AIJOC

10.5005/jp-journals-10003-1090
Psychogenic Vertigo
REVIEW ARTICLE

Psychogenic Vertigo
Henal Shah, Sayantani Mukherjee

ABSTRACT followed by somatization and depression; 30% have mixed

Psychogenic vertigo is a disorder that merits attention from both pathology. 15% have a purely organic disorder while 5%
ENT and psychiatry services as its genesis and complex have idiopathic etiology.6
symptomatology have roots in both these fields. This article is Also, patients with predisposition to both neurotic
an endeavor to sift through all information that is available about (anxiety) as well as space motion discomfort (SMD) traits
it and present concisely about its evolution, its current status
and patients who are more dependent on visual stimuli due
and all clinical aspects that are of contemporary relevance.
to deficits in their vestibular and equilibrium mechanisms
Keywords: Vertigo, Dizziness, Psychogenic, Cognitive therapy,
are certain high-risk groups who are likely to develop
Behavioural.
psychogenic vertigo.7
How to cite this article: Shah H, Mukherjee S. Psychogenic
Vertigo. Otorhinolaryngol Clin Int J 2012;4(2):77-80. Evolution of Disorder
Source of support: Nil The earlier impression of psychogenic vertigo only being a
Conflict of interest: None declared symptom representative of ongoing psychiatric illness has
now, given way to a deeper and multidimensional under-
INTRODUCTION
standing of how the symptom of vertigo, psychiatric
Psychogenic vertigo has always been an ambiguous disorder disorders and neuro-otological dysfunction are related. The
with diffuse symptomatology which is confusing to diagnose present understanding of relation between vertigo and
and difficult to treat. This article is an attempt to look at it psychiatric disorders in terms etiology and clinical
from all perspectives—lateral and longitudinal, and provide presentation is discussed here:
a comprehensive sum-up. The etiological relation of vertigo to psychiatric
Firstly, though we will be using the term ‘psychogenic symptoms can be classified as:6
vertigo’ throughout this article, it has recently been deemed • Predisposition: Individuals possessing anxiety-prone,
outdated. Presently the term ‘psychiatric dizziness’ is avoidant traits by virtue of their genetics, if suffering
preferred.1 from vertigo due to neuro-otological dysfunction, are
Initially it was thought to be purely a psychiatric predisposed clinical psychiatric disorders like depression
pathology mimicking ENT symptoms; but lately, discovery and anxiety.
of underlying biological mechanisms have thrown light onto • Precipitation: Vertigo can be precipitated as a
evidence of concrete neuro-otological involvement in this psychiatric symptom as a part of certain disorders in the
disorder. At present, it is viewed as an interface between neurotic spectrum like panic attacks, panic disorder with
the two with significant somatopsychic considerations. So or without agoraphobia, anxiety disorders, depression,
now, even within the ambit of psychogenic vertigo, purely conversion disorders, post-traumatic stress disorder
psychogenic vertigo is a diagnosis of exclusion.2 (PTSD) and very rarely even psychosis.
Currently, the term ‘psychiatric dizziness’ is used when • Provocation: Excessive/pathological responses to
symptoms are recognized as part of psychiatric illness or stressful life events are suggestive of maladaptive
cannot be explained entirely by vestibular dysfunction.1 coping. These in turn can precipitate recurrent vestibular
dysfunction like Ménière's disease and vestibular
Epidemiology migraine.
Exact incidence and prevalence of psychogenic vertigo are • Perpetuation: Once vertigo sets in, even if the causative
hard to pinpoint. However, up to 60% of cases presenting neuro-otological dysfunction abates, it can sustained by
with chronic dizziness were found to have primary or biopsychological factors like cognitive distortions like
secondary anxiety.3,4 Young women are most likely to catastrophic thinking and learning of maladaptive
present with vertigo as a part of primary psychiatric disorder. patterns via classical and operant conditioning, e.g.
But men, especially older men, have a stronger correlation chronic subjective dizziness (CSD), migraine-anxiety-
between vertigo and development of psychiatric problems related dizziness (MARD).7
(usually neurotic features) secondary to it.5 Presentation-wise, psychogenic vertigo can occur as:8-10
A study by Furman et al showed that 50% of patients of • A symptom (in anxiety, depression, conversion, post-
dizziness with anxiety features turn out to have a pure traumatic stress and rarely psychosis where there is no
psychiatric pathology—most commonly anxiety disorder, vestibular dysfunction).

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Henal Shah, Sayantani Mukherjee

• A part of or a whole syndrome [panic disorder with or • Raphe nuclear - vestibular network: Consists of multiple
without agoraphobia, acrophobia,11 postural phobic serotonergic and some dopaminergic projections to
vertigo (PPV), CSD, MARD where there may be an multiple cortical, midbrain and brain stem areas which
associated vestibular pathology]. regulate cognitive, affective and autonomic responses.
• Psychological overlay of organic vertigo/somatopsychic • Coeruleovestibular network: Has noradrenergic
effects of disequilibrium in certain vulnerable projections and involved in causation of anxiety and
individuals with predisposing psychopathological traits/ panic symptoms.
conditions. • Dorsal raphe nucleus-locus coeruleus loop: Has
Otherwise vertigo and psychiatric symptoms can profusion of serotonergic and nonserotonergic
occasionally present as a chance concurrence.10 projections which mediate sensorimotor, interoceptive
Therefore, psychiatric dizziness is now considered to and cognitive processes.
be of three types—psychogenic, neuro-otogenic and mixed.8 • Monoamine projections to vestibular nuclei are
implicated in genesis of pain and anxiety secondary to
Causative Factors vestibular symptoms.
In present day, the etiology can be divided broadly under • Higher cortical regions which are connected to both
three headings—neuroanatomical, psychodynamic and limbic system and thalamus receiving vestibular inputs
cognition/learning related factors. mediate cognitive reactions to vestibular symptoms.
• Cortical projections to brain stem from limbic areas
Neuroanatomical Considerations cause other autonomic symptoms associated with vertigo
Overlapping clinical presentations between vertigo and and related anxiety.
anxiety and other neurotic disorders has always made the
scientific community wonder about the presence of a Psychodynamic Considerations
neurological linkage.1 A study by Hibbert12 demonstrating
In the pre-biological era, when psychogenic vertigo was
both vertigo and panic attacks can be precipitated by
thought to be a purely psychiatric disorder, psychiatrists
hyperventilation, strengthened the assumption of common
attempted to explain the causation of the symptoms using a
neurological pathways being activated.
Brandt had findings13 suggesting motorist disorientation school of psychological thinking called ‘Gestalt’
syndrome, visual and postural phobic vertigo were psychology.17
implicative of a mixed rather than purely psychological In this, vertigo is explained as follows:
etiology as earlier thought.3 In accordance, Yardley et al14 There is a large field of conscious phenomena which is
found deficits in spatial orientation and attention in central localized in space. This can be divided into two functional
processing in these patients. units. One is the space occupied by our bodies—a constantly
Guidetti et al15 found a link between the labyrinth and changing model called a schema. Another schema represents
the limbic system, laying the foundation for the further and
the external world. These two schemata are interdependent.
extensive research that has happened since then.
Perception of proprioception which influence the body
Now, a plethora of neuroanatomical networks involved
schema is influenced by the attributes of the external
have been brought to fore. They are:1,16
environment and the external environment in turn is
• Afferent interoceptive information processing system:
perceived within the body schema is by virtue of its
Integrate information regarding current sensory
interpretation by the body’s proprioceptors. They interact
processes relative to current physiological conditions
in body; translates into subjective awareness and in a continuous, complex and dynamic manner with each
feelings. other. Any disharmony between the spatial orientations of
• Vestibular-parabrachial nucleus network: Parabrachial the body and environment schemata give rise to the
nucleus seat of integration of vestibular, visceral and perception of vertigo.
nociceptive stimuli; connected to infralimbic cortex and In cases of psychogenic vertigo, unconscious elements
amygdala which give rise to the emotional component - of spatial orientation are brought into consciousness and
conditioned fear and anxious-avoidant reactions. It is physically expressed, causing dissonance between the two
thus also an inbuilt threat-evaluation system.8 schemata. This expression is symbolically representative
• Cerebral cortical vestibular and interoceptive processing of patient's difficulty with his environment and can be
system: It is a gateway for vestibular information to suggestive of conflicts inside him that make him feel he
interact with conscious sensory and cognitive processes. has ‘lapsed’, ‘fallen’ or ‘about to fall/meet his downfall’.

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Psychogenic Vertigo

This explanation still holds true in cases of purely In history, some symptoms in anxious patients point to
psychogenic vertigo. vestibular dysfunction, rather than ruling it out. They are
known under the heading of space and motion discomfort
Cognition and Learning related Considerations (SMD) and consist of a feeling of queasiness at heights in
Cognitive responses that perpetuate a second layer of crowds, if seeing busy/hectic patterns (on walls, floors,
psychological dysfunction are catastrophic thinking and visual display units, etc.) and soft/vibrating floors. Earlier
dysphoric ruminations (repetitive thoughts).8 Catastrophic these symptoms were considered representative of purely
thoughts about consequences of being dizzy and psychogenic vertigo but now, newer research shows that
apprehensive ruminations about its chronicity keep the they indicate organic pathology.1
symptom in conscious focus - magnifying the adverse effects While examining the patient, the clinician should look
of conditioning and emphasizing handicap in daily out certain signs suggestive of anxiety disorders like
functioning.18 exaggerated acoustic startle response and autonomic signs
Maladaptive learning involves classical and operant suggestive of sympathetic overdrive.1
conditioning. Classical conditioning associates motion, Hyperventilation test can delineate whether a patient of
visual and other stimuli (even though they are not triggering psychogenic vertigo has organic pathology or not. 4,8
an organic reaction) with sensation of dizziness and other Califano et al demonstrated that though hyperventilation
reflexive responses, e.g. autonomic symptoms while operant precipitated vertigo in all patients, hyperventilation-induced
conditioning associates them with sensation of dizziness nystagmus was absent in patients having purely psychiatric
and other learned behaviors, e.g. seeking reassurance. etiology though they reported the subjective sensation of
Symptomatology dizziness.19 Vestibular testing in patients of panic symptoms,
acrophobia or agoraphobia may yield results indicative of
Symptoms are vague and no consensus is seen in literature.
organic dysfunction. On the other hand, investigations like
Earlier, vertigo with anxiety features and without
provocative caloric testing, atypical or bizarre responses
apparent organic pathology was described as a part of
may point to true psychiatric manifestation.13 Testing for
functional symptoms3—early and late; early functional
spatial orientation and attention may show deficits in
symptoms were more common and were said to be indicative
patients of PPV, CSD et cetera.14
of neurosis. Other symptoms like blurred consciousness,
To supplement the diagnosis further, objective
drop attacks, memory loss, sense of unreality, worsening
of vertigo in noisy environments were also taken into evaluation tools like rating scales and questionnaires can
consideration. The character of vertigo itself was described be used. Self-reported questionnaires like Patient Health
as ‘turning inside head’. Questionnaire (PHQ)8 can be used. Wilhelmsen et al found
Brain, in later times, described psychogenic vertigo as the Vertigo Symptom Scale—Short Form (VSS-SF) with a
having disequilibrium-like symptoms—feeling of subscale of ‘autonomic-anxiety’ useful in supplementing
unsteadiness of gait or falling sensations.17 the detection of patients of psychogenic vertigo.20
Brandt et al postulated that psychogenic vertigo
Treatment
escalated in gradual crescendo pattern terminating suddenly
and associated with anxiety throughout the episode.13 Interdisciplinary approach with involvement of both ENT
Symptoms suggestive of organic pathology may be and psychiatry services is paramount.1,6,14,16
present in case of comorbid neuro-otological dysfunction. First, the patient has to be psychoeducated regarding
Usually none of them, even nausea or nystagmus, are present nature of their vertigo.
if vertigo is only psychogenic without any vestibular Otoneurologic rehabilitative and integrative therapies
dysfunction.8 have been shown to be beneficial in these patients.7,8
There will be symptoms of associated psychiatric Vestibular and balance rehabilitation therapy (VBRT) for
pathologies if any are present (e.g. anxiety, depression, vestibular dysfunction has shown positive psychological
somatization, PTSD, conversion et cetera). There may be benefits—diminished motion sensitivity, improved
associated phobia of developing of symptoms outside home confidence in balance, less catastrophization and less
and so self-imposed sociooccupational restrictions as well.18 avoidance behavior.
Psychiatric therapies like autogenic or systemic
Diagnosis desensitization have shown benefits in reducing avoidant
This disorder can be diagnosed on basis of a good history, and phobic responses and decreasing anxiety.11,21 These
clinical examination and investigations. therapies are useful in patients not showing improvement

Otorhinolaryngology Clinics: An International Journal, May-August 2012;4(2):77-80 79

Henal Shah, Sayantani Mukherjee

on conventional treatment or having persistent anxiety, 9. Gilain C, Engelbert A. Vertigo and psychological disorders.
insomnia or multiple somatic complaints. Cognitive B-ENT 2008;4(8):49-58.
10. Bamiou DE, Luxon LM. Vertigo: Clinical management and
behavior therapy can be used to correct faulty cognition rehabilitation. In: Gleeson MJ, Jones NS, Clarke R, Luxon LM,
like catastrophic thinking and develop positive coping Hibbert J, Watkinson J (Eds). Scott-Brown’s Otorhinolaryn-
skills.8 gology: Head and Neck Surgery (7th ed). London: Hodder
Pharmacological management plays a role too. A trial Arnold; 2008.
of conventional treatment for vertigo can be given. For 11. Dieterich M Dizziness. The Neurologist 2004;10(3):154-64.
psychogenic vertigo, however a trial of selective serotonin 12. Hibbert GA. Hyperventilation as a cause of panic attacks. British
Med J 1984, 28 Jan;288:263-64.
reuptake inhibitors (SSRIs) like paroxetine, fluoxetine,
13. Brandt T, Daroff R. The multisensory physiological and
sertraline and citalopram in conventional doses for 20 weeks pathological vertigo syndromes. Ann Neurol 1980;7:195-203.
can show some encouraging results. 11 Tricyclic anti- 14. Yardley L, Burgneay J, Nazareth I, Luxon L. Neuro-otological
depressants like amitryptiline in lower doses (10-100 mg; and psychiatric abnormalities in a community sample of people
mean dose, 50 mg) and sometimes, benzodiazepines (long- with dizziness: A blind, controlled investigation. J Neurol
acting ones like diazepam and clonazepam in conventional Neurosurg Psychiatry 1998;65:679-84.
15. Guidetti G, Monzani D, Trebbi M, Rovatti V. La comorbidità
doses) and ion-gated channel blockers (like nimodipine and
del deficit labirintico cronico e del distress psicologico sulla
flunarizine) may also show benefits.16 memoria visuo-spaziale [Impaired navigation skills in patients
It should be remembered that these modalities should with psychological distress and chronic peripheral vestibular
be tried judiciously according to patient's disorder profile hypofunction without vertigo]. Acta Otorhinolaryngologica
and random single or combination therapy is avoidable. Italica 2008;28:21-25.
16. Balaban C, Jacob R, Furman J. Neurologic bases for comorbidity
CONCLUSION of balance disorders, anxiety disorders and migraine:
Neurotherapeutic implications. Expert Rev Neurother 2011;
Psychogenic vertigo has always presented a dilemma in 11(3):379-94.
detection, diagnosis and treatment. However, with careful 17. Brain WR. Vertigo—its neurological, otological, circulatory and
surgical aspects. Br Med J 1938, 17 Sep:605-08.
consideration of symptomatology and investigations, a
18. Dros J, Maarsingh O, Beem L, van der Horst HE, Riet G,
clinician can determine the nature and extent of psychiatric Schellevis F, et al. Impact of dizziness on everyday life in older
involvement in the patient's vertigo and treat accordingly. primary care patients: A cross-sectional study. Health and
A successful treatment outcome can be mutually Quality of Life Outcomes 2011;9:44.
beneficial—recovery for the patient and an enriching 19. Califano L, Melillo MG, Vassallo A, Mazzone S. Nistagmo
experience for the clinician. evocato dall'iperventilazione in un'ampia popolazione di pazienti
vestibolari [Hyperventilation-induced nystagmus in a large series
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anxiety related dizziness (MARD): A new disorder? J Neurol Associate Professor, Department of Psychiatry, BYL Nair Charitable
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