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“It is more important to know what kind of patient has the disease than to know what kind of disease the patient has.
The good physician will treat the disease, but the great physician will treat the whole patient.”
—Sir William Osler
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Dizziness can cause extreme stress, which may in turn lead to anxiety (including panic attacks and agoraphobia), depression, and somatoform disorders. These psychological problems can also cause severe dizziness. At times, these psychological causes may become the primary cause of dizziness and may replace the initial organic cause of dizziness.
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Two good longitudinal studies have assessed the role of psychological problems in dizziness. Kroenke and associates1 examined 94 patients at onset of dizziness and then had the patients complete questionnaires at 4 months and 1 year later. Symptoms improved for 51 patients, stayed the same for 32, and worsened for 11. Etiology of the dizziness affected outcome. The majority of patients with benign paroxysmal positional vertigo (BPPV), neuritis, migraine, or presyncope experienced improvement. Less than half of those with Ménière's disease or psychiatric or nonvestibular disequilibrium showed improvement. The four multivariate predictors of poor outcome were (1) primary psychiatric etiology, (2) dysequilibrium, (3) daily dizziness, and (4) dizziness aggravated by walking.
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Yardley and colleagues2 examined 101 patients at onset of dizziness and 7 months later. The best longitudinal predictors of poor outcome were autonomic symptoms (heart pounding, excessive sweating, hot or cold spells, feeling faint or short of breath) and somatization (general tendency to complain of a diversity of unrelated health problems, ranging from pains in the back to difficulty concentrating). These symptoms had a better prediction of poor outcome than did the etiology of true vertigo, severity, duration, test results, or medication. High and persistent handicap arose from psychiatric or psychosocial problems unrelated to the vertigo.
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This chapter summarizes the interaction between dizziness and psychological problems. It also discusses conversion disorders and malingering. Finally, it presents a practical clinical approach to these problems.
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Psychological Disorders and Their Prevalence
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Dizziness in Patients with Psychological Disorders
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Prevalence of Psychological Disorders
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The prevalence of psychological problems in the general population is very high. Table 18-1 lists the prevalence in the United States as of 2012.3
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