A psychiatric approach to chronic dizziness

Chronic dizziness is a common problem in primary care settings, where approximately 7% of patients have symptoms that last for more than 5 years. One-third have clinically significant psychiatric symptoms, and 1 in 200 is disabled. In neurotology referral centers, 35% to 50% of patients have psychiatric morbidity, most of it undiagnosed and untreated. Mental health professionals can reduce the burden of chronic dizziness by helping patients to understand its three-dimensional psychiatric profile: fear responses such as hypervigilance about motion cues, anticipatory anxiety, and phobic avoidance; changes in mood state ranging from demoralization to major depression; and an intense focus on physical symptoms. Psychiatric symptoms develop in one of three patterns of illness: a psychogenic pattern that is almost exclusively due to panic disorder, an otogenic pattern in which physical causes of dizziness trigger anxiety and depressive disorders, and an interactive pattern in which physical causes of dizziness exacerbate pre-existing anxiety, producing significant medical-psychiatric comorbidity. Treatment research is limited and controlled studies are lacking, but emerging evidence suggests SSRIs may be safe and effective for chronic dizziness. Vestibular and balance rehabilitation therapy may reduce physical symptoms and improve psychiatric morbidity. Cognitive therapy may be a useful intervention, although it has not been tested in patients with chronic dizziness.