Is there a link between vertigo and psychiatric disorders?

A systematic review and meta-analysis from Singapore suggest a potential association between benign paroxysmal positional vertigo (BPPV) and anxiety.

“[A]n issue that remains unaddressed is the association of anxiety and depression with [BPPV]. Abrupt episodes of dizziness caused by BPPV may lead to [anxiety] because of its paroxysmal nature,” said the researchers.

Given the importance of mental health, the team conducted a systematic review and meta-analysis to provide clinicians a clearer picture of the impact of BPPV on mental health.

Of the 23 articles that met the inclusion criteria, 19 were included in the meta-analysis. There were 11 cohort studies, nine cross-sectional studies, and three case-control studies. The systematic review included 2,902 BPPV patients, while the meta-analysis comprised 2,365 participants. [Laryngoscope 2023;doi:10.1002/lary.30957]

Using data from two studies with control arms, a significant association was found between anxiety and BPPV compared with healthy controls (risk ratio [RR], 3.19). This was not the case between depression and vestibulopathy in patients with BPPV (RR, 1.93).

In a pooled analysis of five single-arm studies, the prevalence of anxiety in individuals with BPPV was 27 percent. The prevalence of depression was lower (12 percent) based on a pooled analysis of seven studies.

Potential mechanisms

The mechanisms that could explain for the association between peripheral vertigos and psychiatric comorbidities are complex, but these may be attributed to the otogenic and psychogenic hypotheses. [Laryngoscope 2003;113:1714-1718]

The otogenic hypothesis states that vertigo may lead to secondary psychological distress. [J Psychosom Res 2009;66:417-424] The unpredictability of vertiginous attacks (for instance, from abrupt and unexpected changes in head movements) may worsen psychological distress and impair quality of life. [J Int Adv Otol 2019;15:436-441; Neuroscience 2009;164:1579-1587; J Neurol 2008;255:420-428; J Psychosom Res 1992;36:731-741]

“The vertiginous attacks may trigger imbalance, feelings of environmental spiralling, spatial [disorientation], nausea, and vomiting. Patients with BPPV may avoid activities that precipitate dizziness to spare the potential for dizziness to cause physical harm or social embarrassment,” they said.

Under the psychogenic hypothesis, pre-existing psychological distress can manifest as secondary vertigo or dizziness. “Hyperventilation secondary to psychological distress may stimulate vestibular dysfunction by interfering with vestibular compensation mechanisms or altering peripheral and central somatosensory input in the lower limbs,” the researchers explained.

Screening for psych disorders still important

Despite the large number of studies included in the analysis and the variety of effect size measurements used, several limitations should be taken into account. “[One] is that we were not able to account for the severity of vestibular dysfunction or the chronicity of symptoms, which are known to influence the development of psychological distress,” they said.

Also, there were not enough studies with control groups to achieve meaningful comparisons. Some studies had a high risk of bias, and all were observational in nature. “[Given the lack of] randomized control trials, all conclusions made are correlational rather than causal,” they added.

“Furthermore, we were unable to expand our scope to include all peripheral vestibulopathies and psychiatric conditions and cannot conclude the effect of other types of vestibulopathy on psychiatric conditions,” the researchers continued.

Nonetheless, the analysis builds on the growing body of evidence underpinning the importance of screening and assessment for psychiatric disorders in patients with BPPV.

Although the association between BPPV and depression failed to achieve statistical significance, there appears to be some association between these two variables as well. “This emphasizes the need to treat multiple domains of [mental] health in patients with peripheral vestibulopathies,” they said.

The researchers called for further studies to validate the findings.