Anxiety and Depression Scale (HADS), and Patient Health Questionnaire-9 (PHQ-9). Two independent reviewers conducted extraction of relevant information and evaluation of risk of bias. The Cochrane Collaboration risk of bias tool version 1.0 was used to evaluate risks and assess the quality of the included studies, and Cochrane Review Manager 5.3 software (RevMan 5.3) was used to perform meta-analyses.

Results

The results of six RCTs indicated that combining additional CBT with conventional therapy significantly improved outcomes for PPPD patients compared with conventional therapy alone, especially in DHI-Total scores (Mean Difference [MD = −8.17], 95% Confidence Interval [95% CI: −10.26, −6.09], p< 0.00001), HAMA scores (MD = −2.76, 95% CI: [−3.57, −1.94], p< 0.00001), GAD-7 scores (MD = −2.50, 95% CI [−3.29, −1.70], p< 0.00001), and PHQ-9 scores (MD = −2.29, 95% CI [−3.04, −1.55], p< 0.00001). Subgroup analysis revealed a significant benefit of additional CBT compared with conventional therapies alone, including Vestibular Rehabilitation Therapy (VRT) (MD = −8.70, 95% CI: [−12.17, −5.22], p< 0.00001), Selective Serotonin Reuptake Inhibitor (SSRI) (with controlled SSRI: MD = −10.70, 95% CI: [−14.97, −6.43], p< 0.00001), and VRT combined with SSRI (MD = −6.08, 95% CI [−9.49, −2.67], p= 0.0005) in DHI-Total scores.

Conclusion

Additional CBT combined with conventional therapy may provide additional improvement for patients with PPPD compared with conventional therapy alone. However, more RCTs are needed to support and guide the application of CBT in treating PPPD.

Level of evidence: I; Systematic review of RCTs.

Keywords
Dizziness; Cognitive behavioral therapy; Dizziness handicap inventory

Highlights

Cognitive Behavioral Therapy (CBT) has been widely used in patients with mild to moderate anxiety and depression.

Additional CBT combined with conventional therapy may offer additional improvement to patients with PPPD.

CBT could promote the improvement of symptoms and functional recovery, thereby producing therapeutic effects.

Study	Random sequence generation	Allocation concealment	Blindinng of participants and personel	Blinding of outcome assessment	Incomplete outcome data	Selective reporting	Other sources of bias
Edelman 2012	Low risk	Low risk	High risk	Low risk	Low risk	Low risk	Low risk
Herdman 2022	Low risk	Low risk	High risk	Low risk	High risk	Low risk	Low risk
Qin 2016	Low risk	Low risk	High risk	Low risk	Low risk	Low risk	Low risk
Yu 2018	Low risk	Low risk	High risk	Low risk	Low risk	Low risk	Low risk
Yuan 2016	Low risk	Low risk	High risk	Low risk	High risk	Low risk	Low risk
Zhao 2022	Low risk	Low risk	High risk	Low risk	High risk	Low risk	Low risk

Study	Experiment Group	Control Group	Intervention time	Conducted	Intervention description	Control description	Type of study
Edelman 2012	20-subjective with Chronic Subjective Dizziness	21-subjective with Chronic Subjective Dizziness	3-weekly CBT sessions.	Supervised	Psychoeducation, behavioral experiments, exposure to feared stimuli, and attentional refocusing for 4-weeks	No treatment during RCT, commenced treatment 4-weeks later	RCT
Herdman 2022	19-subjective with Persistent Postural Perceptual Dizziness	20-subjective with Persistent Postural Perceptual Dizziness	6-sessions of INVEST for 4-months, initial session for 60-min, others for 30-min	Supervised	Transparency in communication with cognitive behavioral formulation and psychoeducation, normaling maladaptive postural strategies and attention allocation and relaxation techniques	6-sessions of individual VRT for 4-months including a range of general exercises and more specific adaptation, habituation, visual desensitization, static and dynamic balance exercises.	RCT
Qin 2016	30-subjective with Chronic Subjective Dizziness	30-subjective with Chronic Subjective Dizziness	8-weekly CBT + VRT sessions; one CBT session every 2-weeks for 8-weeks	Supervised and home exercise	Psychological support, health education, cognitive remediation training, exposure training, relaxation training	Balance function training, visual stimulation adaptation training, sports acclimatization training, conducted in both intervention and control group.	RCT
Yu 2018	46-subjective with Persistent Postural Perceptual Dizziness	45-subjective with Persistent Postural Perceptual Dizziness	2-CBT sessions per week for 8-weeks; sertraline every day for 8-weeks	Supervised	Earning the trust of patients; encouraging the patients to communicate with others; making patients expose and check the social factors that cause the PPPD, such as family, work, and social intercourse; making patients have a correct understanding of the occurrence, development, and treatment of PPPD.	Sertraline 50 mg/d ∼200 mg/d, conducted in both intervention and control group.	RCT
Yuan 2016	48-subjective with Chronic Subjective Dizziness	45-subjective with Chronic Subjective Dizziness	8-weekly CBT sessions, 3-VRT sessions every week for 8-weeks	supervised and home exercise	Psychological support, health education, cognitive assessment, relaxation training cognitive remediation training, behavioral training	Cawthorne-Cooksey, sports acclimatization training gaze stabilization training, conducted in both intervention and control group.	RCT
Zhao 2022	40-subjective with Persistent Postural Perceptual Dizziness	42-subjective with Persistent Postural Perceptual Dizziness	9-CBT sessions for 8-weeks	Supervised and home exercise	Disease acceptance, sleep improvement exercise exercises, dizziness emotional cognition, vestibular adaptation training, self-identification and observation, cognitive consolidation and relaxation exercises, emotional management functional activity-related training, exposure exercises, persistence and consolidation	SSRI (Escitalopram Oxalate) 5 mg/d, 10 mg/d after 5 d; Vestibular conditioning, static and dynamic balance training, alternative training, functional mobility related training, conducted in both intervention and control group.	RCT

Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Sede da Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico Facial, Av. Indianópolia, 1287, 04063-002 São Paulo/SP Brasil, Tel.: (0xx11) 5053-7500, Fax: (0xx11) 5053-7512 - São Paulo - SP - Brazil
E-mail: revista@aborlccf.org.br

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[1] Peer Review under the responsibility of Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial.