Treatment of Chronic Subjective Dizziness

Chronic subjective dizziness (CSD) has likely been with us for centuries but has only been recognized as a clinical syndrome relatively recently.

The basic premise of CSD is that a physical problem such as an inner ear infection temporarily damages the vestibular nerve. Whereas in many people the brain is able to readjust for this damage and learn to operate without feelings of imbalance, in other people the brain never learns to adapt.

CSD is strongly associated with anxiety, as well as introverted personality types, and it has been theorized that this may reflect the brain’s predisposition to be hyper-vigilant to threats, including potentially falling over. As a result, after the initial damage to the vestibular network, the brain is perpetually on guard, sending off warnings that one is about to fall, even if the actual danger is past. It’s a bit as if the “check engine” light stayed on despite your car’s motor having been fixed months before.

Treatment Options

CSD can be very disruptive to people’s lives, as the constant sense of imbalance can keep people from doing daily activities such as their job. While no large-scale, controlled trials for CSD have been performed, smaller-scale studies support the use of three main forms of treatment. These forms include:

• Vestibular therapy
• Cognitive-behavioral therapy
• Selective serotonin reuptake inhibitors (normally used to treat depression).

Vestibular Therapy

Vestibular therapy is a type of physical therapy (PT) dedicated to improving someone’s balance. A trained vestibular therapist should guide the treatment exercises. The goal is to train the brain to adjust to the new sensory input regarding equilibrium.

Possible exercises include watching a twirled and striped circle to get used to the dizzying stimulus, walking down a hallway while watching pictures on the walls, or gradually and methodically developing a tolerance to turning the head. In fact, all exercises should be started slowly and increased gradually to avoid provoking such a strong sense of dizziness that the therapy is stopped. Instead, a regular, patient, and persistent exercise program is usually more successful, though full benefits may not be realized for up to 6 months.

A study of people with CSD treated with vestibular training and assessed with posturography afterward found significant improvements in the posturography for many of them, and 79% reported that they felt subjective improvement.

Medications

No studies have specifically focused on patients with CSD, though a few open-label trials have looked at patients with chronic dizziness, many of which likely had CSD. Collectively, these trials seem to suggest some benefit for serotonin selective reuptake inhibitors (SSRIs) and serotonergic-noradrenergic reuptake inhibitors (SNRIs). Common side effects of SSRIs and SNRIs include sleep disturbance and nausea, which may lead to some intolerance. The good news is that in addition to treating the chronic dizziness, these antidepressants were also found to lower rates of anxiety and depression in the patients taking them (go figure).

Psychotherapy

At least five studies have investigated cognitive behavior therapy techniques in patients with CSD. The overall trend among these studies is towards a significant benefit in the reduction of dizziness. Only one trial followed patients out over a year, and this did not see sustained benefits at that point. At this point, more definitive investigations are needed to build on these early results.

Some people resist the notion that anxiety or personality may have any role in their dizziness, feeling that this implies that CSD is “all in their heads.” Such thinking can prevent the use of any medication or treatment usually associated with psychiatric problems such as depression.

Bottom Line

Chronic subjective dizziness is a relatively newly defined disorder, though the symptoms it describes are both ancient and common. If recognized, CSD seems to respond well to vestibular therapy, medications, and possibly cognitive behavioral therapy. Preferably, these techniques would be used in combination to maximize potential benefits.