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Psychological characteristics of patients with Meniere's disease compared with patients with vertigo, tinnitus, or hearing loss.

Abstract

An association between Meniere's disease and psychological distress is frequently reported. Patients who do not have Meniere's disease but who have similar symptoms also experience various kinds of psychological disturbances. We conducted a study to investigate the relationship between Meniere's disease and personality traits, illness behavior, depression, and anxiety. We compared these factors in 77 patients who had Meniere's disease and 133 controls who did not have the disease but had one of its symptoms--either vertigo, tinnitus, or hearing loss. The mental status of study participants was assessed with standard tests. Patients in both groups had higher than normal levels of anxiety and neuroticism. The only significant difference between the two groups was a higher rate of extroversion in the Meniere's disease group. Minor differences emerged when Meniere's patients with tinnitus or vertigo were compared with similar controls. Relationships between psychological observations and otologic symptomatology or an otologic diagnosis were not specific, which illustrates the need to consider the role of illness behavior and personality as targets for psychological support or therapy associated with ENT treatment.

Introduction

Many symptoms typical of some otologic diseases--such as vertigo, tinnitus, and heating loss--are accompanied by psychological disturbances. Symptoms may be present simultaneously, as is the case with Meniere's disease, or alone.

Meniere's disease is generally associated with great psychological distress. Some authors contend that this distress occurs secondary to the disease; other authors believe that the disease itself is actually psychosomatic in origin. (1-5) The psychological distress may manifest as emotional instability, high levels of neuroticism, low levels of extroversion, a tendency toward social disadaptation, and a predisposition to anxiety and depression or a depressive state.

Associations have been noted between Meniere's disease and nervous and meticulous behavior and between Meniere's disease and marital status. A relationship has also been observed between vertigo attacks and distressing factors in Meniere's disease patients, but the relationship appears to be subjective. Approximately 75% of patients with Meniere's disease report that their symptoms limit certain aspects of their life, but the relationship between their discomfort and life satisfaction is only moderate. (6,7)

Some authors believe that there is a genetic predisposition to Meniere's disease. (8-10) In the 1990s, our group conducted a study of 50 Meniere's disease patients to evaluate their personality traits, illness behavior, depression, and anxiety. (11) We found that these patients had significantly higher than normal mean scores for neuroticism and psychological perception of disease. On the other hand, these patients had low scores for affective inhibition (even without great psychological distress, as confirmed by high scores for depression, anxiety, neuroticism, hypochondriasis, disease conviction, dysphoria, and irritability) and low scores for denial. We interpreted these findings as partly representing a result of predisposition factors (e.g., anxiety traits and neuroticism) and partly as representing a sequela of Meniere's disease and indicative of abnormal illness behavior.

Vertigo is probably the symptom that is most frequently associated with psychological disturbances. In the "anxiety neurosis" description of classic psychopathology, the relationship between anxiety and vertigo has already been recognized. In the psychodynamic interpretation, vertigo in particular is considered to be associated with separation anxiety, of which it seems to be a somatic expression.

Some reviews of the link between panic disturbances and vestibular symptoms have been published. (12,13) The greater prevalence of psychiatric disorders in vertiginous patients who have no evidence of otologic changes may mean that psychiatric symptomatology is not simply a reaction to vertigo. Some authors also support the hypothesis that panic disorder is often associated with functional vestibular pathology. (14,15) The link between anxiety disturbances and vertigo is generally interpreted as an effect of somatopsychic and psychosomatic processes, one of which may be sensitization at the cerebral level. (16) Besides anxiety, phobia, and panic attacks (with or without agoraphobia), vertigo is accompanied by depression, dysthymia, and alteration in the quality of life. (17-19)

It has been observed that tinnitus more frequently affects patients with somatic and hypochondrial disturbances than general medical outpatients, indicating that unexplained tinnitus may be a symptom of somatization. Tinnitus sufferers often present with depression, irritability, tension, and sleeping disturbances that modify their quality of life. Some subjects seem to be able to cope positively with the symptom, but others respond negatively. (20,21)

These observations led us to study illness behavior in association with personality traits, anxiety, and depression in such patients, and we published a report in 1996. (11) We found that tinnitus patients had a high state anxiety level along with introversion, neurotic tendency, affective inhibition, and high denial. Cluster analysis identified two subgroups of patients. One subgroup responded normally to psychological tests except for high denial, and the other had high scores for anxiety and depression accompanied by introversion, neuroticism, and illness behavior alterations with high degrees of hypochondriasis and disease conviction, dysphoria, and irritability. The second subgroup was also more often affected by high-intensity tinnitus and, before or after its onset, by psychological symptoms and/or functional somatic symptoms. The second subgroup also made more frequent use of psychotropic drugs. These data are compatible with the hypothesis of a somatopsychic and psychosomatic vicious circle.

Tinnitus and vertigo caused by otologic function pathologies are less frequently associated with psychological suffering. Nevertheless, insecurity in social behavior caused by hearing loss causes feelings of loss of control, which may induce stress reactions. Hearing loss influences the quality of life negatively and may be associated with depression and great emotional disturbance, both social and communicative, particularly in older patients. It also has a negative influence on intimate relations. Psychological suffering is related to the possible concomitant loss of psychological resources, as well as to patients' psychological characteristics. (22-25)

All these observations highlight the frequent association between otologic symptoms and psychological suffering in relation to basic psychological structure and individual illness behavior, although we cannot establish the priority between the psychosomatic or somatopsychic hypotheses. However, from the clinical point of view, it seems more important to recognize whether specific manifestations of psychological suffering and illness behavior exist in relation to otologic symptoms in order to provide specific psychological and psychopharmacologic therapy. Therefore, the question is whether specific elements of suffering among patients with Meniere's disease can be identified in comparison with those who have similar but non-Meniere's symptoms. Perhaps vertigo, tinnitus, and hearing loss are related to a specific type of psychological suffering precisely because of their specific intrinsic differences. (26-28)

The present study was carried out to verify whether the various psychological disturbances are characteristic of each otologic symptom (vertigo, tinnitus, and hearing loss) and whether there is a relationship between these and the psychological distress that appears in the case of Meniere's disease, in which the three symptoms are associated with each other.

Patients and methods

Our study population was made up of 212 consecutively presenting patients who were under observation at the ENT Section of Padova University Hospital in Padova, Italy. This group was made up of 79 patients with Meniere's disease and 133 controls who were affected by either vertigo (n = 28), tinnitus (n = 80), or hearing loss (n = 25) for whom a diagnosis of Meniere's disease was excluded.

The selection criteria for patients with Meniere's disease (11) and tinnitus (24) were stated in reports of our previous studies. Specifically, only Meniere's patients with the three pathognomonic symptoms of the disease--vertigo, tinnitus, and hearing loss--were considered; Meniere's patients who had only the cochlear or vestibular type of disease and those who were in the acute phase were excluded. Only patients who complained of tinnitus and who spontaneously asked to be examined by an ENT specialist for the single symptom of subjective tinnitus of the idiopathic type not associated with other symptoms and/or otologic pathologies were included. Patients suffering from vertigo were included only if there was no association with tinnitus or hearing loss; conversely, hearing loss patients were included only if there was no association with vertigo or tinnitus. Subjects who had experienced head injuries, recent surgery, or a chronic systemic disease and/or damage to other organs were excluded.

All patients underwent a detailed clinical interview, including questions about any psychological or functional somatic symptoms that were present before and/or after the onset of their otologic disturbance (table 1). A psychological evaluation was performed by a psychologist, who used the Eysenck Personality Inventory, the State-Trait Anxiety Inventory, the Zung Self-Rating Depression Scale, and the Illness Behavior Questionnaire (IBQ). (29-32)

Five statistical analyses were performed:

* a comparison of mean test scores of Meniere's patients and controls in relation to normal values using the Student's t test

* multivariate analysis of variance (MANOVA) of test scores considered as dependent variables, using successively different independent sets of variables: (1) Meniere's patients vs. controls, (2) Meniere's patients vs. those with vertigo vs. those with tinnitus, (3) those with vertigo vs. those with tinnitus vs. all patients with hearing loss, including Meniere's patients who were reclassified according to their dominant symptom, and (4) six independent subgroups identified by classifying patients according to symptom and according to the presence or absence of Meniere's disease

* univariate analysis with the Student's t test to evaluate the effect of sociodemographic and clinical variables on test scores. Variables were dichotomized if not already dichotomous. A p value of 0.005 was defined to eliminate type I error due to the high number of tests performed.

* a MANOVA applied to test scores as dependent variables and to diagnostic and clinical variables, which in previous analyses had influenced tests significantly, as independent variables, in order to evaluate interaction effects

* a complete hierarchical linkage cluster analysis to evaluate whether global test scores were capable of defining any homogenous subgroups of patients with particular features highlighted by the psychological tests and, if so, what the relationship was between these features and the otologic diagnosis and symptomatology

The chi-square test and Pearson's correlation coefficient were also applied where appropriate for further evaluation of statistical significance.

Two patients were excluded from the final evaluation because of incomplete data.

Results

A comparison of normative data reported in the literature with the mean test scores of Meniere's patients and controls showed that depressive symptomatology was only slightly lower than the pathologic threshold, whereas state anxiety was higher than the norm in controls and tendentially higher in all patients (table 2). Personality factors revealed higher scores for neuroticism for both Meniere's patients and controls. Extroversion was much lower than the norm in controls with respect to Meniere's patients. Psychoticism was tendentially higher in both groups. The IBQ scores in relation to the reference values from groups of patients hospitalized for various diseases were higher for psychological perception of disease and lower for affective inhibition in both groups. Controls presented greater denial and lower irritability compared with normal values; in Meniere's patients, these aspects were present, but not to a significant extent.

The results of the MANOVA, considered as dependent variables, and the diagnostic groupings, considered as independent variables (Meniere's patients vs. controls), did not show any significant difference (p < 0.249) as a main effect, although controls had significantly lower scores for extroversion (p < 0.002).

Analyses of groups distinguished according to otologic diagnosis (Meniere's disease, vertigo, tinnitus, and hearing loss) did not show any significant differences, nor were any differences observed when patients were distinguished according to predominant symptom.

Considering variable diagnosis (Meniere's vs. controls) and dominant symptom together, an interaction effect was found (p < 0.046), due essentially to affective inhibition (p < 0.003), which was greater in Meniere's patients with hearing loss, and to irritability (p < 0.05), which was greater in Meniere's patients with vertigo (table 3, first column).

The MANOVA performed on six independent groups, obtained by reclassifying patients by diagnosis (Meniere's vs. controls) and dominant symptom, did not reveal any significant differences (table 3). However, greater affective inhibition in tinnitus sufferers was confirmed, and greater hypochondriasis for vertigo patients was shown in the Meniere's group (p < 0.026). In controls differentiated according to dominant symptom, a significant difference for irritability was shown, particularly in tinnitus sufferers compared with hearing loss subjects (p < 0.047), but in any case lower in relation to reference values (2.1 vs. 2.7). Meniere's patients with hearing loss had significantly higher scores for irritability than did non-Meniere's patients with hearing loss (p < 0.041). Lastly, comparisons between tinnitus sufferers, divided into Meniere's patients and controls, revealed a significant main effect (p < 0.036) due to the greater introversion of controls (p < 0.006), accompanied by a tendency toward greater hypochondriasis (p < 0.05) and lower psychological perception of disease (p < 0.06) (table 3).

Data for patients with vertigo also showed a tendency toward greater suffering, particularly with regard to depression and anxiety, although statistical significance was not reached. In particular, vertigo controls had mean scores for depression above the normal threshold; for Meniere's patients with vertigo, the scores were slightly lower. Table 4 shows the significance of comparisons between test scores compared with other hospitalizations, demographic, and clinical variables. Some demographic variables influenced the test results. Sex produced a higher score for depression and a lower score for denial in women. Age gave rise to greater irritability (IBQ) in younger subjects ([less than or equal to] 40 yr), as already noted in the literature. Marital status, employment status, and education level did not seem to influence test results substantially.

Clinical variables, such as disease duration and hospitalizations, did not seem to influence test scores significantly. Disease duration was evaluated both as time from first onset of symptoms (mean: 75 mo; maximum: 477) and time from diagnosis (mean: 52 mo; maximum: 477). The difference in months between the onset of symptoms and diagnosis (mean: 23; maximum: 353) was also examined. Dichotomous evaluations did not show significant differences. Onset of symptomatology more than 24 months earlier occurred in 59.0% of patients (124 of 210). A lapse between symptom onset and diagnosis of 6 months or more occurred in 33.3% of patients (70 of 210). More accurate evaluation using Pearson's correlation coefficient revealed only a moderate positive correlation between disease conviction and months from disease onset and between disease conviction and months from diagnosis (r = 0.15 and 0.14, respectively; p < 0.05).

A family history of psychological symptoms gave rise to lower denial scores and a tendency toward higher scores for state and trait anxiety, disease conviction, and dysphoria. A history of functional somatic symptoms prior to disease onset (different from those typical of the disease) was associated with higher scores for depression and trait anxiety and tendentially higher scores for state anxiety, neuroticism, disease conviction, and dysphoria. Similar but more significant differences were observed in patients who reported functional somatic symptoms only after disease onset.

Psychological symptoms after disease onset produced significant differences in almost all tests, with higher scores mainly for depression, state and trait anxiety, neuroticism, disease conviction, and dysphoria, and tendentially higher scores for hypochondriasis and irritability. Psychological symptoms before disease onset had a lesser effect: higher scores for neuroticism and dysphoria and tendentially higher scores for anxiety and depression, and lower scores for denial. A history of previous psychotropic drug use was the condition that most greatly influenced test results. Scores were significantly higher for depression, anxiety, neuroticism, disease conviction, and dysphoria and tendentially higher for hypochondriasis; they tended to be lower for extroversion and denial.

Multivariate analysis of test results, diagnosis, and significant clinical variables performed to evaluate interaction effects demonstrated the absence of any interaction among variables, diagnosis, and dominant symptom. No significant interaction effects were observed, even among the most significant clinical variables, such as previous psychotropic drug use and psychological or somatic symptomatology subsequent to disease onset.

Psychotropic drug use and subsequent somatic symptoms confirmed their effects on test results, but there was no interaction. Although psychological symptoms demonstrated a positive trend in some evaluation scales, they did not influence the test results significantly in multivariate analysis (table 5). In detail, somatic symptoms subsequent to otologic disturbance were associated with higher depression scores (mean: 49.4 vs. 38.7), higher disease conviction scores (mean: 2.9 vs. 1.8), and lower psychological perception of disease scores (mean: 2.0 vs. 2.5). Previous psychotropic drug use was associated with higher scores for state anxiety (mean: 44.5 vs. 37.8), trait anxiety (mean: 44.5 vs. 37.8), dysphoria (mean: 3.3 vs. 1.6), and neuroticism (mean: 13.8 vs. 9.7).

On a psychological level, cluster analysis led to the classification of patients into two clearly differentiated groups: cluster I and cluster II (table 6). (Only 3 patients fell into a third group, and they were not considered for further analysis). Cluster I (little suffering) patients had low scores on psychological suffering tests and high scores for denial. Personality traits were normal extroversion and low neuroticism. Cluster II (high suffering) patients, who accounted for 41% of the entire group, showed very high levels of depression and anxiety; personality traits were particularly high neuroticism, low extroversion, and high psychoticism. The IBQ yielded high scores for hypochondriasis, disease conviction, dysphoria, and irritability. Affective inhibition was significantly higher in cluster II than in cluster I, although still within the normal range. Denial was significantly lower in cluster II but approached normal values.

Patient distribution in cluster II was no different for Meniere's patients than controls. No differences in relation to dominant symptom were observed.

Discussion

Scores on the symptomatologic scale (anxiety and depression) showed that our patients remained at the upper limit of normal for depression and did not go beyond that threshold. State and trait anxiety clearly exceeded indicative thresholds, demonstrating that this population has evident psychological distress as confirmed by the higher scores for neuroticism and psychoticism revealed by the Eysenck test (table 2).

Study of illness behavior in comparison with the normal IBQ values revealed that the role played by denial was higher in our sample patients, particularly the controls. Irritability, affective inhibition, and psychological interpretation of disease were also greater (table 3). Although it might be thought that these features--particularly greater anxiety, irritability, and denial--were related to duration of disease, only a slight relation with disease conviction was in fact observed.

Comparisons between Meniere's patients and controls in the various tests were negative in terms of statistical significance except for extroversion, due mostly to Meniere's patients with tinnitus. This may be a casual feature because of the slight prevalence of cluster I patients (higher extro-version) among the Meniere's tinnitus patients in relation to the other symptomatologic groups.

Psychological and/or functional somatic symptoms after disease onset and previous psychotropic drug use were particularly important variables in influencing test scores. However, analysis of data clearly demonstrated that the relationship between otologic disturbance and test scores was not influenced by these variables.

Cluster analysis also showed that in cluster II, abnormal illness behavior with introvert and neurotic personality traits was not related to otologic symptoms or diagnosis but rather to previous psychological or functional somatic symptoms. One hypothesis is that this group simply represents the prevalence of psychological suffering in an otologic patient sample. This group may have psychological suffering with frequencies compatible with those found in similar studies--for instance, among general practitioners' patients, in whom there is a well-defined psychiatric diagnosis rate of 24%, to which must be added 40% of under-threshold diagnoses or isolated psychological symptoms. (1)

Another hypothesis is that a specific link between psychological suffering and otologic symptomatology emerges only among a particular subgroup of patients. In fact, the two different features appear on the psychological level. On one hand, there are patients with functional somatic symptomatology, higher disease conviction, and lower psychological disease perception who show psychological disturbances in the body through a mechanism of somatization and who show signs of being more depressed. On the other hand, there are clearly more neurotic patients who mainly show anxiety, dysphoria, and previous psychotropic drug use. However, these features do not seem to be related to either otologic symptoms or diagnosis.

Some differences emerged in the three subgroups (vertigo, tinnitus, and hearing loss) between Meniere's and non-Meniere's patients (table 3). Non-Meniere's patients with tinnitus have lower extroversion, tendentially greater hypochondriasis, and lower psychological perception of illness scores. Within the group of Meniere's patients with vertigo, there was a tendency toward greater hypochondriasis; in those with tinnitus, there was a tendency toward greater extroversion but high neuroticism; in those with hearing loss, there was a tendency toward greater affective inhibition. In both Meniere's patients and controls, there was a similar gradient in the anxiety and depression scores, with vertigo patients heading the list for suffering, followed by those with tinnitus and hearing loss. However, because of their low significance, these data cannot be interpreted in a clinically applicable manner.

It is also possible that some differences resulted from (or others were masked by) the inevitable heterogeneity of the control patients in the three subgroups. The Meniere's patients were also heterogenous, according to the differing importance of one of the typical symptoms, and they were not completely comparable with the groups of controls who presented with the other two symptoms.

In conclusion, our data provide little or no support for the hypothesis that there are different specific relationships between Meniere's disease and vertigo, tinnitus, or hearing loss and personality traits, psychological suffering, and illness behavior. Psychological suffering does not appear to be influenced by duration of illness. Predisposing factors, such as neurotic and introversion traits, may play a primary role in determining individual susceptibility to psychological suffering in relation to illness. However, denial emerges as a factor associated with less psychological suffering.

The fact that relationships between otologic symptomatology or diagnosis and psychological observations are not specific highlights the role of illness behavior and personality as targets for psychological support or therapy associated with ENT treatment.

Acknowledgment

The authors thank Mrs. Gabriel Walton for checking the English version of this manuscript.

References

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Marina Savastano, MD; Gino Marioni, MD; Maria Aita, PsyD

From the ENT Section, Department of Medical-Surgical Specialities, Padova University Hospital, Padova, Italy.

Reprint requests: Marina Savastano, MD, ENT Section, Padova University Hospital, Via Giustiniani 2, 35128, Padova, Italy. Phone: 39-49-821-2029; fax: 39-49-875-2266; e-mail: marina.savastano@unipd.it
Table 1. Demographic, social, and clinical features of
study patients

 n * (%)

Female sex 118/212 (55.7)
Age [less than or equal to] 40 yr 67/211 (31.8)
Married 165/209 (78.9)
Employed 109/210 (51.9)
School attendance [less than or equal to] 11 yr 140/208 (67.3)
Previous psychological symptoms 122/196 (62.2)
Subsequent psychological symptoms 146/196 (74.5)
Previous functional disturbances 96/199 (48.2)
Subsequent functional disturbances 165/199 (82.9)
Psychotropic drug use 79/199 (39.7)
ENT hospitalizations 133/206 (64.6)
Other hospitalizations 151/206 (73.3)
Duration of disease [greater than or equal to] 24 mo 124/210 (59.0)
Difference of [greater than or equal to] 6 mo between 70/210 (33.3)
 symptom onset and diagnosis
Family history of psychiatric disturbances 103/198 (52.0)

* Not all data here available for all patients.

Table 2. Comparison of normal values with findings in Meniere's
disease patients and controls

 Normal Meniere's patients
Assessment values (n = 77)

 Mean SD p Value

Zung-depression <50 47.3 11.5 0.067
STAI-state anxiety <40 42.7 11.0 0.056
STAI-trait anxiety <41 42.1 10.6 0.418
IBQ1-hypochondriasis 3.7 3.4 2.4 0.308
IBQ2-disease conviction 2.6 2.8 1.6 0.280
IBQ3-psychosomatic perception 1.8 2.2 1.0 0.001
IBQ4-affective inhibition 2.7 2.1 1.6 0.001
IB05-dysphoria 2.7 2.4 1.7 0.204
IBQ6-denial 2.7 3.1 1.7 0.089
IBQ7-irritability 2.4 2.0 1.4 0.194
EPI-psychoticism 3.38 3.9 2.2 0.294
EPI-extroversion 13.13 13.1 3.6 0.960
EPI-neuroticism 11.16 12.6 4.6 0.016

 Controls
Assessment (n = 133)

 Mean SD p Value

Zung-depression 48.3 11.9 0.134
STAI-state anxiety 43.7 11.4 0.001
STAI-trait anxiety 42.9 11.2 0.073
IBQ1-hypochondriasis 3.5 2.2 0.418
IBQ2-disease conviction 2.6 1.7 0.897
IBQ3-psychosomatic perception 2.0 0.9 0.015
IBQ4-affective inhibition 2.2 1.6 0.000
IB05-dysphoria 2.6 1.8 0.569
IBQ6-denial 3.4 1.4 0.000
IBQ7-irritability 1.9 1.5 0.011
EPI-psychoticism 3.8 2.1 0.332
EPI-extroversion 11.8 4.1 0.006
EPI-neuroticism 12.6 5.1 0.003

 All patients
Assessment (N = 210)

 Mean SD p Value

Zung-depression 48.1 11.8 0.029
STAI-state anxiety 43.6 11.5 0.000
STAI-trait anxiety 42.8 11.1 0.028
IBQ1-hypochondriasis 3.5 2.3 0.263
IBQ2-disease conviction 2.7 1.7 0.459
IBQ3-psychosomatic perception 2.1 1.0 0.000
IBQ4-affective inhibition 2.1 1.6 0.000
IB05-dysphoria 2.6 1.8 0.294
IBQ6-denial 3.3 1.5 0.022
IBQ7-irritability 2.0 1.5 0.000
EPI-psychoticism 3.8 2.2 0.007
EPI-extroversion 12.2 4.1 0.002
EPI-neuroticism 12.6 5.1 0.000

Key: SD = standard deviation; STAI = State-Trait Anxiety Inventory
IBQ = Illness Behavior Questionnaire; EPI = Eysenck Personality
Inventory.

Table 3. Mean test scores of six subgroups defined by dividing
Meniere's disease patients and controls according to the dominant
symptom *

 Diagnostic group (A)

 Meniere's patients
 (n = 77)

 Vertigo (1) Tinnitus (2) Hearing loss (3)
Dominant symptom (B) (n = 33) (n = 35) (n = 9)

Zung-depression 49.5 45.7 45.3
STAI-state anxiety 44.2 42.0 40.9
STAI-trait anxiety 44.2 41.4 39.4
IBQ1-hypochondriasis 4.1 2.5 3.4
IBQ2-disease
 conviction 3.1 2.6 2.4
IBQ3-psychosomatic
 perception 2.2 2.4 1.9
IBQ4-affective
 inhibition 2.0 1.7 3.6
IBQ5-dysphoria 2.6 2.4 2.3
IBQ6-denial 3.0 3.0 3.4
IBQ7-irritability 2.3 1.8 2.1
EPI-psychoticism 4.2 3.4 4.3
EPI-extroversion 12.7 14.1 10.9
EPI-neuroticism 12.5 12.8 12.3

 Diagnostic group (A)

 Controls
 (n = 133)

 Vertigo (4) Tinnitus (5) Hearing loss (6)
Dominant symptom (B) (n = 28) (n = 80) (n = 25)

Zung-depression 50.3 47.4 48.7
STAI-state anxiety 44.0 43.9 42.5
STAI-trait anxiety 44.5 42.2 42.0
IBQ1-hypochondriasis 3.4 3.5 3.7
IBQ2-disease
 conviction 2.3 2.7 2.6
IBQ3-psychosomatic
 perception 2.1 2.0 1.9
IBQ4-affective
 inhibition 2.2 2.2 2.1
IBQ5-dysphoria 2.9 2.6 2.3
IBQ6-denial 3.2 3.4 3.4
IBQ7-irritability 1.6 2.1 1.4
EPI-psychoticism 3.6 3.8 3.7
EPI-extroversion 11.4 11.9 11.9
EPI-neuroticism 13.6 12.4 11.7

 Diagnostic group (A)

 Comparisons and interactions
 (p value)

 A/B 1/2/3 4/5/6 2/5
Dominant symptom (B) 0.046 0.140 0.862 0.036

Zung-depression 0.900 0.372 0.535 0.510
STAI-state anxiety 0.866 0.641 0.852 0.418
STAI-trait anxiety 0.897 0.376 0.631 0.723
IBQ1-hypochondriasis 0.097 0.026 0.885 0.054
IBQ2-disease
 conviction 0.240 0.361 0.587 0.856
IBQ3-psychosomatic
 perception 0.565 0.390 0.732 0.063
IBQ4-affective
 inhibition 0.033 0.008 0.993 0.205
IBQ5-dysphoria 0.906 0.827 0.463 0.546
IBQ6-denial 0.702 0.775 0.704 0.160
IBQ7-irritability 0.050 0.319 0.047 0.236
EPI-psychoticism 0.316 0.281 0.930 0.365
EPI-extroversion 0.190 0.053 0.890 0.006
EPI-neuroticism 0.633 0.964 0.385 0.734

* Some comparisons and interactions, will relative p values, were
derived Jinni MANOVA results. Key: For an explanation of the "Dominant
symptom" column, see table 2.

Table 4. Statistical significance of psychological test analyses
(Student's t test)

 Zung STAI-S STAI-T IBQ1

Female sex B T
Age [less than or equal to] 40 yr -T
Married
Employed
School attendance [less than or
 equal to] 11 yr T
Previous psychological symptoms T T T
Subsequent psychological symptoms B A A T
Previous functional disturbances A T B
Subsequent functional
 disturbances A B B
Psychotropic drug use A A A T
ENT hospitalizations
Other hospitalizations T
Duration of disease [greater
 than or equal to] 24 mo
Difference of [greater than or
 equal to] 6 mo between symptom
 onset and diagnosis
Family history of psychiatric
 disturbances T T

 IBQ2 IBQ3 IBQ4 IBQ5

Female sex
Age [less than or equal to] 40 yr
Married
Employed
School attendance [less than or
 equal to] 11 yr T B
Previous psychological symptoms A
Subsequent psychological symptoms A T
Previous functional disturbances T T
Subsequent functional
 disturbances A A
Psychotropic drug use A -T
ENT hospitalizations
Other hospitalizations
Duration of disease [greater
 than or equal to] 24 mo
Difference of [greater than or
 equal to] 6 mo between symptom
 onset and diagnosis
Family history of psychiatric
 disturbances T T

 IBQ6 IBQ7 EPI-P

Female sex -B
Age [less than or equal to] 40 yr B
Married -T
Employed
School attendance [less than or
 equal to] 11 yr -T
Previous psychological symptoms T
Subsequent psychological symptoms
Previous functional disturbances
Subsequent functional
 disturbances -T
Psychotropic drug use
ENT hospitalizations
Other hospitalizations -T
Duration of disease [greater
 than or equal to] 24 mo
Difference of [greater than or
 equal to] 6 mo between symptom
 onset and diagnosis
Family history of psychiatric
 disturbances -B

 EPI-E EPI-N

Female sex
Age [less than or equal to] 40 yr
Married
Employed
School attendance [less than or
 equal to] 11 yr A
Previous psychological symptoms A
Subsequent psychological symptoms T
Previous functional disturbances B
Subsequent functional
 disturbances -T A
Psychotropic drug use
ENT hospitalizations
Other hospitalizations
Duration of disease [greater
 than or equal to] 24 mo
Difference of [greater than or
 equal to] 6 mo between symptom
 onset and diagnosis
Family history of psychiatric
 disturbances

Key: B = p < 0.005; T = trend p < 0.05 and > 0.005; A = p [less than
or equal to] 0.0001. Minus sign indicates lower scores in this
group. Dichotomised variables typically distinguish first of two
groups of each variable. For an explanation of the abbreviated column
headings, see table 2.

Table 5. MANOVA of main effects of psychological (PSPO) and somatic
(SMPO) symptoms subsequent to disease and use of psychotropic
drugs (PSIF)

 PSPO (1) SMPO (2)
 p < 0.569 p < 0.014

Dominant symptom F p Value F p Value

Zung-depression 0.97 0.327 15.78 0.000
STAI-state anxiety 2.54 0.113 1.95 0.165
STAI-trait anxiety 3.80 0.053 3.26 0.073
IB01-hypochondriasis 1.85 0.176 1.99 0.160
IBQ2-disease conviction 3.53 0.062 9.03 0.003
IBQ3-psychosomatic perception 0.06 0.801 5.84 0.017
IBQ4-affective inhibition 1.14 0.287 0.51 0.476
IB05-dysphoria 2.17 0.142 0.52 0.473
IBQ6-denial 0.06 0.804 0.47 0.493
IB07-irritability 1.45 0.230 0.27 0.602
EPI-psychoticism 3.72 0.055 0.79 0.376
EPI-extroversion 0.23 0.633 0.60 0.439
EPI-neuroticism 0.82 0.365 1.37 0.243

 PSIF (3)
 p < 0.023

Dominant symptom F p Value

Zung-depression 2.63 0.107
STAI-state anxiety 7.27 0.008
STAI-trait anxiety 6.57 0.011
IB01-hypochondriasis 0.21 0.644
IBQ2-disease conviction 2.65 0.105
IBQ3-psychosomatic perception 1.34 0.249
IBQ4-affective inhibition 0.00 0.976
IB05-dysphoria 16.81 0.000
IBQ6-denial 1.88 0.172
IB07-irritability 1.87 0.173
EPI-psychoticism 0.24 0.627
EPI-extroversion 2.84 0.093
EPI-neuroticism 13.50 0.000

Key F = estimated parameter by MANOVA. For an explanation of the
"Dominant symptom" column. see table 2. Degree of freedom
(d.f.) = 1.188: interactions 1/2, 1/3, 2/3, and 1/2/3 were not
significant (d.f.: 13.176).

Table 6. Test values in clusters II and II

 Normal Cluster I Cluster II
 values (n = 122) (n = 87)

 Mean SD Mean SD

Zung-depression <50 40.05 6.892 58.68 7.560
STAI-state anxiety <40 37.43 7.815 52.63 9.651
STAI-trait anxiety <41 35.60 7.085 53.08 7.098
IB01-hypochondriasis 3.7 2.63 1.997 4.77 2.166
IB02-disease conviction 2.6 2.04 1.417 3.63 1.533
IB03-psychosomatic
 perception 1.8 2.00 0.813 2.25 1.143
204-affective inhibition 2.7 1.79 1.501 2.60 1.667
IBQ5-dysphoria 2.7 1.57 1.426 4.02 1.201
IBQ6-denial 2.7 3.66 1.327 2.63 1.578
IBQ7-irritability 2.4 1.57 1.373 2.56 1.344
EPI-psychoticism 3.38 3.46 2.144 4.34 2.307
EPI-extroversion 13.13 13.04 3.793 10.91 4.116
EPI-neuroticism 11.16 9.64 3.537 16.85 3.568

 Cluster II Cluster I
 vs. normal vs. cluster II

 p Value p Value

Zung-depression 0.000 0.000
STAI-state anxiety 0.000 0.000
STAI-trait anxiety 0.000 0.000
IB01-hypochondriasis 0.000 0.000
IB02-disease conviction 0.000 0.000
IB03-psychosomatic
 perception 0.001 0.063
204-affective inhibition 0.617 0.000
IBQ5-dysphoria 0.000 0.000
IBQ6-denial 0.711 0.000
IBQ7-irritability 0.322 0.000
EPI-psychoticism 0.001 0.005
EPI-extroversion 0.000 0.000
EPI-neuroticism 0.000 0.000

Key: See table 2.
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