Psychological characteristics of patients with Meniere's disease compared with patients with vertigo, tinnitus, or hearing loss.
An association between Meniere's disease Mé·nière's disease
A pathological condition of the inner ear that is characterized by dizziness, ringing in the ears, and progressive loss of hearing. Also called auditory vertigo, endolymphatic hydrops, labyrinthine vertigo. and psychological distress psychological distress The end result of factors–eg, psychogenic pain, internal conflicts, and external stress that prevent a person from self-actualization and connecting with 'significant others'. See Humanistic psychology. 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 vertigo (vûr`tĭgō), sensations of moving in space or of objects moving about a person and the resultant difficulty in maintaining equilibrium. , tinnitus Tinnitus Definition
Tinnitus is hearing ringing, buzzing, or other sounds without an external cause. Patients may experience tinnitus in one or both ears or in the head. , 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 neuroticism
a neurotic condition; psychoneurosis.
See also: Psychology
Noun 1. neuroticism - a mental or personality disturbance not attributable to any known neurological or organic dysfunction
neurosis, psychoneurosis . The only significant difference between the two groups was a higher rate of extroversion extroversion /ex·tro·ver·sion/ (eks?tro-ver´zhun)
1. a turning inside out.
2. direction of one's energies and attention outward from the self. 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 symptomatology /symp·to·ma·tol·o·gy/ (simp?to-mah-tol´ah-je)
1. the branch of medicine dealing with symptoms.
2. the combined symptoms of a disease.
n. 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 ENT ears, nose, and throat (otorhinolaryngology).
ear, nose, and throat
ear, nose and throat.
ENT Ears, nose & throat; formally, otorhinolaryngology treatment.
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 psychosomatic /psy·cho·so·mat·ic/ (-sah-mat´ik) pertaining to the mind-body relationship; having bodily symptoms of psychic, emotional, or mental origin.
1. 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 predisposition /pre·dis·po·si·tion/ (-dis-po-zish´un) a latent susceptibility to disease that may be activated under certain conditions.
1. to anxiety and depression or a depressive de·pres·sive
1. Tending to depress or lower.
2. Depressing; gloomy.
3. Of or relating to psychological depression.
A person suffering from psychological depression. state.
Associations have been noted between Meniere's disease and nervous and meticulous me·tic·u·lous
1. Extremely careful and precise.
2. Extremely or excessively concerned with details.
[From Latin met behavior and between Meniere's disease and marital status marital status,
n the legal standing of a person in regard to his or her marriage state. . 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 genetic predisposition Molecular medicine The tendency to suffer from certain genetic diseases–eg, Huntington's disease, or inherit certain skills–eg, musical talent 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 affective /af·fec·tive/ (ah-fek´tiv) pertaining to affect.
1. Concerned with or arousing feelings or emotions; emotional.
2. inhibition (even without great psychological distress, as confirmed by high scores for depression, anxiety, neuroticism, hypochondriasis hypochondriasis
Mental disorder in which an individual is excessively preoccupied with his own health and inclined to treat insignificant physical signs or symptoms as evidence of a serious disease. , disease conviction, dysphoria dysphoria /dys·pho·ria/ (-for´e-ah) [Gr.] disquiet; restlessness; malaise.dysphoret´icdysphor´ic
gender dysphoria , and irritability irritability /ir·ri·ta·bil·i·ty/ (ir?i-tah-bil´i-te) the quality of being irritable.
myotatic irritability the ability of a muscle to contract in response to stretching. ) 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 sequela /se·que·la/ (se-kwel´ah) pl. seque´lae [L.] a morbid condition following or occurring as a consequence of another condition or event.
n. pl. 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 Noun 1. anxiety neurosis - characterized by diffuse anxiety and often somatic manifestations of fear
neurosis, neuroticism, psychoneurosis - a mental or personality disturbance not attributable to any known neurological or organic dysfunction " description of classic psychopathology psychopathology /psy·cho·pa·thol·o·gy/ (-pah-thol´ah-je)
1. the branch of medicine dealing with the causes and processes of mental disorders.
2. abnormal, maladaptive behavior or mental activity. , the relationship between anxiety and vertigo has already been recognized. In the psychodynamic Psychodynamic
A therapy technique that assumes improper or unwanted behavior is caused by unconscious, internal conflicts and focuses on gaining insight into these motivations.
Mentioned in: Group Therapy, Suicide interpretation, vertigo in particular is considered to be associated with separation anxiety, of which it seems to be a somatic somatic /so·mat·ic/ (so-mat´ik)
1. pertaining to or characteristic of the soma or body.
2. pertaining to the body wall in contrast to the viscera.
Some reviews of the link between panic disturbances and vestibular ves·tib·u·lar
Of, relating to, or serving as a vestibule, especially of the ear.
Pertaining to the vestibule; regarding the vestibular nerve of the ear which is linked to the ability to hear sounds. symptoms have been published. (12,13) The greater prevalence of psychiatric disorders in vertiginous ver·tig·i·nous
1. Affected by vertigo; dizzy.
2. Tending to produce vertigo.
vertiginous adjective Related to vertigo, dizzy 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 Panic Disorder Definition
A panic attack is a sudden, intense experience of fear coupled with an overwhelming feeling of danger, accompanied by physical symptoms of anxiety, such as a pounding heart, sweating, and rapid breathing. 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 sensitization /sen·si·ti·za·tion/ (sen?si-ti-za´shun)
1. administration of an antigen to induce a primary immune response.
2. exposure to allergen that results in the development of hypersensitivity. at the cerebral level. (16) Besides anxiety, phobia phobia: see neurosis.
Extreme and irrational fear of a particular object, class of objects, or situation. A phobia is classified as a type of anxiety disorder (a neurosis), since anxiety is its chief symptom. , and panic attacks panic attacks,
n.pl distressing episodes where an individual experiences palpitations, anxiety, apprehension, sweating, trembling, etc. Can last several minutes and recur unpredictably. (with or without agoraphobia Agoraphobia Definition
The word agoraphobia is derived from Greek words literally meaning "fear of the marketplace." The term is used to describe an irrational and often disabling fear of being out in public. ), vertigo is accompanied by depression, dysthymia dysthymia /dys·thy·mia/ (-thi´me-ah) dysthymic disorder.
A mood disorder characterized by despondency or mild depression. , 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 unexplained
strange or unclear because the reason for it is not known
Adj. 1. unexplained - not explained; "accomplished by some unexplained process" tinnitus may be a symptom of somatization somatization /so·ma·ti·za·tion/ (so?mah-ti-za´shun) the conversion of mental experiences or states into bodily symptoms.
n. . 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 introversion: see extroversion and introversion. , neurotic neurotic /neu·rot·ic/ (ndbobr-rot´ik)
1. pertaining to or characterized by a neurosis.
2. a person affected with a neurosis.
adj. tendency, affective inhibition, and high denial. Cluster analysis Cluster analysis
A statistical technique that identifies clusters of stocks whose returns are highly correlated within each cluster and relatively uncorrelated across clusters. Cluster analysis has identified groupings such as growth, cyclical, stable, and energy stocks. identified two subgroups of patients. One subgroup sub·group
1. A distinct group within a group; a subdivision of a group.
2. A subordinate group.
3. Mathematics A group that is a subset of a group.
tr.v. responded normally to psychological tests Psychological Tests Definition
Psychological tests are written, visual, or verbal evaluations administered to assess the cognitive and emotional functioning of children and adults. 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 psychotropic drug Psychoactive drug Pharmacology A drug that affects brain activities associated with mental processes and behavior Categories Anti-psychotics; antidepressants; antianxiety drugs or anxiolytics; hypnotics. . These data are compatible with the hypothesis of a somatopsychic and psychosomatic vicious circle vi·cious circle
A condition in which a disorder or disease gives rise to another that subsequently affects the first. .
Tinnitus and vertigo caused by otologic function pathologies are less frequently associated with psychological suffering. Nevertheless, insecurity Insecurity
Inseparability (See FRIENDSHIP.)
Insolence (See ARROGANCE.)
introspective, vacillating Prince of Denmark. [Br. Lit.: Hamlet]
cartoon character who is lost without his security blanket. in social behavior In biology, psychology and sociology social behavior is behavior directed towards, or taking place between, members of the same species. Behavior such as predation which involves members of different species is not social. 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 Noun 1. emotional disturbance - any mental disorder not caused by detectable organic abnormalities of the brain and in which a major disturbance of emotions is predominant
affective disorder, emotional disorder, major affective disorder , both social and communicative com·mu·ni·ca·tive
1. Inclined to communicate readily; talkative.
2. Of or relating to communication.
com·mu , particularly in older patients. It also has a negative influence on intimate relations. Psychological suffering is related to the possible concomitant concomitant /con·com·i·tant/ (kon-kom´i-tant) accompanying; accessory; joined with another.
concomitant adjective Accompanying, accessory, joined with another 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 pathognomonic symptom
A symptom that is a definitive indication of a certain disease or condition. of the disease--vertigo, tinnitus, and hearing loss--were considered; Meniere's patients who had only the cochlear cochlear
pertaining to or emanating from the cochlea.
the coiled portion of the membranous labyrinth located inside the cochlea; contains endolymph.
see Table 14. 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 idiopathic /id·io·path·ic/ (id?e-o-path´ik) self-originated; occurring without known cause.
1. Of or relating to a disease having no known cause; agnogenic. 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 con·verse 1
intr.v. con·versed, con·vers·ing, con·vers·es
1. To engage in a spoken exchange of thoughts, ideas, or feelings; talk. See Synonyms at speak.
2. , 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 A systemic disease is one that affects a number of organs and tissues, or affects the body as a whole  Although most medical conditions will eventually involve multiple organs in advanced stage (i.e. 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 Eysenck Personality Inventory,
n.pr questionnaire in a self-report format that measures the personality aspect of extraversion-introversion and neuroticism-stability and includes a lie scale. , the State-Trait Anxiety Inventory, the Zung Self-Rating Depression Scale The Zung Self-Rating Depression Scale was designed by Duke University psychiatrist, Dr. William W.K. Zung to assess the level of depression for patients diagnosed with depressive disorder. , and the Illness Behavior Questionnaire (IBQ IBQ Iowa Brass Quintet (University of Iowa) ). (29-32)
Five statistical analyses were performed:
* a comparison of mean test scores of Meniere's patients and controls in relation to normal values normal values
A set of laboratory test values used to characterize apparently healthy individuals, now replaced by reference values. using the Student's t test
* multivariate analysis multivariate analysis,
n a statistical approach used to evaluate multiple variables.
n a set of techniques used when variation in several variables has to be studied simultaneously. of variance (MANOVA MANOVA Multivariate Analysis of the Variance ) 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 according to
1. As stated or indicated by; on the authority of: according to historians.
2. In keeping with: according to instructions.
3. 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 di·chot·o·mous
1. Divided or dividing into two parts or classifications.
2. Characterized by dichotomy.
di·chot . 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 homogenous - homogeneous 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 chi-square test: see statistics. and Pearson's correlation coefficient Correlation Coefficient
A measure that determines the degree to which two variable's movements are associated.
The correlation coefficient is calculated as: were also applied where appropriate for further evaluation of statistical significance.
Two patients were excluded from the final evaluation because of incomplete data.
A comparison of normative nor·ma·tive
Of, relating to, or prescribing a norm or standard: normative grammar.
nor 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 pathologic /patho·log·ic/ (path?ah-loj´ik)
1. indicative of or caused by some morbid condition.
2. pertaining to pathology. 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 ref·er·ence values
A set of laboratory test values obtained from an individual or from a group in a defined state of health. 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 Noun 1. positive correlation - a correlation in which large values of one variable are associated with large values of the other and small with small; the correlation coefficient is between 0 and +1
direct 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.
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 introvert /in·tro·vert/ (in´tro-vert)
1. a person whose interest is turned inward to the self.
2. to turn one's interest inward to the self.
3. a structure that can be turned or drawn inwards. 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 het·er·o·ge·ne·i·ty
The quality or state of being heterogeneous.
the state of being heterogeneous. of the control patients in the three subgroups. The Meniere's patients were also heterogenous (spelling) heterogenous - It's spelled heterogeneous. , 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 acknowledgment, in law, formal declaration or admission by a person who executed an instrument (e.g., a will or a deed) that the instrument is his. The acknowledgment is made before a court, a notary public, or any other authorized person.
The authors thank Mrs. Gabriel Walton for checking the English version of this manuscript.
(1.) Horner KC, Cazals Y. Stress in hearing and balance in Meniere's disease. Noise Health 2003;5:29-34.
(2.) Horner KC, Cazals Y. Stress hormones Stress hormones such as cortisol and norepinephrine are released at periods of high stress. The hormone regulating system is known as the endocrine system. Cortisol is believed to affect the metabolic system and norepinephrine is believed to play a role in ADHD in Meniere's disease and acoustic neuroma Acoustic Neuroma Definition
An acoustic neuroma is a benign tumor involving cells of the myelin sheath that surrounds the vestibulocochlear nerve (eighth cranial nerve). . Brain Res Bull 2005;66:1-8.
(3.) Celestino D, Rosini E, Carucci ML, et al. Meniere's disease and anxiety disorders Anxiety disorders
A group of distinct psychiatric disorders characterized by marked emotional distress and social impairment, including generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, and posttraumatic stress disorder. . Acta Otorhinolaryngol Ital Ital Italian (linguistics)
ITAL Instituto de Tecnologia de Alimentos (Food Technology Institute; Brazil)
ITAL Information Technology And Libraries 2003;23:421-7.
(4.) Martin C, Martin H, Carre J, et al. [Meniere's disease. A psychosomatic disease?] Rev Laryngol Otol Rhinol (Bord) 1991;112: 109-11.
(5.) Crary WG, Wexler M. Meniere's disease: A psychosomatic disorder psychosomatic disorder
Bodily ailment or symptom, caused by mental or emotional disturbance, in which psychological stresses adversely affect physiological (somatic) functioning to the point of distress. ? Psychol Rep 1977;41:603-45.
(6.) Andersson G, Hagnebo C, Yardley L. Stress and symptoms of Meniere's disease: A time-series analysis Time-series analysis
Assessment of relationships between two or among more variables over periods of time. . J Psychosom Res 1997; 43:595-603.
(7.) Hagnebo C, Melin L, Larsen HC, et al. The influence of vertigo, hearing impairment hearing impairment
A reduction or defect in the ability to perceive sound. and tinnitus on the daily life of Meniere patients. Scand Audiol 1997;26:69-76.
(8.) Morrison AW, Johnson KJ. Genetics (molecular biology molecular biology, scientific study of the molecular basis of life processes, including cellular respiration, excretion, and reproduction. The term molecular biology was coined in 1938 by Warren Weaver, then director of the natural sciences program at the Rockefeller ) and Meniere's disease. Otolaryngol Clin North Am 2002;35:497-516.
(9.) Fung K, Xie Y, Hall SF, et al. Genetic basis of familial familial /fa·mil·i·al/ (fah-mil´e-il) occurring in more members of a family than would be expected by chance.
adj. Meniere's disease. J Otolaryngol 2002;31:1-4.
(10.) Klar J, Frykholm C, Friberg U, Dahl dahl
1. See pigeon pea.
2. or dal A thick creamy East Indian stew made with lentils or other legumes, onions, and various spices. N. A Meniere's disease gene linked to chromosome 12p12.3. Am J Med Genet genet: see civet. B Neuropsychiatr Genet 2006;141:463-7.
(11.) Savastano M, Maron MB, Mangialaio M, et al. Illness behaviour, personality traits, anxiety, and depression in patients with Meniere's disease. J Otolaryngol 1996;25:329-33.
(12.) Asmundson GJ, Larsen DK, Stein MB. Panic disorder and vestibular disturbance: An overview of empirical findings and clinical implications. J Psychosom Res 1998;44:107-20.
(13.) Simon NM, Pollack pollack: see cod.
Either of two commercially important North Atlantic species of food fish in the cod family (Gadidae). MH, Tuby KS, Stem TA. Dizziness dizziness: see vertigo. and panic disorder: A review of the association between vestibular dysfunction and anxiety. Ann Clin Psychiatry 1998;10:75-80.
(14.) Yardley L, Owen N, Nazareth I, Luxon L. Panic disorder with agoraphobia associated with dizziness: Characteristic symptoms and psychosocial psychosocial /psy·cho·so·cial/ (si?ko-so´shul) pertaining to or involving both psychic and social aspects.
Involving aspects of both social and psychological behavior. sequelae sequelae Clinical medicine The consequences of a particular condition or therapeutic intervention . J Nerv Ment Dis 2001;189:321-7.
(15.) Szirmai A, Kisely M, Nagy G, et al. Panic disorder in otoneurological experience. Int Tinnitus J 2005; 11:77-80.
(16.) Ursin H. Sensitization: A mechanism for somatization and subjective health complaints? Behavioral & Brain Sciences 1997;20:469.
(17.) Anderson DC, Yolton RL, Reinke AR, et al. The dizzy patient: A review of etiology etiology /eti·ol·o·gy/ (e?te-ol´ah-je)
1. the science dealing with causes of disease.
2. the cause of a disease. , differential diagnosis differential diagnosis
Determination of which one of two or more diseases with similar symptoms is the one from which the patient is suffering. Also called differentiation. , and management. J Am Optom Assoc 1995;66:545-58.
(18.)Grimby A, Rosenhall U. Health-related quality of life and dizziness in old age. Gerontology gerontology: see geriatrics. 1995;41:286-98.
(19.) Clark DB, Hirsch BE, Smith MG, et al. Panic in otolaryngology otolaryngology
Medical specialty dealing with the ear, nose, and throat (see larynx, pharynx). The connection of these structures became known in the late 19th century. patients presenting with dizziness or hearing loss. Am J Psychiatry 1994;151:1223-5.
(20.) Furman J, Jacob R. Psychiatric dizziness. Neurology neurology (nrŏl`əjē, ny–), study of the morphology, physiology, and pathology of the human nervous system. 1997;48: 1161-6.
(21.) Hiller W, Janca A, Burke KC. Association between tinnitus and somatoform disorders Somatoform Disorders Definition
The somatoform disorders are a group of mental disturbances placed in a common category on the basis of their external symptoms. . J Psychosom Res 1997;43:613-24.
(22.) Dineeu R, Doyle J, Bench J. Audiological and psychological characteristics of a group of tinnitus sufferers, prior to tinnitus management training. Br J Audiol 1997;31:27-38.
(23.) Meric C, Gartner M, Collet L, Chery-Croze S. Psychopathological psy·cho·pa·thol·o·gy
1. The study of the origin, development, and manifestations of mental or behavioral disorders.
2. The manifestation of a mental or behavioral disorder. profile of tinnitus sufferers: Evidence concerning the relationship between tinnitus features and impact on life. Audiol Neurootol 1998;3:240-52.
(24.) Rizzardo R, Savastano M, Maron MB, et al. Psychological distress in patients with tinnitus. J Otolaryngol 1998;27:21-5.
(25.) Eriksson-Mangold M, Carlsson SG. Psychological and somatic distress in relation to perceived hearing disability, heating handicap, and hearing measurements. Psychosom Res 1991;35:729-40.
(26.) Visentin P, Scarafiotti C, Marinello R, et al. Symptoms as predictors of functioning in the community-dwelling elderly. Archives of Gerontology and Geriatrics gerontology and geriatrics
Scientific and medical disciplines, respectively, concerned with all aspects of health and disease in the elderly and with the normal aging process. 1998;26:247-55.
(27.) Ormel J, Kempen GI, Penninx BW, et al. Chronic medical conditions See carpal tunnel syndrome, computer vision syndrome, dry eyes and deep vein thrombosis. and mental health in older people: Disability and psychosocial resources psychosocial resources,
n.pl emotional and cognitive states including self-esteem, optimism, and self-mastery that may affect behavior and health. mediate MEDIATE, POWERS. Those incident to primary powers, given by a principal to his agent. For example, the general authority given to collect, receive and pay debts due by or to the principal is a primary power. specific mental health effects. Psychol Med 1997; 27:1065-77.
(28.) Wise K, Rief W, Goebel G. Meeting the expectations of chronic tinnitus patients: Comparison of a structured group therapy program for tinnitus management with a problem-solving group. J Psychosom Res 1998;44:681-5.
(29.) Eysenck HJ, Eysenck SB. Manual of the Eysenck Personality Questionnaire The Eysenck Personality Questionnaire (1975), or E.P.Q., is a reliable research tool that is validated by criterion analysis. Disadvantages of the questionnaire are that it asks yes/no questions which forces a sometimes innacurate response, and it can be psychometrically inferior. (Adult and Junior). London: Hodder & Stoughton; 1975.
(30.) Eysenck HJ, Eysenck SB. [Manual of the Eysenck Personality Inventory (Adult and Junior)]. Florence: Organizzazioni Speciali; 1990.
(31.) Pilowski I, Spence n. 1. A place where provisions are kept; a buttery; a larder; a pantry.
In . . . his spence, or "pantry" were hung the carcasses of a sheep or ewe, and two cows lately slaughtered.
- Sir W. Scott. N. Manual for the Illness Behaviour Questionnaire (IBQ). 2nd ed. Adelaide: University of Adelaide Its main campus is located on the cultural boulevard of North Terrace in the city-centre alongside prominent institutions such as the Art Gallery of South Australia, the South Australian Museum and the State Library of South Australia. ; 1983.
(32.) Pierfederici A, Bernardi M, Fava GA. Validazione italiana dell'Illness Behavior Questionnaire di Pilowski e Spence. In: Canestrari R, ed. Nuovi Metodi in Psicometria. Florence: Organizzazioni Speciali; 1982.
Marina Savastano, MD; Gino Marioni, MD; Maria Aita, PsyD
From the ENT Section, Department of Medical-Surgical Specialities, Padova University Hospital, Padova, Italy.
Reprint reprint An individually bound copy of an article in a journal or science communication 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: email@example.com
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.