Patients with chronic nonspecific dizziness that has eluded diagnosis
may benefit from further examination in light of a new study.
Just because patients complain of chronic, nonspecific dizziness without an
apparent physical cause doesn't mean that the problem lacks a diagnosis.
Intensive investigation can identify psychiatric or neurologic illnesses in
nearly all these patients, according to psychiatrist Jeffrey Staab, M.D.,
M.S., and neurotologist Michael Ruckenstein, M.D., of the Balance Center at
the University of Pennsylvania Health system in Philadelphia.
Staab and Ruckenstein drew from an initial group of about 2,400 patients
who presented at their center with a variety of vertigo, dizziness, and
imbalance complaints. Clinicians soon diagnosed about 75 percent of them.
“The key question is why all of them weren't diagnosed the first time
around,” said Staab in an interview. “Often, doctors evaluate
patients like this for inner-ear problems, treat them, and then if treatment
fails, just assume it's 'psychogenic.'”
The patients didn't have the familiar spinning sensation that typifies
vertigo caused by inner-ear problems, he said. Instead, chronic subjective
dizziness (CSD) produces a feeling of swaying, often set off by motion cues in
daily life, like being in crowds of people, around flashing light stimuli, or
in heavy traffic. Symptoms could not be assigned to any inner-ear illness,
medical condition, medication use, or radiographically imaged lesion. Many
patients had poor concentration and difficulties in their family or work
lives. They had experienced dizziness for an average of four years before
entering the study.
“The classic concept of 'psychogenic' dizziness must be recognized as
a misnomer that may cause errors of omission in medical evaluations of
patients with chronic dizziness,” they wrote in the February
Archives of Otolaryngology-Head and Neck Surgery.
The researchers prospectively studied the 345 patients referred to the
Balance Center for whom no medical cause of nonvertiginous dizziness or
subjective imbalance could be found initially. See Table
Each patient received three types of examinations, following the center's
protocols. These included neurotologic histories and examinations, audiometric
and balance function tests, and magnetic resonance imaging of the brain. Staab
used a version of the Structured Clinical Interview for DSM-IV for
psychiatric diagnosis. In addition, the patients were screened for other
medical causes of dizziness such as head or neck trauma, visual disturbances,
or cardiac dysrhythmias. Those screening positive for any condition were
referred to specialists for further consultation.
Among the 115 men and 230 women in the study, nearly all (339) were
ultimately diagnosed with psychiatric or neurologic conditions, including
primary or secondary anxiety disorders, migraine, traumatic brain injury, or
abnormal functioning of the autonomic nervous system (dysautonomia). Six were
diagnosed with cardiac dysrhythmias, and all of them also had psychiatric
Of the 345 subjects in the study, nearly 60 percent had anxiety disorders
associated with CSD, and 33 percent of the subjects with psychogenic dizziness
had a primary psychiatric diagnosis. Three patients had conversion disorder or
hypochondriasis. About 37 percent of the 345 patients, or 133, had some
central nervous system disorder that caused their dizziness, including
migraine, postconcussional syndrome, or dysautonomias.
Traumatic brain injury (TBI) was heavily overrepresented among patients
with CSD—15 percent of the study subjects, compared with 0.6 percent of
the general population.
“The pathological mechanisms that cause CSD in patients with TBI are
not known but are probably not related to anxiety, given the low rates [5/52]
of anxiety disorders found in the TBI group,” said the authors.
The rate of anxiety disorders among patients with migraine was four times
higher than the population average. Epidemiological studies have found that 18
percent of Americans have an anxiety disorder, but 77 percent of the migraine
patients in Staab and Ruckenstein's study had clinically significant
Even the small number of cardiac dysrhythmias warrants attention, said
Staab, an assistant professor in the departments of psychiatry,
otorhinolaryngology-head and neck surgery, family medicine, and community
health. Usually doctors think about irregular heartbeat when people complain
about fainting, not dizziness.
“These patients follow an evolution of illness from true neurologic
illness or panic attacks,” Staab told Psychiatric News.“
They become sensitized to motion cues—a kind of Pavlovian
conditioning—and are left with this sensitivity, even after their
physical problem is resolved. The idea that anxiety or migraine are players in
this is not new, although now we can estimate prevalence a little better. What
is new is how much concussion contributes to dizziness.”
About 1 percent of the U.S. population has CSD. Many patients just have
given up. Some turn to complementary or alternative medicine or go on
“Now we can tell patients that this is not a mystery,” said
Staab. “We can explain just what causes their symptoms.”
Treatment choices remain undefined, said Staab. No big, randomized,
controlled trials of treatment for chronic nonspecific dizziness have been
conducted. Some small, open trials have researched treatment in three
directions, however. Selective serotonin reuptake inhibitors have shown some
utility in reducing anxiety and lessening dizzy symptoms. Cognitive-behavioral
therapy has been tried in small numbers of patients, so far without conclusive
data. A form of physical therapy, vestibular balance rehabilitation therapy,
is also under investigation.
Psychiatrists should keep in mind that CSD lies in an area overlapping
somatoform and anxiety disorders, said Staab. “Our challenge, as with
any other somatoform disorder, is to better understand the medical
differential diagnosis and understand the medical linkage among the
At the same time, physicians, whatever their specialty, should not think in
either-or terms, said Staab. “It's not medical versus
“Expanding the Differential Diagnosis of Chronic
Dizziness” is posted at<http://archotol.ama-assn.org/cgi/content/full/133/2/170>.▪