Is your patient’s dizziness psychogenic?
6 questions can help you narrow the diagnosis and rule out medical causes
Psychotropics that may cause dizziness are listed in Table 2, For a list of other medications associated with dizziness, see this article at www.currentpsychiatry.com.
If the above strategies do not reveal a physical cause of dizziness despite multiple physical complaints, consider examining the patient for depression, anxiety, or panic disorder.
Treating a psychiatric cause
If dizziness is found to be psychogenic and the symptoms impede daily activities or contribute to functional decline, treat the psychiatric disorder but carefully weigh the risks and benefits of drug treatment.
Although SSRIs may cause dizziness, these agents are recommended first-line treatment for depression, anxiety, and/or phobia in older patients with dizziness because of their relative lack of anticholinergic action and side effects compared with other antidepressants or anxiolytics.
Coexisting medical symptoms may dictate choice of agent. For example, consider a sedating SSRI for a patient with sleep disturbances caused by dizziness or the psychiatric disorder; choose a nonsedating SSRI if the patient is sleeping normally.
Because SSRIs may cause weight loss, avoid giving them to patients with weight loss associated with dizziness or an underlying psychiatric illness. Mirtazapine, which is associated with weight gain, may offset weight loss. Start mirtazapine at 15 mg at bedtime for older patients.
Start low and go slow when prescribing an SSRI to an older patient. Dosing strategies applicable to younger patients should not be extrapolated to older patients, especially those with dizziness.
We have found that older patients respond well to minimum or below-normal SSRI dosages (Table 3). Titrate very slowly and instruct patients to report dizziness. Reduce the dosage if dizziness emerges.
If the patient does not respond to an SSRI or mirtazapine, consider a serotonin and norepinephrine reuptake inhibitor, which also has favorable anticholinergic and side-effect profiles.
Related resources
- WebMD Health—Dizziness: lightheadedness and vertigo. https://my.webMD.com/hw/health_guide_atoz/hw88500.asp.
- Sloane PD. Clinical research and geriatric dizziness: The blind men and the elephant. J Am Geriatr Soc 1999;47:113-14.
- Kroenke K, Hoffman RM, Einstadter D. How common are various forms of dizziness? A critical review. South Med J 2000;93:160-7.
Drug brand names
- Alprazolam • Xanax
- Amitriptyline • Elavil
- Bupropion • Wellbutrin
- Buspirone • BuSpar
- Carbamazepine • Tegretol
- Chlordiazepoxide • Librium
- Chlorpromazine • Thorazine
- Citalopram • Celexa
- Clonazepam • Klonopin
- Diazepam • Valium
- Divalproex/valproic acid • Depakote
- Escitalopram • Lexapro
- Estazolam • ProSom
- Fluoxetine • Prozac
- Fluphenazine • Prolixin
- Flurazepam • Dalmane
- Gabapentin • Neurontin
- Imipramine • Tofranil
- Lamotrigine • Lamictal
- Lorazepam • Ativan
- Memantine • Namenda
- Mirtazapine • Remeron
- Nefazodone • Serzone
- Nortriptyline • Pamelor
- Olanzapine • Zyprexa
- Oxazepam • Serax
- Oxcarbazepine • Trileptal
- Paroxetine • Paxil
- Perphenazine • Trilafon
- Phenelzine • Nardil
- Phenytoin • Dilantin
- Prochlorperazine • Compazine
- Quazepam • Doral
- Rivastigmine • Exelon
- Selegiline • Eldepryl
- Sertraline • Zoloft
- Tacrine • Cognex
- Temazepam • Restoril
- Thioridazine • Mellaril
- Trazodone • Desyrel
- Triazolam • Halcion
- Trifluoperazine • Vesprin
- Venlafaxine • Effexor
- Zolpidem • Ambien
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Acknowledgment
The authors thank Robert Cluxton, PharmD, University of Cincinnati College of Pharmacy, for helping to prepare this manuscript for publication.
