Phobic postural vertigo: a cognitive-behavior approach

Abstract

Dizziness is one of the most common symptoms in primary care and can be associated with otologic, neurologic, and psychiatric conditions 1,2 . Phobic postural vertigo (PPV) is a specific anxiety-related, chronic and incapacitating condition with subjective imbalance and short attacks of dizziness, and has been described as a prevalent cause of chronic subjective dizziness that cannot be sufficiently explained by patient's vestibular condition 3 . Behavioral therapy, vestibular rehabilitation and serotonin selective re-uptake inhibitor antidepressants (SSRIs) have been pointed as useful treatments 4 . Few cognitive-behavior (CBT) studies for chronic dizziness have been described.We report a patient with chronic dizziness that only achieved complete symptom relieve after adding CBT to the conventional medication treatment. CASEAt the age of 17 this male, patient presented vestibular neuritis episodes due to peripheral vestibular dysfunction, diagnosed by otolaryngologic examinations that showed predominance of the left ear. Differential diagnosis was made by neurological examinations, blood biochemical tests, EEG, MRI, audiometry, negative Dix-Hallpike maneuver responses and absence of nystagmus. He responded positively to treatment with flunarizine, achieving complete relief of symptoms in few weeks.Eight months later, the complaints of dizziness returned with atypical presentation that could not be explained by remaining vestibular lesions. Episodes occurred several times a day, lasting 3-10 seconds and followed by an intense sense of fear, which turned out to be very incapacitating. He completely withdraw from daily activities, including school, avoided moving the head, reading and being alone, and adopted safety behaviors such as only leaving the house with a family member.The patient was medicated with sertraline 50 mg/day and clonazepam 2 mg/day, and referred to a clinical psychologist (A.S.) for CBT. He fulfilled the DSM-IV criteria for agoraphobia, but not for panic disorder, since only dizziness, rarely accompanied by tachycardia, was present during the episodes. Patient was clinically diagnosed with PPV 5 .Treatment sessions were conducted once a week. The initial goal was to reduce the sense of vulnerability and self-devaluation. Cognitive interventions focused on putting this unpleasant life moment in perspective and making plans for the short and the long run. Euthymic mood was yield after 8 weeks of treatment.Information on the etiology of the symptoms and how discomfort was caused by the experience of anxiety was emphasized. He was instructed on how avoidance and hypervigilance behaviors maintained the problem, as the attention focused in every balance change triggered anxiety responses and dizziness, and realized that focusing on the occurrence of symptoms worsened discomfort. Although it restricted the evaluation of intensity and duration of the crisis to the patient's subjective reports, objective monitoring was thus discouraged by the therapist.Once the patient perceived the symptoms as uncontro...

Pre‐ and post‐operative dizziness and postural instability in temporal arachnoid cyst patients

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Vértigo fóbico, una patología silente

“…Los diferentes tratamientos posibles para el VFP incluyen el farmacológico y la psicoterapia (3,4). En aquellos casos donde los pacientes con VFP son refractarios con muchos tipos farmacológicos, podrían ser beneficiados por terapia conductual, que es un tipo de psicoterapia donde se busca la desensibilización mediante exposición a las situaciones causales; es decir, el paciente no debe evitar este tipo de situaciones, pero, por el contrario, las reconocerá al enfrentarlas.…”

“…En aquellos casos donde los pacientes con VFP son refractarios con muchos tipos farmacológicos, podrían ser beneficiados por terapia conductual, que es un tipo de psicoterapia donde se busca la desensibilización mediante exposición a las situaciones causales; es decir, el paciente no debe evitar este tipo de situaciones, pero, por el contrario, las reconocerá al enfrentarlas. Si la explicación y autodesensibilización no resultan suficientes después de semanas o meses, la terapia conductual con drogas o sin ellas debería iniciarse; es decir, mediante terapia con un inhibidor selectivo de la recaptación de serotonina (por ejemplo, paroxetina, 10-40 mg/día) o un antidepresivo tricíclico durante 3-6 meses (3,5,6).…”