Although most cases of chronic dizziness occur as a result of physical disorders, psychiatric issues can be a cause — or a consequence — of chronic dizziness, according to a new case report.
Chronic dizziness can result from a number of underlying health problems, most commonly involving neurologic, vestibular and cardiac diseases. For patients who have seen a variety of specialty physicians without reaching a diagnosis, a psychiatric referral may help them find relief, researchers noted.
The researchers reviewed published studies on the relationship between psychiatric disorders and dizziness, finding psychiatric disorders — often related to anxiety — may be present in up to 15 percent of patients presenting with dizziness. After vestibular diseases, which affect parts of the inner ear and brain responsible for controlling balance, psychiatric disorders appear to be the second most common cause of chronic dizziness.
Dizziness can fall into a number of broad categories, including vertigo (spinning sensation), presyncope (near-fainting), and disequilibrium (imbalance). When a patient’s description of symptoms appears consistent with one of these categories, physicians are better equipped to make an accurate diagnosis.
“One of the reasons the underlying cause can be so difficult to diagnose is that the way dizziness is experienced can vary dramatically. Patients who have a difficult time describing their symptoms, or seem to experience several different symptoms, are likely experiencing non-specific dizziness. When physicians see patients who report general or vague dizziness, it should be a cue to ask about the patient’s mental health."
said lead author Zak Kelm, DO, psychiatry resident at Ohio State University.
The relationship between dizziness and psychiatric disorders is complex and dynamic. It is sometimes difficult to distinguish which one is causing the other or whether the interplay is reciprocal.
Chronic Subjective Dizziness
The authors note that researchers have attempted to better understand this relationship by introducing the term chronic subjective dizziness (CSD).
Patients with CSD experience dizziness most days for more than three months. They often describe feeling heavy headed, light headed or imbalanced.
Some feel as if the floor is moving, while others feel disassociated or far away from their environment. Many patients report their symptoms worsen with complex stimuli, like being in crowded spaces.
According to one study, one-third of patients with CSD had a primary anxiety disorder and no history of vestibular disorder or another disease that could cause dizziness. Another one-third had no history of a psychiatric disorder but had a vestibular disease that triggered an onset of anxiety.
The final one-third had a history of an anxiety or other psychiatric disorder, then developed a medical condition that triggered dizziness. In those cases, the preexisting psychiatric disorder worsened and resulted in chronic dizziness.
Stress And Anxiety
In any of these situations, the underlying or resulting psychiatric disorder needs to be addressed.
“One of the reasons psychiatric disorders are overlooked is because many physicians are uncomfortable suggesting to patients that they might have a mental illness” says Dr. Kelm. “I think asking the patient about their stress levels and whether they’ve experienced anxiety can make the conversation more approachable for both parties."
Once referred to a psychiatrist, some patients have success with cognitive behavioral therapy; however, pharmacotherapy appears to be most helpful. Selective serotonin reuptake inhibitors (SSRIs) have proven effective, with approximately 50 percent of patients given an SSRI experiencing complete remission of symptoms, and 70 percent reporting a significant decrease in symptoms.
Study authors note that this case study has some limitation, in that it was a single case, and “the case is greatly limited by the fact that the patient was lost to follow-up”. So whether a treatment approach appropriate for CSD would have been effective is unknown.
Zak Kelm, MAPP, OMS IV; Kimberly Klapchar, DO; Christopher R. Kieliszak, DO; Christopher Selinsky, DO Psychogenic Dizziness: An Important but Overlooked Differential Diagnosis in the Workup of the Dizzy Patient The Journal of the American Osteopathic Association, May 2018, Vol. 118, e22-e27. doi:10.7556/jaoa.2018.066