Evidence-Based Reviews

Is your patient’s dizziness psychogenic?

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6 questions can help you narrow the diagnosis and rule out medical causes


 

References

Dizziness is common among patients age 65 and older, and more than one-third have a psychiatric disorder that is caused by or is causing their dizziness.1

When older patients present with dizziness, psychiatrists may be asked to alleviate the psychological symptoms and help identify the underlying disease state.2

More than 60 medical and psychiatric disorders and many medications can cause dizziness. To help you sort through the possibilities, we offer:

  • six diagnostic questions to rule out underlying medical problems
  • lists of commonly used psychotropics and other drugs that may cause dizziness
  • advice on treating depression, anxiety, and panic disorder in an older patient with dizziness while avoiding side effects and drug interactions.

Table 1

Four types of dizziness and their usual causes

Vertigo
Benign positional vertigo CNS cause—tumor, demyelination, neurodegenerative disorders
Labyrinthitis
Meniere’s disease
Peripheral vestibulopathy (in 50% of cases)
Vestibular neuronitis
Presyncope
Arrhythmias
Carotid sinus disease
Hypoglycemia
Neurocardiogenic syncope
Organic heart disease
Orthostatic hypotension
Seizures
Situational
Transient ischemic attacks
Disequilibrium
Balance and gait disorder
Mixed CNS diseases (ischemic, degenerative)
Neurodegenerative CNS disorders
Presbystasis
Sensorimotor dysfunction
Psychogenic lightheadedness
Agoraphobia
Anxiety
Depression
Panic disorder
Hyperventilation
Source: Adapted from reference 6

Many causes of dizziness

The term “dizziness” is hard to define because of its nonspecific and variable symptom description, multiple causes, and lack of clear diagnostic and management guidelines. In clinical use, dizziness encompasses abnormal sensations relating to perception of the body’s relationship to space.

Some researchers believe dizziness is a distinct geriatric syndrome because numerous factors related to aging cause dizziness,2 including physiologic changes (presbystasis), accumulated impairment, disease states, and interactions between multiple medications.

Anxiety, somatization, panic disorder, and depression cause dizziness in the elderly, as do:

  • peripheral vestibular disorders
  • brainstem cerebrovascular accident
  • diabetes mellitus
  • neurologic disorders such as Parkinson’s disease
  • and cardiovascular disorders.

Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants also have been shown to cause dizziness, as have numerous nonpsychotropic agents.

Recognizing patterns, testing hypotheses, and extending the diagnostic process over time can help you differentiate psychogenic from medicationinduced or neurologic dizziness.3 Because the presentation is so complex and the differential diagnosis so broad, algorithmic diagnosis is less effective than a flexible clinical approach that allows for uncertainty in evaluating initial symptoms.

Determining the cause

A thorough patient history and physical examination can uncover a cause of dizziness in 75% of cases.4 Look for duration of dizziness symptoms; history of heart disease, diabetes or other illnesses; family history of psychiatric disorders; and other illnesses among family members.

Ask the following six complaint-specific questions to help you narrow the differential diagnosis and rule out nonpsychiatric causes.5

1. WHAT TYPE OF DIZZINESS DOES THE PATIENT HAVE?

Four categories—vertigo, presyncope, disequilibrium, and lightheadedness—are used to classify dizziness (Table 1).6

Vertigo is a sense that the body or environment is Patients may feel as if the floor is tilting, sinking, rising or veering sideways, or they may feel pulled to one side.

Vertigo is commonly caused by peripheral vestibular disorders—including benign positional vertigo, Meniere’s disease, labyrinthitis, and vestibular neuronitis—and central vestibular disorders associated with cerebrovascular disease, tumors, demyelinating diseases, migraines, seizures, multiple sclerosis and other CNS diseases. Acute-onset vertigo and neurologic signs suggest brainstem infarction.

Nystagmus is usually present, horizontal, and may be rotational at times. A vertical-beating nystagmus points to a probable CNS cause and requires urgent neuroimaging and referral to a neurologist or otolaryngologist.

Presyncope describes near-fainting. A dimming of vision and roaring in the ears may precede presyncope.

Depending on its cause, presyncope may occur regardless of position or only when upright. Common causes include orthostatic hypotension, neurocardiogenic syncope, organic heart disease, arrhythmias, carotid sinus disease, seizures, hypoglycemia, and transient ischemic attacks.

Abrupt presyncopal attacks that occur regardless of position suggest a cardiovascular cause. If onset is gradual and not improved by lying down, suspect a cerebral metabolic cause such as hypoglycemia.

Syncope, like presyncope, often is traced to an underlying cardiovascular disease. Dizziness and syncope often coexist, and both can be multifactorial. Dizziness may precede or follow syncopal episodes.

Differentiating syncope and dizziness is important because many underlying causes of syncope can be fatal. By contrast, dizziness symptoms are usually benign and self-limiting.7

A thorough history is critical to distinguishing dizziness from presyncope. Assess medication effects—especially CNS-acting medications, cardiovascular drugs, antihypertensives, antibiotics, and over-the-counter medications such as dextromethorphan and acetaminophen compounds. Also check for dehydration.

Disequilibrium disorder signifies unsteadiness or a loss of balance primarily involving the lower extremities. Symptoms are evoked by walking or standing and relieved by sitting or lying down. Gait is abnormal and balance is compromised without abnormal head sensations.

Common causes include balance and gait disorders, sensorimotor dysfunction, presbystasis, neurodegenerative CNS disorders, and mixed ischemic and degenerative CNS diseases.

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