Psychophysiological dizziness

Douglas J Lanska MD FAAN MS MSPH (Dr. Lanska of the Great Lakes VA Healthcare System and the University of Wisconsin School of Medicine and Public Health has no relevant financial relationships to disclose.)
Originally released October 22, 2003; last updated February 4, 2017; expires February 4, 2020

This article includes discussion of psychophysiological dizziness, chronic subjective dizziness, phobic postural vertigo, psychiatric dizziness, psychic dizziness, psychogenic dizziness, psychogenic vertigo, and psychophysiological vertigo. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

The author explains the clinical presentation, pathophysiology, diagnostic work-up, and management of psychogenic vertigo. A close association between anxiety and dizziness or vertigo has been recognized since antiquity, but recognition and management of this problem continue to be difficult for many clinicians. Anxiety may result from various forms of dizziness because of the sudden, dramatic, and unpleasant associated sensations and from fear of falling, injury, or death. The main concern with differential diagnosis is whether the apparent psychiatric manifestations are a consequence of an underlying organic vestibular or other disorder or whether the condition is primarily psychiatric.

Key points

 

• Anxiety and depression are strongly associated with dizziness.

 

• Patients and their spouses tend to have a high degree of concordance for the patient's self-reported dizziness severity and dizziness handicap, although spouses tend to overestimate the severity of dizziness.

 

• Psychophysiological (psychogenic) dizziness is generally characterized as a vague giddiness or dissociated sensation due to impaired central integration of sensory and motor signals in patients with acute and chronic anxiety. The dizzy sensation is typically persistent (ie, duration is frequently of months or longer), protracted (ie, lasting hours) or continuous, with periodic exacerbations, often punctuated by episodes of hyperventilation-induced presyncope. Specific provocative factors may be identified, such as the presence of crowds, driving, or being in confined places.

 

• Anxiety may also result from other forms of dizziness because of the sudden, dramatic, and unpleasant associated sensations and from fear of falling, injury, or death. Anxiety and depression are particularly frequent concomitants of the neurologic manifestations of Meniere disease and vestibular migraine, compared with patients with vestibular neuritis of benign paroxysmal positioning vertigo.

 

• Psychophysiological (psychogenic) dizziness is thought to be due to impaired central integration of sensory and motor signals, particularly in patients with acute and chronic anxiety.

 

• The main concern with differential diagnosis is whether the apparent psychiatric manifestations are a consequence of an underlying organic vestibular or other disorder or whether the condition is primarily psychiatric.

 

• Psychophysiological dizziness may be alleviated by treatment with antidepressants, anxiolytic medications, and cognitive behavioral modification techniques with desensitization for situational anxiety.

Historical note and terminology

Recognition of a close association between anxiety and dizziness or vertigo has been an integral component of the medical literature since antiquity (Jacob 1988; Balaban and Jacob 2001). A close association between anxiety and dizziness was emphasized by Sigmund Freud in an early paper on anxiety neurosis, an important component in the psychodynamic formulation of psychogenic dizziness (Freud 1895; Kapfhammer et al 1997; Balaban and Jacob 2001). There has been an increased recognition of the situational specificity of certain symptoms, and behavioral therapeutic measures have been instituted to address this (Balaban and Jacob 2001). In the absence of a uniformly accepted nomenclature, many terms have been promulgated that are inconsistently used including chronic subjective dizziness, phobic postural vertigo, psychiatric dizziness, psychic dizziness, psychogenic dizziness or vertigo, and psychophysiological dizziness or vertigo (Brandt 1996; Staab 2006).

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