Which comes first? psychogenic dizziness versus otogenic anxiety

Abstract

OBJECTIVE To investigate the hypotheses that physical neurotologic conditions may trigger anxiety disorders (otogenic pattern of illness), that psychiatric disorders may produce dizziness (psychogenic pattern), and that risk factors for these syndromes may be identified. STUDY DESIGN Retrospective review of all patients (N = 132) treated at a tertiary care balance center from 1998 to 2002 for psychogenic dizziness with or without physical neurotologic illnesses. METHODS All patients underwent comprehensive neurotologic and psychiatric evaluations with attention to the longitudinal course of symptoms and risk factors for psychopathology. Patients were grouped according to the condition first causing dizziness. Risk factors were compared across groups. RESULTS Three equally prevalent patterns of illness were found: anxiety disorders as the sole cause of dizziness (33% of cases), neurotologic conditions exacerbating preexisting psychiatric disorders (34%), and neurotologic conditions triggering new anxiety or depressive disorders (33%). Panic disorder and agoraphobia were significantly more prevalent than less severe phobias in the first two groups, whereas the opposite pattern existed in the third group (P <.0001). More patients in the first two groups had risk factors for anxiety disorders (P <.05). Depression was not a primary cause of dizziness in any patient. Vestibular neuronitis, benign paroxysmal positional vertigo, and migraine were the most common neurotologic conditions. CONCLUSIONS These data support the hypothesis that physical neurotologic conditions may trigger psychopathology as often as primary anxiety disorders cause dizziness. A third pattern appears to be equally common wherein physical neurotologic conditions exacerbate preexisting psychiatric illnesses. Individuals at risk for anxiety disorders may be more likely to have primary psychopathology.

Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the committee for the Classification of Vestibular Disorders of the Bárány Society

“…Thus, PPV, SMD, VV, and CSD may reflect different perspectives on a single, multifaceted clinical entity or they may offer insights into potentially distinguishable subtypes of PPPD (e.g., posturally predominant subtype, visually predominant subtype). Mild anxiety and depressive symptoms and phobic behaviors were included in the descriptions of PPV [12,13], but were considered comorbidities of CSD [24,75,80]. This raises the possibility that PPV may be either a distinct phobic subtype of PPPD or encompass PPPD plus a specific phobia of dizziness-related experiences.…”

“…Individuals who respond to the precipitating event with a high level of anxiety and body vigilance appear likely to progress to PPPD (i.e., to traverse the arrow from the initial structural event through this transient psychological stage to the chronic functional disorder) [23,28,30]. Anxiety-related personality traits or pre-existing anxiety disorders appear to increase the risk of developing PPPD [7,76,80]. In about 30% of patients, PPPD begins with acute psychological distress (black dot, b) and then progresses to the functional disorder [79].…”

Imipramine for vestibular dysfunction in panic disorder: a prospective case series

“…Also there are theories that vestibular input may affect panic disorders due to alterations on the serotoninergic system 7 . Serotoninergic pathways departing from the nucleus raphe have been demonstrated to play an important role in anxiety processing in rats 21 .…”

“…This lack of adequate evaluation may lead patients away from an adequate diagnosis and treatment 7 . There are few studies using imipramine on the treatment of chronic dizziness associated with panic disorder.…”

Chronic dizziness presenting in a patient with panic disorder: response to imipramine

“…Many patients with chronic dizziness without a clear organic origin, also called idiopathic dizziness, may have an association with a psychiatric disorder 3 . Nevertheless many patients with organic dizziness may also initiate or worsen a psychiatric disorder 4,5 . The association between dizziness and psychiatric disorders is well known, but it still is understudied, mainly due to a lack of a multidisciplinary evaluation of these patients.…”