Balance Disorders: Dizziness and Vertigo

Treatment of Associated Anxiety

Presented by:

Gina Byrnes, MSW, LCSW, ACT

January 30, 2014

Anxiety and Dizziness : The Connection

• Chronic Dizziness or Vertigo associated with Vestibular Disorders is often accompanied by secondary psychological problems including:

• Anxiety or fear

• Hyperventilation

• Phobic avoidance of situations or movements associated with dizziness

Anxiety and Dizziness: The Connection• Anxiety: “An emotional state experienced when a person

anticipates threat or is threatened in some way”

• Anxiety is a normal part everyday life -

typically unpleasant, but manageable

it quickly decreases once the fear is faced

• Anxiety becomes problematic when there is a misperception of the danger involved, and the threat is exaggerated

Anxiety and Dizziness: The Connection

Three Components of Anxiety

Physiological – heart racing, shakiness, dizziness

tingling in hands or feet, shakiness

Cognitive – What we tell ourselves, think about and

pay attention to when anxious

Behavioral - What we do or how we respond

Escape/Avoidance & Coping

Anxiety and Dizziness: The Connection

Similar presentation between Anxiety associated with Vestibular Disorders and Panic Disorder

• Certain Situations trigger fear of Panic/Dizziness• Preoccupation with Physiological Symptoms• Catastrophic Thinking • Strategies Intended to Prevent Panic/Dizziness start to

Take Over Daily Life – Avoidance/Escape & Safety Behaviors

Treatment Approach – Cognitive Therapy Addresses the Misperception and Overestimation of Threat

Anxious Thinking Change Normalized ThinkingFocus on Likelihood of Focus on Realistic

Likelihood

Serious Threat/Danger Process of Various Outcomes

Focus on Inability to Cope, Focus on Ability to Cope

Helplessness & Vulnerability & Problem –Solve Challenging

Circumstances

Intense Anxiety

Minimal AnxietyFrom The Anxiety and Worry Workbook: The Cognitive Behavioral Solutin, David A. Clark and Aaron T. Beck

p. 98, 2012, The Guilford Press

Treatment Approach – Cognitive Therapy

• Catch the Anxious Thought

What is the first thing that went through my mind when I started feeling anxious?

What was the situation (Who What When Where)• Identify any possible Thinking Errors

Overestimation – overestimating likelihood of something bad happening

Catastrophizing – Assuming the worst possible outcome

Maladaptive Thinking – Technically correct but

not helpful and add to anxiety

Treatment Approach – Cognitive Therapy

Evaluating the Anxious Thoughts for Accuracy

1.Do I know for certain that (feared outcome) will happen, is happening?

2.Am I 100% sure that ………(I will get dizzy, fall, become incapacitated)?

3.Does (being dizzy) really mean that (I will lose control, be embarrassed)?

4.What evidence do I have that…..(I cannot leave the house, I cannot drive)?From Group Cognitive Therapy of Anxiety: A Transdiagnostic Treatment Manual by Peter J. Norton.

Copyright 2012 by the Guilford Press.

Treatment Approach – Cognitive Therapy

Evaluating the Anxious Thoughts for Accuracy(cont.)

5.Is there another explanation for ………(my discomfort, feeling unsteady) besides………….(a vertigo attack, loss of control, etc.)

6.What are the chances that ……(what I fear) will actually happen/has actually happened?

7.If I did………(have an episode of dizziness) what is the worst that would really happen?

8.If …………….did happen, how bad would it be?

From Group Cognitive Therapy of Anxiety: A Transdiagnostic Treatment Manual by Peter J. Norton.

Copyright 2012 by the Guilford Press.

Treatment Approach – Cognitive Therapy

Developing a more Reasonable Alternative Response

• “I’ve been through vertigo before, I know I can handle it”• “The worst thing that can happen is I will be

uncomfortable and need to make some temporary adjustments”

• “Just because it feels bad, doesn’t always mean it is bad”• “I can handle more than I think I can”• “Even though I’m afraid to drive, my doctor says I can”

Treatment Approach – Behavioral Therapy

Planning to Face the Fear- Exposure Therapy

• Addresses the Avoidance/Escape Behavior that increase anxiety

• Practice both in session and out – activities one associates with dizziness or even bring on dizziness symptoms

• Develop greater tolerance and/or symptoms diminish as anxiety diminishes

REFERENCES• Abramowitz, J.S.; Deacon, B.J. , Whiteside, S.P.H.; (2011) Exposure Therapy for Anxiety, Guilford

Press.• Clark, D.A., Beck, A.T.; (2012) The Anxiety and Worry Workbook: The Cognitive Behavioral

Solution; Guilford Press. • Norton, P.J., (2012) ; Group Cognitive Behavioral Therapy: A Transdiagnostic Approach; Guilford

Press.• Holmberg, J.; Karlberg, M.; Harlacher, U.; Rivano-Fischer, M. Magnusson, M.; Treatment of Phobic

Postural Vertigo: A Controlled Study of Cognitive Behavioral Therapy and self-controlled Desensitization. Journal of Neurology, 2006; 253: 500-506.

• Holmberg, J.; Karlberg M.; Harlacher U.; Magnusson M; One Year Follow-up of Cognitive Behavioral Therapy for Phobic Postural Vertigo. Journal of Neurology, 2007; 254: 1189-1192

• Johansson, M. Akerlund, D.; Larsen, H.C.; Andersson, G., Randomized Controlled Trial of Vestibular Rehabilitation Combined with Cognitive Behavioral Therapy for Dizziness in Older People. American Journal of Otolaryngology-Head and Neck Surgery, 2001; 125: 151-156

• Mahoney, A.E.J.; Edelman, S.; Cremer, P.D.; Cognitive Behavioral Therapy for Chronic Subjective Dizziness: Longer Term Gains and Predictors of Disability; 2013, American Journal of Otolaryngology-Head and Neck Surgery, 2013; 34: 115-126.

• Yardley, L.; Redfern, M.S.; Psychological Factors Influencing Recovery from Balance Disorders; Journal of Anxiety Disorders, 2001; 15: 107-119.