Ameţeala indusă de anxietate

Introduction

Many patients go to the ENT specialist complaining about dizziness and vertigo. Usually, if there are no findings at the neurology department, the ENT specialist performs several vertigo-specific evaluation tests and, if all these are negative, he tries to reassure the patient that everything is fine and that his vertigo is not as real as it may seem to him. But the vertigo is real for the patient and he cannot understand why this is happening. One of the reasons your patient may experience vertigo although all the ENT tests come back negative is anxiety dizziness.

The American Psychological Association (APA) defines anxiety as “an emotion characterized by feelings of tension, worried thoughts and physical changes like increased blood pressure”⁽¹⁾.

Anxiety is a normal and often healthy emotion because when a human being faces harmful triggers these feelings are essential for survival. Since our earliest days, we had to escape from predators, and the danger we encountered set off alarms in our body⁽²⁾. The danger causes a rush of adrenalin which triggers these anxious reactions in a process called the “fight-or-flight” response. This prepares humans to physically confront or flee any potential threats to safety. These alarms become noticeable in the form of a raised heartbeat, sweating, and increased sensitivity to surroundings. For example, that nervous feeling before an important life event or during a difficult situation is a natural echo of the original fight-or-flight reaction⁽³⁾. However, when a person regularly feels disproportionate levels of anxiety, it might become a medical disorder⁽⁴⁾.

There are several types of anxiety disorders:

1. Generalized anxiety disorder (GAD). This is the stage when the anxiety interferes with the daily function. This is a chronic disorder involving excessive, long-lasting anxiety and worries about nonspecific life events, objects and situations. GAD is the most common anxiety disorder, and people with this disorder are not always able to identify the cause of their anxiety⁽⁵⁾.

The patient can experience the following symptoms to persistent or extreme levels:

• restlessness, and a feeling of being “on-edge”

• uncontrollable feelings of worry

• increased irritability

• concentration difficulties

• sleep difficulties, such as problems in falling or staying asleep.

2. Panic disorder. Brief or sudden attacks of intense terror and apprehension characterize panic disorder. Panic attacks tend to occur and escalate rapidly, peaking after 10 minutes. However, a panic attack might last for hours⁽⁶⁾.

Symptoms of panic attack may include:

• shaking

• confusion

• dizziness

• nausea

• breathing difficulties.

3. Specific phobia. This is an irrational fear and avoidance of a particular object or situation. Phobias are not like other anxiety disorders, as they relate to a specific cause⁽⁷⁾.

4. Agoraphobia. This is a fear and avoidance of places, events or situations from which it may be difficult to escape or in which help would not be available if a person became trapped. People often misunderstand this condition as a phobia of open spaces and the outdoors, but it is not that simple. A person with agoraphobia may have a fear of leaving home or using elevators and public transport⁽⁸⁾.

5. Social anxiety disorder, or social phobia. This is a fear of negative judgment from others in social situations or of public embarrassment. Social anxiety disorder includes a range of feelings, such as stage fright, a fear of intimacy, and anxiety around humiliation and rejection⁽⁹⁾.

6. Separation anxiety disorder. High levels of anxiety after separation from a person or place that provides feelings of security or safety characterize separation anxiety disorder⁽⁹⁾.

The up-listed symptoms and types of anxiety may be useful when you investigate a patient with dizziness complains who comes back negative in the vestibular tests.

Dizziness is a common symptom of elevated stress, including the stress anxiety. Anxiety, stress, and hyperstimulation-caused dizziness are often misdiagnosed as vertigo, benign paroxysmal positional vertigo (BPPV), Meniere’s disease, labyrinthitis, and vestibular neuritis. It is reported that psychiatric disorders appear to be the second most common cause of chronic dizziness⁽¹⁰⁾.

Anxiety dizziness symptom description⁽¹¹⁾:

• Sudden feelings of dizziness, lightheadedness, faint, off balance, unsteady, feelings that the patient might faint or pass out.

• Feeling like walking on a cloud.

• Feel as if the floor is moving or swaying from side to side.

• Feeling like the room is trembling, swaying, rocking, or moving.

• Feeling like there’s a spinning feeling or pressure in the head.

This dizziness/lightheadedness feeling can also be experienced as a sudden dizzy/lightheaded ‘spell’ that disappears shortly. Some patients have short episodes, others may experience longer episodes that can last for days, weeks or even months.

This dizziness lightheaded feeling can precede, accompany, or follow an episode of nervousness, anxiety, fear and elevated stress, or occur for no apparent reason. It can range in intensity from slight to moderate or severe⁽¹²⁾.

The patients who suffer from anxiety will describe the symptom as being more noticeable when undistracted, resting, trying to fall asleep, or when waking up.

In some people, episodes of anxiety-induced dizziness and lightheadedness can trigger dizziness, vertigo or imbalance and therefore be accompanied by an immediate stress response (or panic attack) and its resulting sensations and symptoms, such as nausea, vomiting, sweating, feeling disoriented, rapid heart rate, heart palpitations, having a sudden urge to escape, and so on⁽¹³⁾. On the other hand, dizziness can be anxiety-producing.

Causes of anxiety dizziness

• Hyper- and hypoventilation. Hyper and hypoventilation can change the CO₂ levels in the blood, which can cause anxiety-like symptoms, such as dizziness. Hyperventilation is the result of breathing too quickly and blowing off too much carbon dioxide. When you think of anxiety-induced hyperventilation, you imagine someone being unable to catch his breath and speak in clear sentences⁽¹⁴⁾.

• An active stress response. The stress response secretes stress hormones into the bloodstream where they induce specific physiological, psychological and emotional changes that enhance the body’s ability to deal with a threat. Some of the stress response changes cause the body to shunt blood to body parts vital for survival and away from those that aren’t. These changes also cause the heart rate and respiration to increase and can make a person to feel ‘dizzy’ and lightheaded⁽¹⁵⁾.

• Persistently elevated stress. Stress impacts the body’s nervous system. Too much stress can cause the nervous system to act in odd ways, which can affect our sense of balance⁽¹⁶⁾.

• Sleep deprivation and fatigue. Behaving in an overly apprehensive manner stresses the body, and a body that’s under sustained stress can become hyperstimulated. Hyperstimulation can cause sleep problems, which can lead to sleep deprivation and fatigue. Dizziness commonly occurs when we are overtired⁽¹⁷⁾.

How to stop anxiety dizziness

It is more important for the ENT specialist to recognize an anxiety dizziness and refer it to a psychiatrist for an adequate treatment. But there is some advice you can give to your patient in order to improve his disease until he finds the correct treatment:

• If the dizziness is caused by hyper- or hypoventilation, adopting a natural breathing style – relaxed, slower, and deeper. This will correct the CO₂ levels, which will eliminate ventilation-induced dizziness⁽¹⁸⁾.

• If the dizziness is caused by an active stress response, calming down will bring an end to the stress response and its changes.

• If the dizziness is caused by persistently elevated stress, reducing the stress should eliminate this symptom.

• If the dizziness is caused by sleep deprivation and fatigue, increasing sleep, rest and giving the body sufficient time to regain its normal energy will eliminate fatigue-caused dizziness⁽¹⁹⁾. 

Contribution of authors: All authors equally contributed to this work.

Conflict of interests: The authors declare no conflict of interests.