Letters to the Editor
Behaviour Therapy for Dizziness?
A woman in her mid-30s presented with recurrent, unexplained dizziness. Two years prior to presentation, she had a 3- to 4-hour period of dizziness, nausea, and vomiting. She saw her family doctor and was told that she had a viral illness, but since then, she has become fearful of further episodes of dizziness. When she felt dizzy, she immobilized her head and neck for several hours until the feeling of dizziness disappeared. She saw numerous physicians who performed many investigations to rule out medical conditions. She was quite distressed about these episodes and had significant anticipatory anxiety with respect to the dizziness. She had decreased functioning at her work because of dizziness. However, she did not meet criteria for panic attacks. Otherwise, she was healthy and had no other psychiatric or medical comorbidity. She did not take any medications. There was no family history of anxiety problems.
The diagnosis of limited-symptom panic disorder was the best explanation for this presentation. Although pharmacotherapy (that is, a serotonin reuptake inhibitor [SRI]) was considered, this treatment modality was avoided, owing to the sensitivity of patients with panic disorder to side effects of antidepressants and to this woman’s limited-symptom panic attacks.
She was treated with 4 individual sessions, using exposure and response prevention. In the first 2 sessions, it was explained to the patient that she had developed fear of the dizziness sensation through classic conditioning. The more she tried to avoid the sensation, the more sensitive she had become to any head movement that resulted in slight dizziness sensations. She was asked to gradually expose herself to the dizziness sensation by spinning around for 30 to 60 seconds daily. She responded well to the systematic desensitization, with no further episodes of dizziness. She was followed for 6 months and maintained her improvement.
Dizziness that is unrelated to a medical condition is a common problem in the population (1–3) and is associated with significant disability and high rates of medical services use (4,5). Recent studies have demonstrated that a significant proportion of persons with unexplained dizziness have an underlying anxiety disorder diagnosis (6,7). Recognition and treatment of this problem is likely to reduce disability and costs to society. A recent open-label trial confirmed that most people with psychogenic dizziness respond to treatment with an SRI anti- depressant (8). Of the sample in this study, however, 25% stopped the anti- depressant because of adverse effects (8). With respect to nonpharmacologic strategies, data support behaviour therapy and vestibular rehabilitation as similar and effective in treating psychiatric dizziness (9–11). The problem with cognitive- behavioural therapy is the lack of availability of trained clinicians to conduct this treatment.
This case highlights 2 important issues: 1) individuals presenting with dizziness who do not meet the full criteria for panic attacks may be underrecognized and undertreated or delayed in receiving treatment, and 2) the feasibility of applying brief behavioural interventions in primary care and otolaryngology clinics should be further explored (12).
References
1. Yardley L, Owen N, Nazareth I, Luxon L. Panic disorder with agoraphobia associated with dizziness: characteristic symptoms and psychosocial sequelae. J Nerv Ment Dis 2001;189:321–7.
2. Furman JM, Jacob RG. Psychiatric dizziness. Neurology 1997;48:1161–6.
3. Asmundson GJ, Larsen DK, Stein MB. Panic disorder and vestibular disturbance: an overview of empirical findings and clinical implications. J Psychosom Res 1998;44:107–20.
4. Nazareth I, Yardley L, Owen N, Luxon L. Outcome of symptoms of dizziness in a general practice community sample. Fam Pract 1999;16:616–8.
5. Yardley L, Nazareth I, Luxon L. Psychiatric dysfunction and dizziness. Lancet 1999;353:2069.
6. Furman JM, Jacob RG. A clinical taxonomy of dizziness and anxiety in the otoneurological setting. J Anxiety Disord 2001;15:9–26.
7. Stein MB, Asmundson GJ, Ireland D, Walker JR. Panic disorder in patients attending a clinic for vestibular disorders. Am J Psychiatry 1994;151:1697–700.
8. Staab JP, Ruckenstein MJ, Solomon D, Shepard NT. Serotonin reuptake inhibitors for dizziness with psychiatric symptoms. Arch Otolaryngol Head Neck Surg 2002;128:554–60.
9. Yardley L, Beech S, Zander L, Evans T, Weinman J. A randomized controlled trial of exercise therapy for dizziness and vertigo in primary care. Br J Gen Pract 1998;48:1136–40.
10. Yardley L, Burgneay J, Andersson G, Owen N, Nazareth I, Luxon L. Feasibility and effectiveness of providing vestibular rehabilitation for dizzy patients in the community. Clin Otolaryngol 1998;23:442–8.
11. Beidel DC, Horak FB. Behavior therapy for vestibular rehabilitation. J Anxiety Disord 2001;15:121–30.
12. Yardley L, Beech S. Nurse-delivered exercise therapy for dizziness. Nurs Times 1999;95:50–1.
Paper previously presented at the Canadian Psychiatric Association Annual Meeting; October 2002; Banff (AB).
Jitender Sareen BSc, MD, FRCPC
Winnipeg, Manitoba
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