When the patient’s symptoms are mild or poorly described, small items of the history—a desire to keep still and a disinclination to stoop or walk during an attack, a tendency to list to one side, an aggravation of symptoms by turning over in bed or closing his eyes, a sense of imbalance when making a quick turn on foot or in a car, and a preference for one position of the body or head—help to identify them as vertigo. At the other end of the scale are attacks of such abruptness and severity as to virtually throw the patient to the ground. Independently occurring vertiginous attacks of the usual variety mark these falling episodes as part of Ménière disease (see further on). On the other hand, a dizzy sensation that is not made worse markedly by vigorous shaking of the head is unlikely to relate to vertigo, particularly that type due to peripheral vestibular disease.
All but the mildest forms of vertigo are accompanied by some degree of nausea, vomiting, pallor, perspiration, and some difficulty with walking. The patient may simply be disinclined to walk or may walk unsteadily and veer to one side, or he may be unable to walk at all if the vertigo is intense. Forced to lie down, the patient realizes that one position, usually on one side with eyes closed, reduces the vertigo and nausea, and that the slightest motion of the head aggravates them. One common form of vertigo, benign positional vertigo (see further on), occurs with the repositioning that accompanies lying down, sitting up, turning, or looking upwards. The source of the gait ataxia associated with vertigo (vertiginous ataxia) is recognized by the patient as being “in the head,” not in the control of the legs and trunk. It is noteworthy that the coordination of individual movements of the limbs is not impaired in these circumstances—a point of difference from most instances of cerebellar disease. Loss of consciousness as part of a vertiginous attack nearly always signifies another type of disorder (seizure or faint).
Nonvertiginous Types of Dizziness
It is important to distinguish vertigo from the more common complaints for which the term dizziness is used by patients. These include the feeling of impending fainting (near syncope), a disorder of gait (disequilibrium), and an ill-defined feeling of lightheadedness. Many patients in the last category who initially complain of dizziness will, on closer questioning, describe his symptoms as a “distant feeling,” “walking on air,” “inability to focus,” or some other unnatural sensation in the head. These sensory experiences are particularly common in states characterized by anxiety or panic attacks—often, but not always, with depression.
This constellation of nonvertiginous symptoms has been loosely referred to as “phobic,” “functional,” and “psychogenic” vertigo. Every clinician encounters numerous such patients. In Brandt’s (1996) extensive experience, phobic vertigo (his term) was second only to benign positional vertigo (described below) as a cause of consultation in his dizziness clinic. He relates the disorder to anxiety and panic spells, but finds that it exists more often as an independent entity that is subject to improvement after careful explanation and reassurance. We agree with Furman and Jacobs that the term psychiatric dizziness, if used at all, should be restricted to dizziness that occurs as part of a recognized psychiatric syndrome, notably extreme anxiety disorder. Often, there is a component of avoidance of crowds, open spaces and tight circumstances. There seems to be little point in signifying the nonvertiginous symptoms with separate designations based on the settings in which they commonly occur (“supermarket syndrome,” “motorist disorientation syndrome,” “phobic postural vertigo,” “street neurosis”) but they do emphasize the psychogenic nature and may facilitate recognition of the syndrome. Furman and Jacobs have related anxiety-type dizziness to minor degrees of vestibular dysfunction, but we have not found it possible to determine whether there is a genuine labyrinthine disorder in all of these patients.