Anxiety and Dizziness

Anxiety is a normal part of life, and dizziness is a common symptom. Most people have experienced anxiety-induced dizziness at some point, but some people suffer from intermittent or chronic bouts of anxiety and dizziness. Persistent anxiety with dizziness is often related to an anxiety disorder.

Dizziness can also cause anxiety, especially when dizzy spells occur regularly and interfere with normal function. Many cases of dizziness are triggered by specific movements, but some people have unexplained dizziness. In either case, people can be very anxious about becoming dizzy.

Importantly, anxiety and dizziness can reinforce each other. For example, if you are anxious about becoming dizzy, your risk for dizziness increases. When you become dizzy, your level of anxiety increases. Over time, this cycle can become debilitating and increases your risk for developing new psychiatric disorders and worsen existing ones, so it is important to learn how to manage anxiety and dizziness.

Anxiety disorders

People who experience recurrent or chronic anxiety may have an anxiety disorder. According to the National Institute on Mental Health (NIMH), about 20% of adults meet the criteria for an anxiety disorder, with a slight increase in women (~23%). There are several types of anxiety disorders, including:

• Generalized anxiety disorder

• Social anxiety disorder (social phobia)

• Post-traumatic stress disorder (PTSD)

• Panic disorder

• Obsessive-compulsive disorder (OCD)

• Agoraphobia

• Other phobias (e.g. fear of heights, fear of needles)

• Separation anxiety disorder

All of these anxiety disorders can cause people to feel dizzy or lightheaded, and in some cases anxiety-related dizziness can become a chronic, debilitating condition.

Dizziness

Dizziness is an umbrella term that is used to describe a few different sensations:

• Vertigo: A spinning or tilting sensation; the feeling that you’re moving when you’re not
• Presyncope: Feeling like you are going to faint (fainting is called syncope); lightheadedness; giddiness
• Disequilibrium: A sense of imbalance or instability, often experienced when you are walking

The most common cause of dizziness is dysfunction in a part of the inner ear called the peripheral vestibular system. This system is responsible for monitoring your position and movement and relaying that information to the brain, where it is integrated with information from the visual, sensory, and motor systems. If information from the vestibular system doesn’t match the information from the other systems, you will feel dizzy or out of equilibrium. This can lead to anxiety about moving and may cause people to avoid doing the things they love.

The second most common cause of dizziness may be psychiatric disorders, particularly anxiety disorders. There are likely several factors that contribute to the development of anxiety-induced dizziness, including genetics and environment, but regardless of the cause, most people can learn how to manage their anxiety and minimize dizziness. Physical therapy and mindfulness-based techniques are very effective strategies to get anxiety and dizziness under control.

Relationships between dizziness and anxiety

The observation that dizziness is linked to anxiety leads to the question of which comes first, dizziness or anxiety? The answer seems to be, it depends. There are three broad diagnostic categories that have been described for the different types of relationship between anxiety and dizziness (which is also known as a “vestibular symptom”):

• Psychiatric vestibular disorders: An anxiety disorder that causes dizziness
  • Example: Someone with a fear of needles may feel dizzy or lightheaded when they have their blood drawn
• Structural vestibular disorders: Dizziness that is caused by a structural abnormality in the peripheral vestibular system (inner ear) or another balance system causes anxiety
  • Example: Someone who gets dizzy when they turn their head may develop anxiety about moving, especially if they are in a public setting
• Functional vestibular disorders: Dizziness that is related to anxiety but that can’t be linked to a psychological or structural disorder; functional disorders describe abnormal function in a physiological system that is structurally normal,
  • Example: Someone who gets motion sickness may become anxious about driving or riding in a vehicle

These categories have some overlap, and they may co-exist with each other and with other disorders. Diagnosis is based on whether there is a definite cause for the anxiety and/or dizziness, the frequency and duration of episodes, how long they have been going on, and whether other symptoms are present.

Health, anxiety, and dizziness

After vestibular (inner ear) disorders, psychiatric disorders are the second most common cause of dizziness. In fact, the World Health Organization’s (WHO) International Classification of Diseases includes diagnostic criteria for “psychiatric vestibular disorders,” which attributes vestibular symptoms (e.g. dizziness) to a psychiatric disorder. Between 10-15% of people who seek medical treatment for dizziness also have a psychiatric disorder, and people who frequently feel dizzy are at increased risk for developing a psychiatric disorder.

Why do anxiety and dizziness occur together?

We still don’t fully understand all the ways that anxiety and dizziness are related, but evidence suggests that there are multiple potential ways that they can occur together and exacerbate each other:

• Peripheral vestibular system disorders are the leading cause of dizziness, and they can make it difficult to carry out normal tasks without becoming dizzy. People can develop potentially debilitating anxiety about becoming dizzy, and if dizziness and anxiety are not managed, people are increasingly at risk for developing a psychiatric disorder or worsening a pre-existing mental health condition.
• Brain imaging studies have identified a bidirectional connection between the parts of the brain that are involved with anxiety and dizziness. This means that when the part of the brain that causes anxiety becomes active, it sends signals to the parts of the brain that cause dizziness to increase activity. Similarly, when someone becomes dizzy, the part of the brain that causes anxiety becomes more active.
• The brain consumes more energy than any other organ, and without adequate blood pressure it does not receive enough oxygenated blood or glucose (sugar). Low blood pressure and low blood glucose are two common causes of dizziness, and they may also be associated with increased anxiety. Thus, the circulatory system can play a role in some episodes of dizziness with anxiety.

There is some evidence that the connectivity between brain regions can be changed by behavior. For example, people who learn techniques to manage anxiety have decreased connectivity between the parts of the brain that cause anxiety and dizziness, and increased connectivity between the parts of our brain that control executive function and anxiety. On the other hand, when people cannot manage their symptoms and are overwhelmed by anxiety and dizziness, the anxiety-dizziness connection in the brain is strengthened while the connection between executive function and anxiety is weakened. In other words, we may be able to talk ourselves into or out of feeling anxious and dizzy.

Ironically, if you become anxious during a spell of dizziness, you are more likely to take a misstep or fall. Anxiety causes you to stiffen your posture and limit your gaze to what is right in front of you. A stiff posture can prevent you from catching yourself if you start to fall, and if you restrict what you look at to a narrow range, you might not see an obstacle in your path. Risks associated with falling are especially high for elderly people, for whom a fall can be very serious, even life-threatening.

Chronic dizziness and anxiety

Studies have shown that the majority of people (~60%) with chronic dizziness also have an anxiety disorder, and 80% of people who experience dizziness related to migraine or dysrhythmia (an abnormal heart rate) also meet criteria for an anxiety disorder.

Persistent postural‐perceptual dizziness (PPPD)

In 2017, four chronic vestibular disorders were combined into one new disorder: Phobic postural vertigo (PPV), space‐motion discomfort (SMD),                   visual vertigo, and chronic subjective dizziness (CSD) became persistent postural‐perceptual dizziness (PPPD).

PPPD is known as a chronic functional vestibular disorder, because it is persistent, it cannot be attributed to a psychiatric disorder or a structural abnormality, and it includes vestibular symptoms (i.e. dizziness). A diagnosis of PPPD requires the following criteria be met:

• Symptoms are present more days than not for at least three months
• Symptoms can be made worse by postural changes or complex visual stimuli
• A triggering event may have caused the initial dizziness without anxiety, but over time fear and anxiety about becoming dizzy developed
• Symptoms cause distress and avoidance behavior (psychological symptoms)
• Symptoms cause functional impairment (physical symptoms)
• Cannot be explained by another condition

Vestibular migraine

As if migraine headaches weren’t bad enough, about one third of people who get them also experience dizziness or vertigo. 30% of people with migraines have a diagnosed anxiety disorder, and more than 75% of people who get migraines say that they are anxious during the migraine. How migraine, anxiety, and dizziness are related is not well understood.

Ending anxiety and dizziness

There are very effective strategies to help you manage anxiety and reduce the risk for dizziness. The treatment plan that is best for you will depend on your specific circumstance, but treatments like physical therapy are beneficial for anyone who wants to reduce anxiety and dizziness.

Many people may have the best results with a combination of treatments. For example, patient education, physical therapy, and behavioral therapy has been shown to be more effective than treatment with any one therapy. In addition, eating a healthy diet and getting regular exercise have been shown to increase treatment efficacy.

Physical therapy

Physical therapy providers teach clients exercises that can help them overcome dizziness and manage anxiety. Dizziness that is related to vestibular disorders respond very well to vestibular rehabilitation therapy (VRT) and exercises to improve posture and balance. Physical therapy for dizziness also helps anxiety; when people feel balanced and stable, they will become more confident and less anxious.

Interestingly, a recent study compared the effectiveness of a physical therapy exercise called the canalith repositioning maneuver (CRM) on people who had dizziness related to BPPV with people who had both BPPV and a psychiatric disorder. They found that the first physical therapy treatment session was not as effective for people with both BPPV and a psychiatric disorder, but that treatment success increased in subsequent sessions. Psychiatric disorders increase the risk for BPPV recurrence after CRM, but it is possible that CRM in combination with behavioral therapy could prolong the benefits of physical therapy.

Behavioral therapy

One of the most successful behavioral therapies to treat psychological and functional anxiety and dizziness is cognitive behavioral therapy (CBT). The goal of CBT is to identify negative thought patterns that cause anxiety and increase the risk of a dizzy spell and replace them with positive thoughts patterns. Over time, this improves mood and reduces anxiety.

Dizziness that is caused by structural abnormalities (e.g. peripheral vestibular system dysfunction) will likely require physical therapy as a primary treatment modality, but behavioral therapy may still be beneficial.

Medications to treat anxiety and dizziness

Antidepressants in the selective serotonin reuptake inhibitor (SSRI) family can be very helpful for people who have anxiety with dizziness. Antidepressants have been shown to work better when they are used in combination with behavioral therapy and/or physical therapy.

Prescription anti-anxiety medications like benzodiazepines are widely used, but regular use is associated with a high risk for developing a physical and psychological dependence. In addition, dizziness is a side effect of benzodiazepines in some people.

Although medications have their place in treating anxiety and dizziness disorders, in many cases physical therapy and behavioral therapy are as (or more) effective than pharmacological treatment options.

FYZICAL takes a whole-person approach to patient care. Our providers use medication- and surgery-free methods to help clients manage anxiety and minimize dizziness, with outstanding results.

FYZICAL offers free assessments that can help you understand your dizziness and anxiety and create a tailored exercise program that will help you manage your symptoms. Find a FYZICAL location near you and make an appointment today.

To learn more about how FYZICAL Therapy & Balance Centers can help you, download our free e-book.