Assessment and management of psychological problems in the dizzy patient

Investigations over the last 20 years have moved the field of neuro-otology beyond the nonspecific concept of psychogenic dizziness to a more detailed understanding of interactions between neuro-otological and psychiatric disorders. Diagnostic studies of patients with Ménière's disease, vestibular neuritis, and benign paroxysmal positional vertigo suggest a model in which patients with predisposing factors, such as anxious temperaments or persistent anxiety during acute vestibular crises, are more likely to develop chronic dizziness with comorbid anxiety or depressive disorders. Outcome studies of patients with dizziness have shown that long-term disability depends more on psychological than physical factors. These medical-psychiatric interactions hold the keys to effective management of many patients with dizziness. Laboratory research has revealed neuroanatomical connections between central vestibular pathways and networks in the brain that control fear-related behavioral responses. These likely serve normal physiological functions in all individuals but appear to be the substrate for the close association between dizziness and anxiety in neuro-otological patients. Clinical studies of dizzy patients without active neuro-otological deficits have defined a syndrome of subjective dizziness and persistent imbalance known as phobic postural vertigo or chronic subjective dizziness. This syndrome can be reliably distinguished from other causes of chronic dizziness. Traumatic brain injuries, dysautonomias, and migraine headaches may cause a perplexing pattern of chronic or recurrent dizziness that is easily mistaken for a psychosomatic illness. Antidepressant medications, vestibular and balance rehabilitation therapy, and cognitive psychotherapy are showing increasing promise for treating both physical and psychological symptoms in patients with chronic dizziness due to various illnesses.