A clinical taxonomy of dizziness and anxiety in the otoneurological setting
Introduction
In this paper, we will discuss the various ways in which dizziness, balance disorders, and anxiety or other psychiatric conditions may interact clinically. Our discussion of this interaction includes a description of the symptomatology of dizziness and the concept of space and motion sensitivity (SMS) and space and motion discomfort (SMD) as they occur in anxiety disorders and vestibular disorders. After laying this foundation, the interface between vestibular and psychiatric disorders in general will be explicated, from the perspective of an otoneurological clinician in a dizziness clinic.
Dizziness as an experience is internal or private in nature. As with other private sensations (e.g., pain), the verbal labeling of the experience is not subject to direct social validation. Therefore, different verbal descriptors are used by different individuals, and conversely, the same verbal descriptor may mean different sensations for different individuals. Synonyms for dizziness often are defined by an analogy to physical events or actions, such as voluntarily hyperventilating, voluntarily spinning around, or taking an amusement park ride. Terms such as floating, spinning, swimming, walking on clouds, giddiness, feeling unreal, disoriented, or lightheaded all have connotations to external actions or events. Note that many of these terms do not connote a sense of “spinning.”
Section snippets
Dizziness in panic disorder
In medical practice, the patient's description of their dizziness has been considered a clue to the etiology of their problem. For example, spinning of the environment has been considered suggestive of a balance disorder, whereas spinning in the head has been considered suggestive of a psychiatric disorder. Unfortunately, such inferences are not accurate. For example, patients with panic disorder report the symptom of environment spinning both during and between panic episodes. We examined our
Dizziness in balance disorders
Fig. 1 provides a framework for classifying patients with a chief complaint of dizziness. Dizziness is the primary complaint in 2.6% of primary care visits (Sloane, 1989). At the center (area A), we find a core of relatively well-defined clinical syndromes. We will discuss some of these syndromes below. Outside of the square of syndromal dizziness fall the many patients who have a balance system disorder that cannot be assigned a specific diagnosis (area B). Rather, such patients have
Vestibular dysfunction, central compensation, and SMS
An overlooked aspect of vestibular symptomatology is that it can be situation specific. The situational aspects of vestibular symptoms are explained by the fact that the balance system receives input from three sensory systems: the visual system, the somatosensory system, and, of course, the vestibular system. Even individuals with normal balance systems utilize the nonvestibular channels. For example, body sway in the standing position is higher when a person's eyes are closed as opposed to
An otoneurological perspective on the interface between balance disorders and psychiatric disorders
Psychiatric conditions are common in otoneurological settings. Although anxiety disorders are particularly common, other psychiatric conditions are encountered as well. Fig. 1 illustrates that the interface between psychiatric and balance disorders spans all four categories of dizziness etiologies. Thus, the presence of a psychiatric disorder does not “rule out” a balance disorder. Patients with dizziness may have a balance disorder, a psychiatric disorder, both a balance disorder and a
Unresolved issues
There are several unresolved issues regarding the taxonomy of dizziness and anxiety in the otoneurological setting. An area that is particularly poorly understood and not discussed in this paper is the influence of time course of the disease process. Some patients appear to develop an anxiety disorder without a clinically obvious prior or concurrent balance disorder, although they actually may have had a balance disorder in the more distant past. In this paper, we propose diagnostic criteria
Acknowledgements
This study was supported by PO1DC03417.
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