title: State Anxiety Subjective Imbalance and Handicap in Vestibular Schwannoma.
abstract: BACKGROUND
  Evidence is emerging for a significant clinical and neuroanatomical relationship between balance and anxiety. Research has suggested a potentially priming effect with anxiety symptoms predicting a worsening of balance function in patients with underlying balance dysfunction. We propose to show that a vestibular stimulus is responsible for an increase in state anxiety, and there is a relationship between increased state anxiety and worsening balance function.
  
  
  OBJECTIVE
  (1) To quantify state anxiety following a vestibular stimulus in patients with a chronic vestibular deficit. (2) To determine if state anxiety during a vestibular stimulus would correlate with the severity of chronic balance symptoms and handicap.
  
  
  METHODS
  Two separate cohorts of vestibular schwannoma (VS) patients underwent vestibular tests (electronystagmography, cervical and ocular vestibular evoked myogenic potentials, and caloric responses) and questionnaire assessments [vertigo handicap questionnaire (VHQ), vertigo symptom scale (VSS), and state-trait anxiety inventory (STAIY)]. Fifteen post-resection VS patients, with complete unilateral vestibular deafferentation, were assessed at a minimum of 6 months after surgery in Experiment 1 (Aim 1). Forty-five patients with VS in situ formed the cohort for Experiment 2 (Aim 2). Experiment 1: VS subjects (N = 15) with a complete post-resection unilateral vestibular deafferentation completed a state anxiety questionnaire before caloric assessment and again afterward with the point of maximal vertigo as the reference (Aim 1). Experiment 2: state anxiety measured at the point of maximal vertigo following a caloric assessment was compared between two groups of patients with VS in situ presenting with balance symptoms (Group 1, N = 26) and without balance symptoms (Group 2, N = 11) (Aim 2). The presence of balance symptoms was defined as having a positive score on the VSS-VER.
  
  
  RESULTS
  In Experiment 1, a significant difference (p < 0.01) was found when comparing STAIY at baseline and at the peak of the subjective vertiginous response in post-resection patients with a unilateral vestibular deafferentation. In Experiment 2, VS in situ patients with balance symptoms had significantly worse state anxiety at the peak vertiginous response than patients without balance symptoms (p < 0.001), as did patients with a balance-related handicap (p < 0.001).
  
  
  CONCLUSIONS
  Anxiety symptoms during a vestibular stimulus may contribute to a priming effect that could explain worsening balance function.
authors.affiliation: Institute of Neurology, National Hospital for Neurology and Neurosurgery, UCL, London, UK; Nelson R. Mandela School of Medicine, UKZN, Durban, South Africa.
authors.forename: Yougan
authors.initials: Y
authors.lastname: Saman
authors.affiliation: Neuro-otology Department, National Hospital for Neurology and Neurosurgery , London , England.
authors.forename: Lucie
authors.initials: L
authors.lastname: Mclellan
authors.affiliation: Royal National Throat, Nose and Ear Hospital , London , UK.
authors.forename: Laurence
authors.initials: L
authors.lastname: Mckenna
authors.affiliation: Centre for Integrative Physiology, University of Edinburgh , Edinburgh , UK.
authors.forename: Mayank B
authors.initials: MB
authors.lastname: Dutia
authors.affiliation: ENT and Skull Base Department, Guys Hospital, London, UK; ENT and Skull Base Department, Kings College Hospital, London, UK.
authors.forename: Rupert
authors.initials: R
authors.lastname: Obholzer
authors.affiliation: Neurogastroenterology Group, Queen Mary University of London , London , UK.
authors.forename: Gerald
authors.initials: G
authors.lastname: Libby
authors.affiliation: Neuro-otology and Skull Base Department, National Hospital for Neurology and Neurosurgery , London , UK.
authors.forename: Michael
authors.initials: M
authors.lastname: Gleeson
authors.affiliation: Neuro-otology Department, National Hospital for Neurology and Neurosurgery, London, England; Ear Institute, UCL, London, UK.
authors.forename: Doris-Eva
authors.initials: DE
authors.lastname: Bamiou
keywords: anxiety; balance; cognitive behavioral therapy; handicap; vestibular schwannoma