Chapter 14-18: Nonspecific Dizziness

TEXTBOOK PRESENTATION

Ill-defined dizziness is often secondary to a psychiatric disorder such as panic disorder, generalized anxiety disorder, depression, somatization disorder, alcohol dependence, or personality disorder. The dizziness is often of long duration (years) and poorly defined. Patients may complain of fogginess, feeling woozy, mental fuzziness, loss of energy, or a wobbly or a floating sensation. Patients may complain of other associated symptoms particularly if they have panic attacks, including chest pain, shortness of breath, impending sense of doom, palpitations, perioral paresthesias, tingling in the hands and feet, and light-headedness.

DISEASE HIGHLIGHTS

1. 20–38% of patients attending a clinic specializing in dizziness demonstrated panic disorder.

2. Psychiatric symptoms may develop without any identifiable organic cause or develop after episodes of true vertigo or syncope.

3. Symptoms can be secondary to hyperventilation, which leads to hypocapnia resulting in decreased cerebral blood flow.

4. Patients may complain of light-headedness or near syncope.

5. Milder variants of somatization disorder are more common than the full-blown entity. Such variants may be precipitated by stress or minor physiologic disturbances. Paradoxically, such patients are often disturbed by negative test results rather than reassured.

EVIDENCE-BASED DIAGNOSIS

1. Continuous sensation of vertigo lasting longer than 1–2 weeks without daily variation is likely psychogenic. This is to be distinguished from intermittent vertigo, recurring for weeks, precipitated by motion.

2. One study reported 62% of patients with hyperventilation had other significant psychiatric disorders.

3. Symptom reproduction by induced hyperventilation is nonspecific.

4. Care must be taken before ascribing dizziness to a psychiatric etiology.

   1. Multiple studies have demonstrated a high prevalence of anxiety (22–67%) among patients with well-defined organic etiologies of their dizziness.

   2. Anxiety scores are as high in patients with acute labyrinthine failure and vestibular dysfunction as among patients with no vestibular diagnosis.

Psychiatric symptoms may be sequelae of the dizziness rather than the cause.

5. Certain physical findings suggest a psychogenic etiology.

   1. Moment-to-moment fluctuations in impairment

   2. Excessive slowness or hesitation

   3. Exaggerated sway on Romberg, improved by distraction

   4. Sudden buckling of knee, typically without falling

   5. A cautious “walking on ice” pattern

TREATMENT

1. Appropriate evaluation to exclude organic etiologies.

2. Discuss patient’s concerns and fears about the diagnosis.

3. Educate the patient not to overly restrict physical activities since this impairs CNS compensation and may worsen the physical symptoms.

4. Selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines are used in patients with panic attacks and anxiety disorders. SSRIs are preferred due to potential problems with benzodiazepines (eg, dependence, tolerance, exacerbation of symptoms on discontinuation, sedation, interference with cognition in the elderly, and exacerbation of depression).

5. Cognitive behavioral therapy has also been effective.