Is your patient’s dizziness psychogenic?

Vague lightheadedness is often associated with somatic symptoms such as headache. Some patients describe a floating sensation.

Lightheadedness is frequently associated with anxiety, panic disorder, depression, and somatization. Hyperventilation and agoraphobia are other common causes.

Multiple symptoms, multiple types. Classifying an older patient’s dizziness can be challenging because many patients report symptoms that suggest two or more subtypes.² Also, patients often have trouble describing their dizziness symptoms, sometimes using terms such as “giddiness,” “wooziness,” or “confusion.”

To help patients explain dizziness symptoms more accurately, ask specific questions such as:

• Do you at times feel like you’re about to faint?
• Do you feel as if the room is moving?
• Do you sometimes feel as though you’re going to fall?

Table 2

Psychotropics that may cause dizziness

2. HOW DO DIZZINESS SYMPTOMS RELATE TO POSITION OR MOTION?

By reproducing dizziness symptoms, some quick-maneuver tests can help patients describe their symptoms and may reveal a medical cause.

Dix-Hallpike maneuver.³ Move the patient rapidly from a seated to prone position with the head below the horizontal plane and turned 45 degrees for 10 seconds; then have the patient sit up. Repeat with the head turned to the other side. If dizziness does not occur within a few seconds after each test, rule out benign positional vertigo.

Seated head turn, or head-thrust test, measures qualitative vestibular function.⁸ Move the head rapidly by 45 degrees in a brief, small-amplitude thrust to one side while the patient focuses on your nose; this gauges vestibularocular control. Repeat the test in the other direction. A refixation corrective saccade, occurring as the patient tries to fixate on the target, indicates a possible vestibular disorder.

‘Get-Up and Go’ test, which takes less than 10 seconds, measures balance in older patents.⁹ Have the patient stand up, walk 10 feet, turn around, walk back, and sit down. Watch for staggering, unsteadiness, and use of hands to balance. Onset of symptoms suggests dizziness brought on during activities of daily living and provides information on how dizziness is affecting the patient’s ability to function.

Romberg test. Have the patient stand with heels together, first with eyes open and then closed. Vision and proprioceptive signals are used to compensate for vestibular loss. Thus, a balance disturbance with eyes closed suggests vestibular or spinal proprioceptive problems and may predict risk of falls caused by inability to compensate.⁸

3. WHAT IS THE COURSE OF DIZZINESS?

Differentiating acute, sudden-onset dizziness from chronic, gradual-onset dizziness can help uncover the problem’s cause and seriousness. The latter often has a psychological cause or may point to vestibular or minor cardiovascular problems. Tinetti et al² identified anxiety or depressive symptoms as risk factors among community-based older persons who reported dizziness episodes lasting 1 month.

Table 3

Recommended SSRI starting dosages for older patients

An acute presentation can suggest a panic disorder or acute anxiety state, but first rule out serious conditions such as acute myocardial infarction, arrhythmias, acute infections, GI bleeding, and carbon monoxide poisoning.

Also ask about:

• exacerbating and relieving factors. For example, positional changes, exercise or other physical activity, eating, or missing a meal can trigger presyncope. Also find out about situations that may bring on anxiety, panic, or phobia. Onset of dizziness following these situations may suggest psychogenesis.
• recent falls and injuries. Recurrent falls with presyncope suggest a probable orthostatic or cardiovascular diagnosis in older adults.

4. ANY PAST MEDICAL PROBLEMS?

Ask disease-specific questions. For example:

• Tinnitus or hearing loss could point to a vestibular disorder.
• Metabolic and cardiovascular disorders such as diabetes, ischemic heart disease, postural hypotension, and seizures can result in presyncope.
• Orthostasis, coronary ischemic events, hypoglycemia, and transient ischemic attacks may cause dizziness.

5. IS DIZZINESS RECURRENT?

Panic disorder, anxiety disorders, phobia, and psychogenic hyperventilation are commonly associated with chronic, recurrent dizziness episodes.

6. WHAT MEDICATIONS IS THE PATIENT TAKING?

All psychotropics are suspect when a patient presents with dizziness. When dizziness occurs after a dose or start of therapy, evaluate response to the medication and consider reducing the dosage or changing the medication. If symptoms persist, refer the patient back to the primary care physician to investigate for other causes of dizziness.