Comparative study of Cognitive-Behavioral Therapy with Pharmacotherapy for Persistent Postural-Perceptual Dizziness: A Pilot Study

doi:10.21203/rs.3.rs-4531525/v1

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Comparative study of Cognitive-Behavioral Therapy with Pharmacotherapy for Persistent Postural-Perceptual Dizziness: A Pilot Study

https://doi.org/10.21203/rs.3.rs-4531525/v1

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We conducted a non-randomized, open-label, parallel-group study on patients with persistent postural-perceptual dizziness (PPPD) to compare cognitive-behavioral therapy ([CBT] group, n = 20) received a 6-session CBT program with pharmacotherapy ([PT] group, n = 22) received serotonin-related antidepressants. Outcomes were assessed using the Dizziness Handicap Inventory (DHI), the Hospital Anxiety and Depression Scale (HADS), and the Niigata PPPD Questionnaire (NPQ). Assessments were performed before and 3 months post-treatment. There were no significant differences in patients background such as sex, age, precipitating conditions, and vestibular function tests, however, illness duration was significantly longer in the CBT group than the PT group. Both CBT and PT significantly lowered the levels of dizziness-related handicaps in daily life (DHI), depression (HADS-D), anxiety (HADS-A), and symptom exacerbations by triggers (NPQ), while two-way ANOVA revealed no treatment x time interaction. Nonetheless, CBT yielded a larger Hedges’ g effect size in improving DHI, HADS-A and NPQ than PT. While PT is reportedly sometimes discontinued due to adverse events such as vomiting, all patients in the CBT group could complete the program with no adverse effects. CBT is a potential therapy for PPPD which is safe and effective as equal to or greater than PT even for patients with prolonged illness.

Clinical trial registration numbers and date of registration: UMIN-CTR: UMIN000054701, 18/06/2024

Health sciences/Health care/Quality of life

Health sciences/Diseases/Psychiatric disorders

Biological sciences/Psychology

Health sciences/Diseases

Cognitive-behavioral therapy (CBT)

persistent postural-perceptual dizziness (PPPD)

depression

anxiety

dizziness handicap inventory (DHI)

Hospital Anxiety and Depression Scale (HADS)

Niigata PPPD Questionnaire (NPQ)

pharmacotherapy

In 2017, the Barany Society, a prominent international society for neuro-otology, published the diagnostic criteria for persistent postural-perceptual dizziness (PPPD) [1]. This definition was subsequently integrated into the 11th revision of International Classification of Diseases (ICD-11) of the World Health Organization (WHO) in 2018. PPPD is a chronic vestibular syndrome that includes symptoms such as dizziness, unsteadiness, and non-spinning vertigo, persisting for at least more than 3 months. Symptom exacerbations occur during specific situations, such as being in an upright posture or walking, active or passive motion regardless of the direction or position, and exposure to moving visual stimuli or complex visual patterns. PPPD frequently manifests after other neurological or psychological maladies, culminating in significant distress and functional debilitation; however, precipitants cannot account for the patient’s symptoms.

Despite the nascent introduction of PPPD, existing literature indicates its prevalence among chronic vestibular patients ranges between 20.8–37% [2, 3], suggesting it may be the predominant etiology of chronic dizziness. Vestibular rehabilitation, pharmacotherapy (PT), and cognitive-behavioral therapy (CBT) are the proposed therapeutic modalities [4]; however, empirical evidence buttressing these treatments remains limited. An amalgamated therapeutic approach is occasionally adopted [5, 6]; however, a lack of randomized controlled trials and comparative studies poses challenges in treatment selection.

We formulated a CBT program for individual implementation targeting Japanese patients with PPPD. Next, we conducted a study with two objectives. First, we aimed to evaluate the therapeutic efficacy and safety profile of the CBT program, with the primary outcome measure being the Dizziness Handicap Inventory (DHI) and the secondary outcome measures being the Hospital Anxiety and Depression Scale (HADS) and the Niigata PPPD Questionnaire (NPQ) for addressing symptom exacerbations in PPPD. These were assessed through pre- and post-treatment comparisons. Regarding safety, adverse events and dropout rates were monitored. Lastly, we aimed to compare the therapeutic outcomes of the CBT with those of PT.

2.1 Study design and ethical considerations

This study was conducted at the Department of Otolaryngology Head and Neck Surgery of Niigata University Hospital, with patients recruited from the outpatient clinic. All patients provided written informed consent. The study protocol was based on the principles of the Declaration of Helsinki and was approved by the Institutional Review Board of the Niigata University Hospital (approval no.: #2019-0322). The research volunteers were informed in advance about the purpose, methods, safety considerations, and potential risks of the experiment through verbal explanations. They participated in the study after providing their informed consent. CBT was conducted prospectively as a single-arm pre-post study to evaluate its safety and efficacy. The intervention results were compared with a historical control from the Department that received PT.

The CBT and PT groups comprising 20 and 22 patients, respectively, were compared. The sample size was determined based on prior studies [7] and feasibility considerations [8]. Although this was not a randomized study, treatment selection bias was reduced as much as possible by the following measures: Firstly, consecutive patients were enrolled, and secondly, CBT or PT alone was performed for all patients during each treatment period (January 2019~December 2019, PT; 2020~, CBT).

2.2 Patients

PPPD was diagnosed using the Barany Society criteria [1].

2.2.1. CBT group

Consecutive adult patients with PPPD diagnosed after 2020 were enrolled in the CBT group. The inclusion criteria were as follows: 1) They had either not received PT previously or had no dose increase of agents within the past 3 months. 2) They were willing to participate in the study, proficient in reading and writing Japanese, and could attend regular CBT sessions. 3) They were assessed for eligibility after receiving a comprehensive explanation of the purpose and methods of the study. 4) For those treated by PT, the dose and/or agents were not changed during the study.

No compensation was provided for participation. Two certified clinical psychologists specializing in CBT developed a structured CBT treatment program. Sessions were conducted every 2 weeks, with each session lasting 50 minutes, for a total of six sessions. If the patient was absent, the session was rescheduled for the following week. Table 1 provides a detailed breakdown of the sessions included in this program.

2.2.2. PT group

Data of consecutive patients diagnosed with PPPD between January 2018 and December 2019 were retrieved from the database. During this period, when CBT had not yet been introduced to our institute, PT was solely performed for all patients with PPPD. Enrolled patients had not received prior PT at other institutions. The PT group comprised 6 individuals on SSRI (escitalopram, 10 mg/day), 13 on SNRI (venlafaxine, 37.5–75 mg/day), and three on NaSSA (mirtazapine, 15 mg/day).

2.3. Measurements

The primary outcome measure of this study was DHI and the secondary outcome measures were HADS, NPQ, and safety. Demographic data, precipitating diseases, and results of vestibular function tests were obtained from the chart review.

2.3.1. Primary outcome

(1) DHI:

The DHI is a self-administered assessment scale to measure handicaps in daily life due to dizziness. It consists of 25 items with a three-level scoring system, and severity is measured on a scale of 0 to 100 points [9]. The reliability and validity of the Japanese version of DHI have been confirmed [10,11].

2.3.2 Secondary outcomes

(1) HADS:

The HADS is a measure of anxiety and depression states. It consists of seven items each for anxiety and depression, rated on a four-level scale, with severity scores ranging from 0 to 21 points [12]. The reliability and validity of the Japanese version of HADS have been confirmed [13].

(2) The Niigata PPPD questionnaire (NPQ):

The NPQ evaluates a symptom exacerbation of PPPD. It consists of 12 items with a seven-level scoring, and severity scores range from 0 to 72 points [14]. The reliability and validity of the NPQ have been confirmed [14].

(3) Tolerability and safety

The tolerability of the CBT was assessed using the dropout rate. The safety of the CBT was monitored by collecting adverse event reports.

2.3.2. Measurement timing

Regarding the timing of item measurements, for CBT, all items were measured before the treatment and approximately 3 months after the final session of the CBT program. For PT, all items were assessed before the treatment and approximately 3 months after its commencement.

2.4. Statistical analysis

Descriptive statistics summarized patient characteristics using mean and standard deviation (SD), as appropriate. A two-way mixed-design analysis of variance (ANOVA) was conducted, with time and treatment methods (including CBT and pharmacological therapy) as independent variables, and DHI, HADS anxiety and depression, and NPQ scores as dependent variables. This analysis aimed to assess the initial efficacy of CBT and pharmacological treatments. Within-group effect sizes, from pre to post-treatment, were calculated using Hedges' g to scrutinize the treatment effects of each method. Identical analyses were conducted for DHI, HADS anxiety, HADS depression, and NPQ scores. Statistical analysis was performed using the R Core Team [15].

3.1. Patient characteristics of CBT and PT groups

As shown in Table 2, the CBT cohort encompassed 20 participants (14 women and 6 men) with a mean age of 48.65±16.24. The median illness duration was 39.5 months, ranging from 8 to 180 months. Pre-treatment indices for the CBT group were as follows: DHI score of 49.60± 18.53, HADS anxiety score of 8.75±4.74, HADS depression score of 7.60±4.32, and NPQ score of 39.05±16.03.

As shown in Table 2, the PT group comprised 22 participants (15 women and 7 men) with a mean age of 48.55±12.31 years. The median illness duration was 25.73 months, ranging from 3 to 161 months. Pre-treatment indices for the PT group were as follows: DHI score of 51.64±21.94, HADS anxiety score of 8.77±5.04, HADS depression score of 7.82 ±3.23, and NPQ score of 36.23±14.78. Data are mean ± SD.

Independent t-tests revealed no significant differences in age, DHI score, HADS anxiety score, HADS depression score, and NPQ score between the CBT and PT groups. As normality was not observed for illness duration, the Mann–Whitney U test was employed, revealing a significant difference between the groups (U=284, p=0.02): the illness duration was significantly longer in the CBT group than in the PT group. According to Fisher's exact test, there was no significant difference in sex between the CBT group and the PT group.

As shown in Table 3, the precipitating diseases of the participants in the CBT group were as follows: acute attack of peripheral vestibular vertigo (n=6), no specific precipitants (n=5), BPPV (n=3), stress reaction (n=2), chronic anxiety disorders (n=1), Meniere's disease (n=1), mal de debarquement (n=1), and vestibular neuritis (n=1). In the PT group, the precipitating diseases were acute attack of peripheral vestibular vertigo (n=7), BPPV (n=5), stress reaction (n=3), no specific precipitants (n=2), vestibular neuritis (n=2), Meniere's disease (n=1), postoperative status of acoustic tumor (n=1), and vestibular migraine (n=1). There were no significant differences in the precipitating diseases between the CBT and PT groups.

As shown in Table 4, there were no significant differences in the vestibular function results, including, canal paresis (CP) %, vestibulo-ocular reflex-direction preponderance (VOR-DP) %, c- and o-vestibular myogenic potentials (VEMP), subjective visual vertical (SVV), and posturography, between the two groups. Moreover, all these data were within normal ranges in both groups.

3.2. Assessment of tolerability and safety in the CBT group

All patients completed the CBT program with no adverse events related to CBT.

3.3. Measurement of assessment indices　

3.3.1. Results of Repeated Measures ANOVA

For the primary outcome, DHI, the main effect of time was confirmed: DHI (F(1,40) = 43.49, p < .001, ηG2 = 0.14, 95% CI [0.06, 0.23]). As secondary outcome, HADS and NPQ, a significant main effect of time was observed, indicating a significant decrease in index scores from pre- to post-treatment assessments: HADS anxiety (F(1,40) = 26.52, p < .001, ηG2 = 0.11, 95% CI [0.03, 0.19]), HADS depression (F(1,40) = 22.18, p < .001, ηG2 = 0.07, 95% CI [0.02, 0.14]), and NPQ (F(1,40) = 16.60, p < .001, ηG2 = 0.09, 95% CI [0.02, 0.18]).

However, no significant differences were observed between treatment modalities between the two groups: HADS anxiety (F(1,40) = 0.13, p = .72, ηG2 = 0.00, 95% CI [0.00, 0.02]), HADS depression (F(1,40) = 0.11, p = .74, ηG2 = 0.00, 95% CI [0.00, 0.03]), DHI (F(1,40) = 0.27, p = .60, ηG2 = 0.00, 95% CI [0.00, 0.06]), and NPQ (F(1,40) = 0.02, p = .88, ηG2 = 0.00, 95% CI [0.00, 0.00]).

A repeated measures ANOVA was conducted to examine the effects of time (pre-treatment vs. post-treatment) and treatment modality (CBT vs. pharmacological therapy) on the outcome measures (HADS anxiety, HADS depression, DHI, and NPQ). The results revealed a significant main effect of time for all indices, indicating a significant reduction in symptom severity from pre to post-treatment assessments. However, there was no significant main effect of treatment modality or interaction between time and treatment modality, suggesting that both CBT and PT were equally effective in reducing symptoms.

3.3.2. Corset plots and effect size

The corset plots in Fig. 1-2 visualize the respective scale measures before (Pre) and after (Post) the treatment. The half-violins show the distribution by treatment group at each time point, the box plots show the scatter of the data, and the circle and triangle shapes show the individual changes before and after the treatment.

Calculated within-group effect sizes for each treatment were as following (Table 5): DHI, CBT (Hedges’ g=0.929, 95% CI [0.268, 1.589]), PT (Hedges’ g=0.675, 95% CI [0.060, 1.289]); HADS anxiety, CBT (Hedges’ g=0.800, 95% CI [0.148, 1.452]), PT (Hedges’ g=0.557, 95% CI [-0.052, 1.166]); HADS depression, CBT (Hedges’ g=0.522, 95% CI [-0.117, 1.160]), PT (Hedges’ g=0.531, 95% CI [-0.077, 1.139]); NPQ, CBT (Hedges’ g=0.706, 95% CI [0.060, 1.353]), PT (Hedges’ g=0.482, 95% CI [-0.124, 1.088]). Table 5 presents the results for　the CBT and PT groups.

To date, no comparative study has been conducted between CBT and PT on patients with PPPD. In the present study, the effects of prospectively performed CBT were compared with prior PT prescribed in our department as a historical control. No baseline characteristics, such as demographic data, vestibular function results, and precipitating diseases, differed between the two groups except for the duration of illness, making comparisons meaningful. As shown in Table 5, all measurements (HADS-A, HADS-D, DHI, and NPQ) after CBT or PT were significantly decreased compared with pretreatment levels. Repeated measures ANOVA revealed that there was neither a significant effect on treatment nor interaction between time and treatment. These results suggest that CBT and PT are both effective in reducing the severity of anxiety/depression, handicap in everyday life due to dizziness, and symptom exacerbation of PPPD and that the difference in the treatment modality (CBT or PT) does not influence on the chronological effects by the treatment. Moreover, Hedges’ g effect size on DHI, HADS-A, and NPQ were larger by CBT than those by PT, and the confidence interval of Hedges’ g effect size of PT on three of the four measurements (HADS-A, HADS-D, and NPQ) included zero.

Cumulatively, in the clinical settings, the CBT program that was newly developed for Japanese patients with PPPD may exhibit at least similar or even better effects on the above measurements compared with PT. Moreover, for both treatments, the confidence intervals for depression (HADS depression) included zero, so the effects on depressive symptoms need to be further investigated. The results regarding depression may be because the pre-treatment depression scores did not exceed the cutoff value.

We have previously reported satisfactory results of CBT on patients with PPPD who were refractory to PT [17]. Regarding the tolerability and safety, there were neither dropouts nor adverse events in CBT, while serotonin-related antidepressants sometimes cause moderate grade of adverse events such as vomiting and sleepiness, resulting in discontinuation [18]. Furthermore, illness duration of the CBT group was as long as 49.39 months, which was significantly longer than the PT group (25.73 months). Therefore, CBT may be satisfactory treatments for PPPD in terms of effectiveness and safety even long after the onset of PPPD.

In previous studies [6, 16], the effect size of CBT on DHI was 0.45 and 1.11, respectively, while that in the present study was 0.93. We assume that the different effect sizes among the studies would be derived from the different treatment modalities: previous studies adopted CBT along with other treatments, such as vestibular rehabilitation.

In this study, not only DHI but also NPQ was used as an indicator of the severity of PPPD symptoms. The effect sizes of CBT on DHI and NPQ were 0.93 and 0.71, respectively, and the confidence intervals for both did not include zero. While DHI is an indicator of disability in daily life due to dizziness, NPQ can measure the exacerbation of symptoms by specific triggers for PPPD, such as upright position/walking, motion, and visual stimulation. Therefore, the CBT program developed in this study not only improves the overall difficulties in the daily life of patients with PPPD but also alleviates the exacerbation caused by triggers, perhaps because the interoceptive exposure session in the CBT program incorporated the exposure to triggers.

This study had a few limitations. First, it was designed as a pilot study without a randomization and was not a non-inferiority trial. Second, because only two clinical psychologists conducted the treatments in this study, biases related to the skills of the treatments cannot be excluded. To address these limitations, future research should involve a larger number of patients by randomized controlled trials with multiple treatments.

In conclusion, CBT may be a safe and effective treatment for PPPD that is comparable with PT, even long after the onset of the disease.

Acknowledgments

We would like to thank Editage (www.editage.jp) for English language editing.

This work was supported by JSPS KAKENHI Grant Number JP 23K18988，21H03084, 19K18799.

We extend my sincere appreciation to the patients who took part in this study.

Author contributions　

Kang, J. played a central role in this study, contributing to the conception and design, performing treatments, analyzing data, and writing the manuscript. Tanaka, T. was also heavily involved, participating in the study's conception and design, carrying out treatments, and contributing to the writing of the manuscript. Yagi, C. was involved in the initial conception and design of the study and provided final approval of the manuscript. Horii, A. contributed to the study's conception and design, assisted in writing the manuscript, and gave final approval. Kurashige, T. was involved in analyzing the data and providing final approval of the manuscript. All authors played important roles in ensuring the study's successful completion and dissemination.

Data availability statement

The data generated and analyzed in this study are available from the corresponding author upon reasonable request.

Competing Interests Statement

The authors declare no conflict of interest.

Staab, J. P. et al. Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the committee for the Classification of Vestibular Disorders of the Bárány Society. J. Vestib. Res. 27, 191–208 (2017).
Kim, H. J., Lee, J. O., Choi, J. Y. & Kim, J. S. Etiologic distribution of dizziness and vertigo in a referral-based dizziness clinic in South Korea. J. Neurol. 267, 2252–2259 (2020).
Yagi C, Kimura A, Horii A. Persistent postural- perceptual dizziness: a functional neuro-otologic disorder. Auris Nasu Larynx 51: 588–598, 2024
Popkirov, S., Stone, J. & Holle-Lee, D. Treatment of persistent postural-perceptual dizziness (PPPD) and related disorders. Curr. Treat. Options Neurol. 20, 50 (2018).
Yu, Y. C., Xue, H., Zhang, Y. X. & Zhou, J. Cognitive behavior therapy as augmentation for sertraline in treating patients with persistent postural-perceptual dizziness. Biomed. Res. Int. 2018, 8518631 (2018).
Herdman, D., Norton, S., Murdin, L., Frost, K., Pavlou, M. & Moss-Morris, R. The INVEST trial: a randomised feasibility trial of psychologically informed vestibular rehabilitation versus current gold standard physiotherapy for people with Persistent Postural Perceptual Dizziness. J. Neurol. 269, 4753–4763 (2022).
Herdman, D., Norton, S., Pavlou, M., Murdin, L. & Moss-Morris, R. Protocol for a randomised controlled feasibility study of psychologically informed vestibular rehabilitation for people with persistent dizziness: INVEST trial. Pilot Feasibility Stud. 7, 156 (2021).
Moore, C. G., Carter, R. E., Nietert, P. J. & Stewart, P. W. Recommendations for planning pilot studies in clinical and translational research. Clin. Transl. Sci. 4, 332–337 (2011).
Jacobson, G. P. & Newman, C. W. The development of the Dizziness Handicap Inventory. Arch Otolaryngol. Head Neck Surg. 116, 424–427 (1990).
Goto, F., Tsutsumi, T. & Ogawa, K. The Japanese version of the Dizziness Handicap Inventory as an index of treatment success: exploratory factor analysis. Acta Otolaryngol. 131, 817–825 (2011).
Masuda, K., Goto, F., Fujii, M., & Kunihiro, Y. Usefulness of the dizziness handicap inventory (Japanese version) questionnaire. Equilib. Res. 63, 555–563. (2004). In Japanese.
Zigmond, A. S. & Snaith, R. P. The hospital anxiety and depression scale. Acta Psychiatr. Scand. 67, 361–370 (1983).
Matsudaira, T. et al. Factor structure of the Hospital Anxiety and Depression Scale in Japanese psychiatric outpatient and student populations. Health Qual. Life Outcomes. 7, 42 (2009).
Yagi, C. et al. A Validated questionnaire to assess the severity of persistent postural-perceptual dizziness (PPPD): The Niigata PPPD questionnaire (NPQ). Otol. Neurotol. 40, e747-e752 (2019).
R Core Team. _R: A Language and Environment for Statistical Computing_. R Foundation for Statistical Computing, Vienna, Austria. https://www.R-project.org/ (2023).
Kuwabara, J. et al. Acceptance and commitment therapy combined with vestibular rehabilitation for persistent postural-perceptual dizziness: A pilot study. Am. J. Otolaryngol. 41, 102609 (2020).
Kang, J., Tanaka, T., Yagi, C., Horii. A. Cognitive-behavioral therapy (CBT) for two patients with persistent postural-perceptual dizziness (PPPD). Equilib. Res. 82, 16–25 (2023). In Japanese
Edinoff, A. N. et al. Selective Serotonin Reuptake Inhibitors and Adverse Effects: A Narrative Review. Neurol Int. 13, 387–401 (2021).

Table 1. Cognitive-behavioral therapy treatment program

Session 1	Anamnesis, psychoeducation	Taking a history, exercising to confirm an occurrence of dizziness symptoms. Explaining the CBT based on anxiety and fear model where excessive focus on bodily sensations would constitute a vicious circle.
Session 2	Goal setting	Confirming the negative impact of dizziness symptoms on daily life and how the patient envisions life after successful treatment. Examining current coping strategies (avoidance behaviors).
Session 3	Interoceptive exposure	Reducing fear associated with dizziness sensations through repeated exposure to vertiginous experience evoked by rotating chair, head movement, and eye tracking. Promoting awareness of one's own "entrapment in internal sensations".
Session 4	Behavioral experiments, behavioral activation	Predicting the future that would result from engaging in avoided activities and actually having the patient carry them out.
Session 5	Cognitive restructuring	Modifying the patient's predictions (negative cognitions). Transforming the prediction such as from "dizziness sensations will cause me to fall" to "falling is rare even when dizziness sensations occur".
Session 6	Recapitulation and relapse prevention	Reflecting on what was effective and learned throughout the program. Confirming coping strategies for future symptom occurrences.

Table 2. Baseline characteristics of CBT and PT groups

Variables	CBT (n=20) Mean (SD)	PT (n=22) Mean (SD)	p-value
Age	48.65 (16.24)	48.55 (12.31)	0.981
Sex (M/F)	6/14	7/15	1
Illness duration (month)	49.39 (46.69)	25.73 (35.79)	0.019
DHI	49.60 (18.53)	51.64 (21.94)	0.748
HADS (Anxiety)	8.75 (4.74)	8.77 (5.04)	0.988
HADS (Depression)	7.60 (4.32)	7.82 (3.23)	0.853
NPQ	39.05 (16.03)	36.23 (14.78)	0.556

Abbreviations: CBT, cognitive-behavioral therapy; PT, pharmacological therapy; SD, standard deviation; DHI, Dizziness Handicap Inventory; HADS, Hospital Anxiety and Depression Scale; NPQ, Niigata persistent postural-perceptual disease questionnaire; For Age, DHI, HADS, and NPQ, t-tests were performed. For sex, Fisher's exact test was used. For illness duration, the Mann–Whitney U test was conducted.

Table 3. Precipitating disease for patients with persistent postural-perceptual disease in cognitive-behavioral and pharmacological therapy groups

CBT	n = 20	PT	n = 22
Acute attack of peripheral vestibular vertigo	n = 6	Acute attack of peripheral vestibular vertigo	n = 7
No specific precipitants	n = 5	BPPV	n = 5
BPPV	n = 3	Stress reaction	n = 3
Stress reaction	n = 2	No specific precipitants	n = 2
Chronic anxiety disorders	n = 1	Vestibular neuritis	n = 2
Meniere’s disease	n = 1	Meniere’s disease	n = 1
Mal de debarquement	n = 1	Postoperative status of acoustic tumor	n = 1
Vestibular neuritis	n =1	Vestibular migraine	n = 1

Abbreviations: BPPV, benign paroxysmal positional vertigo; CBT, cognitive-behavioral therapy; PT, pharmacological therapy

Table 4. Results of vestibular function tests of CBT and PT group

Variables	CBT (n=20) Mean ± SD	PT (n=22) Mean ± SD	p-value (Mann‒Whitney U test)
CP, %	16.4 ± 16.3	16.0 ± 11.7	0.945
VOR-DP in RCT, %	11.3 ± 10.2	11.5 ± 8.8	0.794
IAAR in cVEMP, %	15.1 ± 22.6	22.2 ± 27.5	0.081
IAAR in oVEMP, %	24.9 ± 30.2	16.5 ± 23.5	0.246
SVV, degree	1.64 ± 1.45	2.48 ± 2.25	0.207
Elliptical balance area, cm² Eyes open Eyes closed	8.95 ± 9.24 13.4 ± 13.8	6.14 ± 4.18 8.41 ± 6.13	0.308 0.299

Abbreviations: CBT, cognitive-behavioral therapy; PT, pharmacological therapy; CP, canal paresis; VOR, vestibulo-ocular reflex; DP, directional preponderance; RCT, rotatory chair test; IAAR, interaural asymmetry ratio; cVEMP and oVEMP, cervical and ocular vestibular-evoked myogenic potentials; SVV, subjective visual vertical; SD, standard deviation

Table 5. The results for the cognitive-behavioral therapy, and pharmacotherapy groups

CBT

p-value（ηG2）　

(n=20)

(n=22)

Pre

Post

Pre

Post

Variables

Mean

(SD)

Mean

(SD)

Hedges’ g

(95%Cl)

Mean

(SD)

Mean

(SD)

Hedges’ g

(95%Cl)

treatment　

time

interaction

DHI

49.60

(18.53)

32.60

(17.33)

0.93

(0.27,1.59)

51.64

(21.94)

36.55

(21.99)

0.68

(0.6,1.29)

0.60

(0.01)

0.00

(0.14)

0.69

(0.00)

HADS

(Anxiety)

8.75

(4.74)

5.20

(3.91)

0.80

(0.15,1.45)

8.77

(5.04)

6.09

(4.39)

0.56

(-0.05,1.17)

0.72

(0.00)

0.00

(0.11)

0.48

(0.00)

HADS

(Depression)

7.60

(4.32)

5.40

(3.94)

0.52

(-0.12,1.16)

7.82

(3.23)

5.91

(3.80)

0.53

(-0.08,1.14)

0.74

(0.00)

0.00

(0.07)

0.74

(0.00)

NPQ

39.05

(16.03)

27.45

(16.16)

0.71

(0.06,1.35)

36.23

(14.78)

29.14

(14.12)

0.48

(-0.12,1.09)

0.89

(0.00)

0.00

(0.02)

0.33

(0.01)

Abbreviations: CBT, cognitive-behavioral therapy; PT, pharmacological therapy; DHI, Dizziness Handicap Inventory; HADS, Hospital Anxiety and Depression Scale; NPQ, Niigata PPPD questionnaire; SD, standard deviation; CI, confidence interval; ηG2, generalized eta squared

No competing interests reported.

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Comparative study of Cognitive-Behavioral Therapy with Pharmacotherapy for Persistent Postural-Perceptual Dizziness: A Pilot Study

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