Anxious … and Off Balance Which comes first? Dizziness and falls? Or the fear of either happening? Anxiety and balance problems can become a feedback loop. Features
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Features  |   July 01, 2018
Anxious … and Off Balance
Author Notes
  • Julie A. Honaker, PhD, CCC-A, is director of the Vestibular and Balance Disorders Laboratories at the Head and Neck Institute at Cleveland Clinic. honakej@ccf.org
    Julie A. Honaker, PhD, CCC-A, is director of the Vestibular and Balance Disorders Laboratories at the Head and Neck Institute at Cleveland Clinic. honakej@ccf.org×
Article Information
Balance & Balance Disorders / Features
Features   |   July 01, 2018
Anxious … and Off Balance
The ASHA Leader, July 2018, Vol. 23, 54-61. doi:10.1044/leader.FTR2.23072018.54
The ASHA Leader, July 2018, Vol. 23, 54-61. doi:10.1044/leader.FTR2.23072018.54
Peggy was a healthy 54-year-old who never worried about her balance. But that changed a year ago when she lifted her head off her pillow one morning and found the room spinning around her. No matter which way she moved her head, she felt symptoms of vertigo. Finally, five minutes later, they stopped.
She hasn’t experienced any such episodes of extreme vertigo since, but she now feels “off,” as if she is riding on a boat or “floating,” especially during and after physical activity. She notices this sensation when she is upright and walking. Overall, she feels better when sitting still, but the symptoms still lurk. Additionally, bright lights, reading, watching TV and working on the computer exacerbate her symptoms.
Seeking relief, Peggy consulted an audiologist, who recommended vestibular therapy focusing on central adaptation exercises (vestibulo-ocular reflex [VOR] exercises). She attended several training sessions and tried some at-home exercises—a walking program, gaze stabilization exercises and standing balance tasks. However, she could not tolerate the exercises because they made her symptoms worse.
Unable to continue her work as a marketing associate, Peggy is on long-term disability and fears she will lose her job. She avoids usual activities like driving, shopping, working on the computer and even gardening, and is gravely concerned she will experience another vertigo episode. Her symptoms of dizziness are starting to take over her life, causing stress to her and her family. Her medical workup to date has been unremarkable and has ruled out any life-threatening cause for her symptoms, but she worries that her dizziness will never resolve.
When working with patients like Peggy, we audiologists are tasked with understanding the past and present causes of vestibular symptoms. In her case, her current symptoms may not relate to the past reason for her vertigo episode, and there may be an underlying psychogenic cause. Similar to the chicken-and-egg scenario, which comes first: the emotional response (anxiety, panic or depression) or the dizziness? The answer is both can be the case. Thus, as audiologists, we need to understand the emotional aspects of balance disorders and how we can better identify and help patients manage these aspects.

Perceived threat of falling could relate to advanced age or impaired physical function, but the emotional response (anxiety) may be most responsible for activity restriction and changes in the balance system.

Psychiatric aspects of imbalance
The idea that persistent dizziness could have nonvestibular origins dates back to the late 1800s. Psychiatric disorders including panic, anxiety or depression can have associated vestibular symptoms (vertigo, dizziness, unsteadiness). Additionally, patients with these psychiatric conditions may report lower quality of life, physical and functional decline, and perceived handicap (see sources). In addition to reported symptoms and concerns, patients with psychiatric disorders may show changes in their balance control, such as increased body sway (see sources).
The threat of balance problems and resulting injury can bring on anxiety, which can, in turn, hamper balance function. For example, older people who have not fallen may develop a fear of falling. This perceived threat of falling could relate to advanced age or impaired physical function, but the emotional response (anxiety) may be most responsible for activity restriction and changes in the balance system.
As a result, the fear of falling may lead to less mobility, decreased quality of life, lower muscle tone and strength, poor balance, and increased risk of future falls. Indeed, when people fear falling, it’s not unusual to see them reduce their gait speed and step length, and change their posture. They may stand with their feet spread wide apart, increase the time that both feet are on the ground during walking, and lean backward and sway their body more than usual.
This raises the question: Why can balance fears affect balance function? Research by Brunel University London rehabilitation psychology researchers indicates fear of falling may alter people’s attention, which could negatively affect their motor control.
Another team of researchers, led by Mayo Clinic psychiatrist Jeffrey Staab, describes a stiffening strategy that reduces range of motion during postural control tasks. This strategy could change body sway patterns (lower-amplitude, higher-frequency sway). People who fear falling may also limit their head movement, which can limit proper initiation of the vestibulo-ocular reflex to promote gaze stability (see sources).
As we move about during our daily lives, we must quickly integrate sensory input from our environment, and a stiffening behavior may reduce our capability to perform activities of daily living. Clinicians see this pattern even in those without balance problems when they walk across a narrow beam raised above the ground. Their gait slows and their strides shorten, and this gait pattern declines even more when adding tasks on top of walking (for example, talking while walking). They tend to develop compensatory strategies to maintain their upright stance and prevent a fall, but these strategies are maladaptive.
Such balance-compromising behaviors are not limited to changes in gait patterns and postural control; they may extend to visual behaviors. For example, an adult who is anxious about falling may fixate on an obstacle that they must navigate over or around. They use this compensatory strategy to ensure accurate and safe approach, but they may look away from the obstacle prior to stepping. This can result in missing the obstacle, rather than stepping over it.
Also, when approaching multiple obstacles, these people may not focus on what is steps ahead—only what is directly front of them, thus reducing their ability to generate a spatial map (see sources). In sum, increased fear and anxiety can lead to stiffening movement and altered postural control, gait, head movements and visual search strategies. All of this can impede balance.

Balance-compromising behaviors are not limited to changes in gait patterns and postural control; they may extend to visual behaviors.

Dogged by dizziness
As with falling, anxiety and/or depression may contribute to problems with dizziness, or vice versa. Upwards of 50 percent of patients with vestibular disorders may develop anxiety, depression or panic disorders (per this Current Opinion in Neurology article). Anxiety and depression may also affect recovery of balance function, leading to prolonged symptoms.
For instance, in an article published this year in Frontiers in Neurology, researchers from Shengjing Hospital of China Medical University found that patients with anxiety and/or depression and benign paroxysmal positional vertigo (BPPV) had lower first-time treatment success rates than comparative patients without psychological comorbidities.
For some patients, overwhelming concern about experiencing another vertigo episode may lead them to steer clear of public places or even to avoid leaving their house (agoraphobia), as with Peggy, the patient in the opening example. Like Peggy, these patients may also experience postural instability and increased sensitivity to visual stimuli. Personality traits like neuroticism and introversion only make a person more susceptible to such symptoms after a vestibular insult (see sources).
Research out of Seoul National University indicates that people with high anxiety may respond more strongly to visual over vestibular inputs. As a result, they may depend more on visual cues (over-relying on vision to help with balance function), which could be maladaptive and a source of persistent vestibular symptoms, such as visually provoked symptoms.
This brings us to diagnosis, and what we call chicken-or-egg anxiety-related dizziness. We can choose from a host of names for the phenomenon, including phobic postural dizziness, space-motion discomfort, visual vertigo, chronic subjective dizziness, and the newly introduced persistent postural-perceptual dizziness (PPPD, see sidebar below). In Peggy’s case, her chronic dizziness met the diagnostic criteria for PPPD and her treatment began with educating her on the disorder and reasons for her dizziness symptoms.

For some patients, overwhelming concern about experiencing another vertigo episode may lead them to steer clear of public places or even to avoid leaving their house.

Pathways to recovery
Whether related to dizziness or falls, anxiety can clearly play a role in balance disorders. But what can we do as clinicians to better assess, address and manage these co-occurrences? We need to address both physical and emotional aspects of the patient’s condition.
When we first see a patient, we need to start with the clinical history, a physical examination and integration of vestibular and other laboratory results. In the 2016 book “Balance Function Assessment and Management” (page 741), the Mayo Clinic’s Jeffrey Staab suggests we address these three questions:
  • Does the patient have an active neurotologic condition (neurological disorder of the ear)?

  • Does the neurotologic condition explain all of the patient’s symptoms?

  • Does the patient have behavioral symptoms indicative of psychiatric morbidity?

These questions, Staab says, help us to sort past from present symptoms and to identify any co-morbidities—including behavioral symptoms such as activity avoidance or restrictions. A number of screening tools can also help identify any psychiatric co-morbidities. These include the Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder 7-item (GAD-7) and the Hospital Anxiety and Depression Scale (HADS). Also look for activity restrictions and avoidance behavior with the Dizziness Handicap Inventory (DHI) or Activities Specific Balance Confidence Scale (ABC).
Much can be gained from simply talking with the patient about any avoidant behavior, anxiety and alterations in activities. This discussion not only strengthens your case for additional management options, but helps the patient better understand how these concerns may affect their balance.
Indeed, patient education is a key aspect of treating emotional aspects of balance disorders (see sources)—something Peggy’s audiologist knew. When Peggy revealed how much her dizziness was limiting her activities, the audiologist explained to her exactly how her PPPD can play a role.

Much can be gained from simply talking with the patient about any avoidant behavior, anxiety and alterations in activities.

Other treatment avenues include referral to a psychiatrist for medical management and/or referral to a mental health professional for psychotherapy (cognitive-behavioral therapy), which demonstrates promising short- and long-term benefits (see sources). To help control the patient’s anxiety and/or depression, a psychiatrist may prescribe selective serotonin re-uptake inhibitors (SSRIs) or serotonin norepinephrine re-uptake inhibitors (SNRIs, see sources), as well as properly coordinate the patient’s medications and wean them off problematic ones.
Yet another treatment option is vestibular and balance rehabilitation therapy, provided by a trained vestibular therapist, in which gentle habituation exercises combat visually provoked symptoms. This treatment may include repeated exposure to visual stimuli. An effective management plan for these patients reduces symptoms, retrains the patient to use balance strategies, and helps them overcome avoidance behaviors. For Peggy, this strategy helped her regain balance confidence and reduce her symptoms of dizziness.
Peggy’s case illustrates the importance of a clinician taking the time to understand a patient’s anxieties and concerns related to balance. Identifying and managing these symptoms can ultimately improve that patient’s balance outcomes. One of the most important tools available to clinicians is a compassionate discussion with patients about avoidant behaviors. Questioning the true source of their symptoms can be key to conquering those symptoms.
What Exactly Is Persistent Postural-Perceptual Dizziness?

Known as PPPD, persistent postural-perceptual dizziness became an official disorder last year, with defining criteria as a chronic functional vestibular disorder that includes both physical and psychological symptoms.

A subcommittee of the Bárány Society’s Committee for Classification of Vestibular Disorders issued a statement outlining PPPD’s main criteria: persistent nonvertiginous dizziness exacerbated by upright postural and spatial perception stimuli.

PPPD diagnosis requires that all Bárány Society criteria be met:

  • Symptoms persist and are present for most of the time for three months or more. These symptoms may last for long periods of time (hours), but can alternate in severity.

  • Symptoms may not have a provocative feature, but can be exacerbated by upright posture, active or passive movement, or complex visual stimuli.

  • Symptoms often have some triggering event (such as vestibular neuritis, BPPV, migraine) that causes initial symptoms of dizziness, vertigo or unsteadiness.

  • Symptoms cause distress and avoidance behavior. Patients may appear at their wits’ end due to functional impairment of symptoms.

  • Symptoms are not better explained by another condition.

Diagnosis begins with taking a careful history and may include synthesizing information from physical examination, vestibular laboratory testing and diagnostic neuroimaging. Patients with PPPD may have co-existing anxiety and depression, but this is not a diagnostic feature of PPPD. They may have co-occurring neurotologic disease, but this doesn’t explain all presenting symptoms.

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July 2018
Volume 23, Issue 7