Question 1

I know someone anxious, depressed, and a more type A doer, who has been over-working for the past 6 months and recently started having vertigo. They wonder if working too much and being stressed contributed to their vertigo?

Sarah Edelman · Accepted Answer

With vertigo, it feels like you or your surroundings are moving (or spinning). It tends to be associated with vestibular or CNS conditions such as BPPV, Meniere's disease, vestibular migraines, vestibular neuritis, etc. With dizziness, you are more likely to feel woozy, unsteady, unbalanced, veering to the side. PPPD usually triggers dizziness rather than vertigo. But if they have an accompanying vestibular condition or CNS condition, they may experience episodes of both. The jury is out on whether stress actually triggers vertigo. I have certainly seen patients who are adamant that it started when they were under a lot of stress, and even now they get more vertigo when they are stressed. 
It could be true for some patients but I haven't seen any research literature to back that up.

Question 2

How do you handle clients with significant medical conditions contributing to their dizziness who may be sensitive to psychological explanations that perpetuate/worsen the dizziness?

Sarah Edelman · Accepted Answer

Two things:

1. You need to explain the concept of somatisation – real physical symptoms that are triggered by the brain (specifically the limbic system) rather than a local organic cause. Anxiety has a strong impact on body responses. The obvious ones are heart rate, blood pressure, muscle tension, etc. But ongoing vigilance (anxiety) can trigger a wide variety of somatic symptoms (e.g., dizziness, wobbly legs, feelings of imbalance, heat surges, electrical sensations, tightness in the throat, etc.). We all experience somatic symptoms at times. e.g., when we are under stress we may experience headaches, physical exhaustion, neck pain or irritable bowel. We may lose our appetite and have trouble sleeping. These are real physical symptoms that most people can relate to, but they are being triggered by anxiety.

2. Sometimes organic medical conditions are creating symptoms, but if the client is hypervigilant, the anxiety itself also contributes to symptoms. Many people I see have vestibular conditions such as BPPV or Meniere's disease. But if they are constantly vigilant to their symptoms, it is quite likely that they are also experiencing some somatic symptoms. You can often illustrate this by getting them to do a mindful awareness and allowing exercise. If their arousal drops and their vigilance lowers, they often notice a reduction in symptoms. Ask, "what do you think is going on there?"

Question 3

I have been using CBT to help a client with post-traumatic dizziness with good effect. I am hoping you can suggest ways to prepare the client in the case the dizziness reoccurs when she experiences high stress situations in future?

Sarah Edelman · Accepted Answer

I often say, "The dizziness comes and goes – that's normal. Your job is not to try and stop or control the dizziness but to get on with your life regardless of whether it's there. It tends to fizzle out when you are doing other things and not focusing on it."

Question 4

How to work with patients when they present with significant dizziness impacting on engagement?

Sarah Edelman · Accepted Answer

Try to demonstrate the effect of vigilance - attention to their symptoms. You can get them to stand up and even walk in a slow circle to trigger some dizziness if they are not experiencing any. Stand next to them and ask them questions that require a lot of cognitive resources, e.g. what did you have for dinner yesterday? The day before? The day before that? Who sent you emails yesterday? The day before? What did you see on social media yesterday? The day before? Get them to talk about memories that were emotionally powerful, e.g., the birth of one of their children or describe the child now. You can use these as behavioural experiments to demonstrate that if they switch their mind away from hypervigilance, their symptoms diminish.

Question 5

I have an 88yo client w/PPPD and deteriorating eyesight.  With the limitations of COVID and declining vision, opportunities to help her engage in valued actions even while dizzy are feeling increasingly limited.  What would you suggest? Thank you!

Sarah Edelman · Accepted Answer

Oh, that is a hard one! I'd focus on getting her to be active to the best of her ability, including doing some exercise every day if possible. Also, get her to engage in mentally absorbing tasks. Maybe listening to podcasts? Playing cards is a terrific distractor, if she is able to see them. Find interests or support groups. Stay active.

I also have a video for clients that could be helpful. This presentation was directed to people with Meniere's disease, so some of the content focuses particularly on that condition. However, much of it is about how to manage PPPP from the client's perspective. You can find it here:

https://www.youtube.com/watch?v=FKo2-PX1lHU

Question 6

How do you tease apart whether the dizziness is a cause or symptom of anxiety?

Sarah Edelman · Accepted Answer

The key issue is situational variation. If they have less dizziness when they are at home or in a familiar setting, and more symptoms when they are out of their comfort zone, psychological factors are likely to be playing a role. Many people have little or no dizziness when driving, largely because their attention is automatically focused on the road. (Some of course, who are experiencing panic when driving may be more anxious on the road, but usually it's the other way around.) Sometimes the dizziness recedes or disappears when they are on a holiday, or when they change environment. Or, if they have fewer symptoms when they are distracted with tasks but more symptoms when they have the cognitive space to be vigilant. Lead them through an arousal reduction exercise – I usually do mindful awareness and allowing. Often they become aware that they actually are quite anxious, which they may not have noticed until now. If they can reduce arousal, very often the symptoms will also diminish. That demonstrates the psychological factors (anxiety) play a causal role.

Question 7

Are there known psychological factors that predispose someone to experiencing chronic subjective dizziness?

Sarah Edelman · Accepted Answer

The research literature suggests that the following traits are significant predictors:
Obsessive compulsive personality style; labile affect (Brandt, 1994).
Neuroticism, behavioural inhibition  (Staab, 2006) 
Anxious and introverted personality style (Staab, Rohe, Eggers, Shepard 2013).

In my experience, the strongest psychological predictors are high trait anxiety and previous or co-existing mental illness (most often anxiety disorders and mood disorders). Comorbidity is very frequent. Many clients have strong obsessional traits and continue to engage in overanalysing and overthinking, even when they understand that it's self-defeating.

Question 8

Can you describe the components of CBT intervention that you use to treat dizziness? Is there more of an emphasis on the cognitive or behavioral?

Sarah Edelman · Accepted Answer

Treatment includes psycho-education about somatisation and PPPD, formulation (how it started and what is perpetuating the symptoms), recognising hypervigilance (how much of the time are your symptoms in the front or back of your mind? – most often in the back of the mind). Identify safety behaviours – both behavioural (e.g., googling symptoms) and cognitive (overthinking and overanalysing). Breaking the habit of safety behaviours – may need to be graded reduction. Training in mindful awareness and mindful allowing (not so much meditation, but learning to be aware of body sensations, and in particular, practising surrender – don't try to control or reduce the symptoms. Just allow.

Exposure with distraction – encourage walking whilst podcasting (needs to be very engaging to the client), and get the client to practice absorption in the podcast. Build mentor awareness – "What's going on in my mind right now?… I'm worrying about my symptoms once again." Now switch attention to task.

I have made a training video where I explain PPPD treatment to clinicians. 
It is available on Youtube at https://www.youtube.com/watch?v=9yC_L7mg6J0

Question 9

Do you find that chronic hyperventilation can be a factor in your patients with dizziness?

Sarah Edelman · Accepted Answer

I have been told this by other practitioners and it is intuitively plausible, but I have not seen any evidence for this. I always observe breathing when doing mindful observing and allowing exercises. The majority do not appear to be hyperventilating.

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