Chronic Dizziness and Anxiety

[size=150]Chronic Dizziness and Anxiety - Effect of Course of Illness on Treatment Outcome[/size]

Jeffrey P. Staab, MD, MS; Michael J. Ruckenstein, MD, MSc
Arch Otolaryngol Head Neck Surg vol 131, Aug 2005

*Objective: To investigate the hypothesis that the efficacy of selective serotonin reuptake inhibitors (SSRIs) for chronic subjective dizziness (CSD) and anxiety depends on the longitudinal pattern of the patients’ symptoms. Patients: Eighty-eight consecutive patients treated with an SSRI for CSD and anxiety between 1998 and 2003. All patients were referred for evaluation of unremitting dizziness. They entered SSRI treatment after comprehensive neurotological and psychiatric evaluations revealed a syndrome of CSD with accompanying anxiety. Interventions: Patients with CSD were treated with an SSRI according to an established protocol for at least 8 weeks or until they proved intolerant to medication. Main Outcome Measures: Changes in dizziness and anxiety as measured by the Clinical Global Impressions–Improvement scale. Results: Patients with the otogenic and psychogenic patterns of illness had a more complete response to SSRI treatment than did patients in the interactive group (P < 0.01). Rates of SSRI intolerance were similar for all 3 groups. Conclusions: Selective serotonin reuptake inhibitors are effective for patients with CSD and anxiety. However, patients with clinically significant anxiety predating neurotological illness may require more intensive interventions. *

[size=150]Study Notes[/size]:

  1. Otogenic - this group had histories of transient or current neuroto- logical illnesses (eg. vestibular neuronitis, Ménière’s disease), but they developed persistent dizziness and anxiety for the first time after their acute neurotological event.

  2. Psychogenic - this group had primary anxiety disorders (eg. panic or generalised anxiety disorder) that presented with prominent dizziness in the absence of any neurotological illness.

  3. Interactive - this group had preexisting anxiety disorders or an anxiety diathesis (eg. self-limited periods of excessive worry) without dizziness. The developed chronic dizziness and an exacerbation of their psychiatric condition after they acquired a physical neurotologic illness.

They used the following SSRIs in the study: Prozac, Paxil, Zoloft, Cipramil and Lexapro. SSRI meds were titrated up from low doses to the full therapeutic dose over a 4 week period. Measures were taken at 8 weeks. They detected no difference in any of the meds as far as efficacy goes.

The otogenic and psychogenic group fared equally well with a reduction in both dizziness and anxiety. Reasons for this excellent response are not entirely clear, because SSRIs are not typically used to treat the types of phobic symptoms most commonly seen in these patients. It is possible that low-level anxiety symptoms responded to SSRI treatment, which indirectly improved their dizziness. However, the high percentage of patients with a complete remission of both dizziness and anxiety suggests that the SSRIs may have had a more direct effect on dizziness itself. Serotonin is present in the vestibular nuclei and affects the responsiveness of motion sensitive neural pathways from the vestibular nuclei through the inferior olive to the nodulus and flocculus of the cerebellum. These may be sites where SSRIs can directly decrease dizziness.

Neurotologists and others who regularly treat patients with chronic dizziness can feel confident recommending SSRI treatment for patients with otogenic and psychogenic patterns of illness.

Hi Scot,

I’ve been diagnosed with both BPPV and more resently MAC.
I have been having more headaches of late…following a long period
of BPPV and a constant sensations of movement, which brought on several
anxiety attacks…being in constant vertigo state I think was probable cause of it.
My headaches seem to be worse lately…I have been following the diet for
MAV for the last 4 weeks…I do not feel any change yet…not sure why…
This brings me to my question about medications…the doctor just ordered
a perscription for nortriptyline…after reading the side affects… I’m afraid to take it.
After reading your article about chronice dizziness and anxiety I wanted to ask
you your take on this medication or If you know of any history results you could share
with me…Any information would be greatly appreciated and helpful…
My deepest thanks regarding,

Kathleen, I have been bothered with MAV for probably eight years and have tried just about everything. My doctor put me on Nortrytilene with minimal results. The only side effects I experienced were afternoon sleepness. I took dosages of up to 50 mg before I gave up on them. I am now looking to try theraputic hypnosis. I’m wondering if anyone else has tried hypnotherapy.