Primary Care Update
Is your patient’s dizziness psychogenic?
6 questions can help you narrow the diagnosis and rule out medical causes
Dizziness is common among patients age 65 and older, and more than one-third have a psychiatric disorder that is caused by or is causing their dizziness.1
When older patients present with dizziness, psychiatrists may be asked to alleviate the psychological symptoms and help identify the underlying disease state.2
More than 60 medical and psychiatric disorders and many medications can cause dizziness. To help you sort through the possibilities, we offer:
- six diagnostic questions to rule out underlying medical problems
- lists of commonly used psychotropics and other drugs that may cause dizziness
- advice on treating depression, anxiety, and panic disorder in an older patient with dizziness while avoiding side effects and drug interactions.
Four types of dizziness and their usual causes
Source: Adapted from reference 6
Many causes of dizziness
The term “dizziness” is hard to define because of its nonspecific and variable symptom description, multiple causes, and lack of clear diagnostic and management guidelines. In clinical use, dizziness encompasses abnormal sensations relating to perception of the body’s relationship to space.
Some researchers believe dizziness is a distinct geriatric syndrome because numerous factors related to aging cause dizziness,2 including physiologic changes (presbystasis), accumulated impairment, disease states, and interactions between multiple medications.
Anxiety, somatization, panic disorder, and depression cause dizziness in the elderly, as do:
- peripheral vestibular disorders
- brainstem cerebrovascular accident
- diabetes mellitus
- neurologic disorders such as Parkinson’s disease
- and cardiovascular disorders.
Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants also have been shown to cause dizziness, as have numerous nonpsychotropic agents.
Recognizing patterns, testing hypotheses, and extending the diagnostic process over time can help you differentiate psychogenic from medicationinduced or neurologic dizziness.3 Because the presentation is so complex and the differential diagnosis so broad, algorithmic diagnosis is less effective than a flexible clinical approach that allows for uncertainty in evaluating initial symptoms.
Determining the cause
A thorough patient history and physical examination can uncover a cause of dizziness in 75% of cases.4 Look for duration of dizziness symptoms; history of heart disease, diabetes or other illnesses; family history of psychiatric disorders; and other illnesses among family members.
Ask the following six complaint-specific questions to help you narrow the differential diagnosis and rule out nonpsychiatric causes.5
1. WHAT TYPE OF DIZZINESS DOES THE PATIENT HAVE?
Vertigo is a sense that the body or environment is Patients may feel as if the floor is tilting, sinking, rising or veering sideways, or they may feel pulled to one side.
Vertigo is commonly caused by peripheral vestibular disorders—including benign positional vertigo, Meniere’s disease, labyrinthitis, and vestibular neuronitis—and central vestibular disorders associated with cerebrovascular disease, tumors, demyelinating diseases, migraines, seizures, multiple sclerosis and other CNS diseases. Acute-onset vertigo and neurologic signs suggest brainstem infarction.
Nystagmus is usually present, horizontal, and may be rotational at times. A vertical-beating nystagmus points to a probable CNS cause and requires urgent neuroimaging and referral to a neurologist or otolaryngologist.
Presyncope describes near-fainting. A dimming of vision and roaring in the ears may precede presyncope.
Depending on its cause, presyncope may occur regardless of position or only when upright. Common causes include orthostatic hypotension, neurocardiogenic syncope, organic heart disease, arrhythmias, carotid sinus disease, seizures, hypoglycemia, and transient ischemic attacks.
Abrupt presyncopal attacks that occur regardless of position suggest a cardiovascular cause. If onset is gradual and not improved by lying down, suspect a cerebral metabolic cause such as hypoglycemia.
Syncope, like presyncope, often is traced to an underlying cardiovascular disease. Dizziness and syncope often coexist, and both can be multifactorial. Dizziness may precede or follow syncopal episodes.
Differentiating syncope and dizziness is important because many underlying causes of syncope can be fatal. By contrast, dizziness symptoms are usually benign and self-limiting.7
A thorough history is critical to distinguishing dizziness from presyncope. Assess medication effects—especially CNS-acting medications, cardiovascular drugs, antihypertensives, antibiotics, and over-the-counter medications such as dextromethorphan and acetaminophen compounds. Also check for dehydration.
Disequilibrium disorder signifies unsteadiness or a loss of balance primarily involving the lower extremities. Symptoms are evoked by walking or standing and relieved by sitting or lying down. Gait is abnormal and balance is compromised without abnormal head sensations.
Common causes include balance and gait disorders, sensorimotor dysfunction, presbystasis, neurodegenerative CNS disorders, and mixed ischemic and degenerative CNS diseases.
Vague lightheadedness is often associated with somatic symptoms such as headache. Some patients describe a floating sensation.
Lightheadedness is frequently associated with anxiety, panic disorder, depression, and somatization. Hyperventilation and agoraphobia are other common causes.
Multiple symptoms, multiple types. Classifying an older patient’s dizziness can be challenging because many patients report symptoms that suggest two or more subtypes.2 Also, patients often have trouble describing their dizziness symptoms, sometimes using terms such as “giddiness,” “wooziness,” or “confusion.”
To help patients explain dizziness symptoms more accurately, ask specific questions such as:
- Do you at times feel like you’re about to faint?
- Do you feel as if the room is moving?
- Do you sometimes feel as though you’re going to fall?
Psychotropics that may cause dizziness
Source: Clinical Pharmacology version 2.11. Tampa, FL: Gold Standard MultiMedia, 2004.
2. HOW DO DIZZINESS SYMPTOMS RELATE TO POSITION OR MOTION?
By reproducing dizziness symptoms, some quick-maneuver tests can help patients describe their symptoms and may reveal a medical cause.
Dix-Hallpike maneuver.3 Move the patient rapidly from a seated to prone position with the head below the horizontal plane and turned 45 degrees for 10 seconds; then have the patient sit up. Repeat with the head turned to the other side. If dizziness does not occur within a few seconds after each test, rule out benign positional vertigo.
Seated head turn, or head-thrust test, measures qualitative vestibular function.8 Move the head rapidly by 45 degrees in a brief, small-amplitude thrust to one side while the patient focuses on your nose; this gauges vestibularocular control. Repeat the test in the other direction. A refixation corrective saccade, occurring as the patient tries to fixate on the target, indicates a possible vestibular disorder.
‘Get-Up and Go’ test, which takes less than 10 seconds, measures balance in older patents.9 Have the patient stand up, walk 10 feet, turn around, walk back, and sit down. Watch for staggering, unsteadiness, and use of hands to balance. Onset of symptoms suggests dizziness brought on during activities of daily living and provides information on how dizziness is affecting the patient’s ability to function.
Romberg test. Have the patient stand with heels together, first with eyes open and then closed. Vision and proprioceptive signals are used to compensate for vestibular loss. Thus, a balance disturbance with eyes closed suggests vestibular or spinal proprioceptive problems and may predict risk of falls caused by inability to compensate.8
3. WHAT IS THE COURSE OF DIZZINESS?
Differentiating acute, sudden-onset dizziness from chronic, gradual-onset dizziness can help uncover the problem’s cause and seriousness. The latter often has a psychological cause or may point to vestibular or minor cardiovascular problems. Tinetti et al2 identified anxiety or depressive symptoms as risk factors among community-based older persons who reported dizziness episodes lasting 1 month.
Recommended SSRI starting dosages for older patients
Starting dosage (mg/d)
Maximum dosage (mg/d)
10 to 20
5 to 10
25 to 50
* Most patients will not need more than 20 mg/d. Dosages 40 mg/d should be divided into twice-daily doses.
Source: Adapted from Reuben DB, Herr K, Pacala JT, et al. Geriatrics at your fingertips (5th ed). Malden, MA: Blackwell Publishing, 2003:47.
An acute presentation can suggest a panic disorder or acute anxiety state, but first rule out serious conditions such as acute myocardial infarction, arrhythmias, acute infections, GI bleeding, and carbon monoxide poisoning.
Also ask about:
- exacerbating and relieving factors. For example, positional changes, exercise or other physical activity, eating, or missing a meal can trigger presyncope. Also find out about situations that may bring on anxiety, panic, or phobia. Onset of dizziness following these situations may suggest psychogenesis.
- recent falls and injuries. Recurrent falls with presyncope suggest a probable orthostatic or cardiovascular diagnosis in older adults.
4. ANY PAST MEDICAL PROBLEMS?
Ask disease-specific questions. For example:
- Tinnitus or hearing loss could point to a vestibular disorder.
- Metabolic and cardiovascular disorders such as diabetes, ischemic heart disease, postural hypotension, and seizures can result in presyncope.
- Orthostasis, coronary ischemic events, hypoglycemia, and transient ischemic attacks may cause dizziness.
5. IS DIZZINESS RECURRENT?
Panic disorder, anxiety disorders, phobia, and psychogenic hyperventilation are commonly associated with chronic, recurrent dizziness episodes.
6. WHAT MEDICATIONS IS THE PATIENT TAKING?
All psychotropics are suspect when a patient presents with dizziness. When dizziness occurs after a dose or start of therapy, evaluate response to the medication and consider reducing the dosage or changing the medication. If symptoms persist, refer the patient back to the primary care physician to investigate for other causes of dizziness.
If the above strategies do not reveal a physical cause of dizziness despite multiple physical complaints, consider examining the patient for depression, anxiety, or panic disorder.
Treating a psychiatric cause
If dizziness is found to be psychogenic and the symptoms impede daily activities or contribute to functional decline, treat the psychiatric disorder but carefully weigh the risks and benefits of drug treatment.
Although SSRIs may cause dizziness, these agents are recommended first-line treatment for depression, anxiety, and/or phobia in older patients with dizziness because of their relative lack of anticholinergic action and side effects compared with other antidepressants or anxiolytics.
Coexisting medical symptoms may dictate choice of agent. For example, consider a sedating SSRI for a patient with sleep disturbances caused by dizziness or the psychiatric disorder; choose a nonsedating SSRI if the patient is sleeping normally.
Because SSRIs may cause weight loss, avoid giving them to patients with weight loss associated with dizziness or an underlying psychiatric illness. Mirtazapine, which is associated with weight gain, may offset weight loss. Start mirtazapine at 15 mg at bedtime for older patients.
Start low and go slow when prescribing an SSRI to an older patient. Dosing strategies applicable to younger patients should not be extrapolated to older patients, especially those with dizziness.
We have found that older patients respond well to minimum or below-normal SSRI dosages (Table 3). Titrate very slowly and instruct patients to report dizziness. Reduce the dosage if dizziness emerges.
If the patient does not respond to an SSRI or mirtazapine, consider a serotonin and norepinephrine reuptake inhibitor, which also has favorable anticholinergic and side-effect profiles.
- WebMD Health—Dizziness: lightheadedness and vertigo. my.webMD.com/hw/health_guide_atoz/hw88500.asp.
- Sloane PD. Clinical research and geriatric dizziness: The blind men and the elephant. J Am Geriatr Soc 1999;47:113-14.
- Kroenke K, Hoffman RM, Einstadter D. How common are various forms of dizziness? A critical review. South Med J 2000;93:160-7.
Drug brand names