At present, such “classic” functional disorders of the nervous system as hysterical paralysis and blindness have practically disappeared. They were replaced mainly by somatoform disorders, including those manifested by dizziness, with a tendency to a protracted course. Statistics of visits to the clinic of nervous diseases of the Military Medical Academy named after V.I. CM. Kirov of patients with complaints of dizziness shows that psychogenic dizziness ranks third among other clinical forms. Moreover, it can develop within the framework of a depressive or neurotic state, schizophrenia, panic attack, phobia, hysteria, somatoform dysfunction of the autonomic nervous system, etc.
Despite the fact that psychogenic dizziness should always remain a diagnosis of exclusion, timely diagnosis of this condition, explaining to the patient the reasons for his complaints, and prescribing adequate treatment is important . Below we will consider one of the most common variants of psychogenic dizziness encountered in clinical practice – phobic postural dizziness.
Phobic postural vertigo
Phobic postural dizziness (PPG) is understood as a clinical syndrome that includes, firstly, dizziness, described by patients as “fog in the head”, instability, a feeling of intoxication, which, as a rule, are associated with special conditions (descending stairs, walks along a busy street, at night) or situations that are perceived by the patient as provoking factors (being in the subway, public place, driving a car), secondly, anxiety and autonomic reactions (nausea, vomiting, lability of the pulse and blood pressure) and, third, avoidant behavior in relation to these situations in the absence of objective clinical signs of organic neurological disorders.
PPH is typical for obsessive-compulsive individuals and usually develops after significant irritation of the vestibular apparatus (especially in benign paroxysmal positional vertigo, vestibular neuronitis) or stress.
PPG is characterized by attacks of imbalance, fear, which occur without the presence of episodes of real falls (possible falls preceding the formation of secondary PPG), but with the formation of avoidant behavior.
The severity of symptoms decreases with the distraction of the patient, as well as after taking small doses of alcohol, in some patients – during sports. The quality of life of patients with PPH significantly decreases with the generalization of vegetative-somatic symptoms and the growth of social maladjustment of the patient. In the premorbid character structure, predominantly obsessive traits and perfectionism are revealed, predisposing to the formation of stable obsessive-compulsive disorders and psychogenic depression.
The manifestations of PPG largely correspond to the structure of panic disorder, including recurrent attacks of anxiety, obsessive fear of recurrence of an attack accompanied by dizziness, and avoidance behavior. However, it should be borne in mind that the fear of repeated dizziness with avoidant behavior can also be observed in patients with vestibular dysfunctions, which makes it possible to distinguish between primary and secondary panic disorder, which develops on the basis of otological pathology.
Diagnostics. For differential diagnosis, it is important to conduct a comprehensive examination of such patients (MRI of the brain, consultation with a neurologist, ENT doctor), exclude possible concomitant somatic pathology (endocrine disorders, anemic syndrome, arrhythmias, etc.), convince the patient of the benign nature of his disease. Indeed, sometimes such patients find themselves without the help of specialists: otorhinolaryngologists exclude their pathology, therapists and neurologists also do not find any significant deviations, which even more fixes the patient on his own experiences, forming a feeling of having a “rare, incomprehensible” disease with a dubious prognosis for recovery.
The treatment of patients with FPH should be based on a combination of medicinal and non-medicinal (psychotherapy, vestibular and respiratory gymnastics) methods of treatment. The first-line drugs are antidepressants (selective serotonin reuptake inhibitors – paroxetine, venlafaxine – and tricyclic antidepressants – amitriptyline). Benzadiazepines are also used (phenazepam, diazepam, alprazolam, etc.). In some cases, a positive effect in the treatment of anxiety disorders is achieved with the use of “small” antipsychotics (sulpiride, tiapride, thioridazine). As an additional therapy, the drug betahistine is used, which reduces the excitability of the vestibular apparatus and is effective for all types of dizziness, including psychogenic. It is mandatory to treat the underlying somatic and neurological pathology, which leads to a deterioration in postural and vestibular functions (for example, treatment of diabetes mellitus, vitamin B12 deficiency, hypo- or hyperthyroidism).