I. Definition of mental vertigo
Psychogenic vertigo is a dizziness related to emotion.
In 1986, the diagnostic criteria of psychogenic vertigo were proposed, and hyperventilation syndrome and mental depression, anxiety and fear were classified as psychogenic vertigo.11 In 1990, the vertigo produced by acute and chronic anxiety disorder, phobia and hysteria were classified as psychophysiological vertigo. It can be seen that psychogenic vertigo is not a specific psychiatric disease, but a general term for dizziness caused by a variety of psychosomatic diseases. In patients with hyperventilation syndrome, panic disorder, anxiety disorder, depression, and personality disorders, this type of vertigo is easily produced. The medical history, clinical examination and laboratory findings are not directly related to organic vestibular diseases. Li Gang, Department of Neurology, Shenzhen People’s Hospital
Overview of pathogenesis
In 1972, it was reported that among 125 patients with dizziness in neurology outpatient clinic, psychogenic vertigo accounted for 32%, of which hyperventilation syndrome accounted for 23% and psychiatric disorders accounted for 9%; in 1977, it was reported that among 2716 patients in neurology outpatient clinic, 13.2% had psychogenic disorders, most of which had headache and dizziness as the main complaints; in 1986, it was reported that among vertigo outpatients, psychogenic vertigo accounted for 20%; in 1993, it was reported that psychogenic vertigo was the main complaint. Sloane et al. 1994 reported that in a clinic studying vertigo in the elderly (>60 years), psychiatric disorders were found in only 3% of cases, but 24.5% of vertigo attacks were due to psychiatric factors.
Among patients with otologic hearing loss and vertigo, the incidence of psychiatric disorders is much lower; however, among patients with persistent vertigo, psychiatric factors have the second highest impact, with about 10% to 25% of vertigo due to psychiatric factors; and among patients with psychiatric disorders, especially panic disorders or anxiety disorders, complaints of vertigo and decreased balance function are extremely common. The age of onset of psychogenic vertigo is relatively young, mostly between 20 and 40 years old in men and between 20 and 50 years old in women, with a slightly higher incidence in women than in men. The incidence rate of women is slightly higher than that of men, and Lin Jiong? et al. reported that 62.8% of women are perfectionists who are anxious, eager and demanding.
Etiology and pathogenesis
The attacks of psychogenic vertigo are related to mental factors such as tension, panic, fear of heights, anxiety and depression. People with personality disorders are also prone to vertigo symptoms. In the modern industrial society with stressful work, complicated interpersonal relationship and high unemployment rate, there are often people who have psychological disorders or mental illnesses because they cannot bear the pressure from many aspects. 1990 reported that among 470 neurology inpatients, 9% were psychiatric patients, with pain, unstable gait and dizziness as the most common complaints. It was reported that 50% of the dizziness patients consulted in the ENT department were mentally stressed. It is even noted that 42% of patients in their neuro-otology clinic need psychological help.
The pathogenesis of psychogenic vertigo is generally believed to be due to the patient’s panic attack, which causes hyperventilation and a large amount of carbon dioxide in the blood, resulting in vasoconstriction, increased resistance of the blood vessel wall, and a faster heartbeat, resulting in palpitations; cerebral vasoconstriction and local ischemia of the brain tissue, resulting in dizziness and weakness and reduced concentration; in addition, due to the alkaline body fluid, free calcium in the blood decreases, causing muscle tonicity and The peripheral nerves are sensitive and the skin is numb. Patients feel dizzy, and some have vertigo without the nausea and vomiting that accompany it. Hyperventilation is not only an increase in the rate and depth of breathing, but mainly refers to the effect of breathing more than the body’s metabolic needs. Therefore, some patients do not have an obvious acceleration of breathing at the onset of the disease, and the patient does not feel hyperventilation, instead, it is more common to see it in the form of sighing.
IV. Clinical symptoms
More than 90% of patients complain of dizziness, often with recurrent long-term persistent dizziness, but cannot clearly describe the exact sensation of dizziness. Whenever they are in crowded places such as supermarkets or department stores, dizziness will occur. The onset of psychogenic vertigo is different from the vertigo caused by acute vestibular system lesions, but it is a feeling of internal rotation of the head or swaying of the whole body, unstable gait, and a feeling of illusion and unrealism. Some patients have vertigo without the nausea and vomiting that accompany vertigo. Some patients have rotational vertigo, but spontaneous nystagmus is not visible under glasses. About 60% or more of patients have headache symptoms, which are usually relatively mild headache and head discomfort.
2. Patients may also have symptoms of hyperventilation syndrome such as dyspnea, sighing, palpitations, chest tightness, numbness of the extremities, and redness of the face.
V. Diagnosis
1. Medical history
The diagnosis of psychogenic vertigo mainly comes from the questioning. First of all, it is necessary to exclude whether the patient has some kind of psychological stress or mental disorder. If the patient cannot clearly describe the actual feeling of dizziness, when the dizzy patient feels “like everything and nothing”, the possibility of mental illness can be considered at this time. Some patients may suffer from hyperventilation syndrome, such as poor breathing, sighing, palpitations, chest pain, numbness in the extremities, and redness of the face.
2.Physical examination of the whole body
Generally no positive signs will be found. Although the patient has vertigo, the clinical examination of neuro-otology is generally normal.
3.Electrographic examination of eye disease
Spontaneous nystagmus is not visible under Frenzel’s glasses. Nearly half of the patients with ENG will have blinking waves or large and random eye movements. Hot and cold water test: Most patients have normal variable temperature response. Some patients have vestibular hyperresponsiveness, which may be due to the decrease of carbon dioxide content in blood during hyperventilation, formation of alkaline body fluid, and loss of free calcium, which decreases the resting potential of neuronal cell membrane and causes the excitability of neurons to rise, producing an overresponsiveness. A small number of patients may present with hallux valgus palsy, but when the history is followed, these patients often have a past history of vertigo, nausea, and vomiting, but subsequent episodes of dizziness are different from the previous vertigo, suggesting that the hallux valgus palsy is a residual sign of previous organic vertigo and that the subsequent dizziness is mostly due to anxiety or panic attacks.
It is believed that those who have suffered from organic vestibular lesions may easily lead to psychiatric disorders such as neurosis, especially in patients with obsessive-compulsive personality, who may easily turn organic disorders into psychiatric disorders, and possible vestibular disorders should be excluded.
4, hyperventilation test
Hyperventilation test helps to diagnose psychogenic vertigo. In order to trigger symptoms such as vertigo and panic attacks similar to the patient’s complaints, the patient can be made to breathe rapidly and deeply at will. Bass et al. suggested to let the patient breathe as rapidly as possible for 3 min at about 30 times per minute, and suggested to breathe rapidly and deeply for 90 s. It is suggested to let the patient breathe rapidly and deeply for 20-24 times as possible in 25-50 s. Most patients can induce dizziness or discomfort similar to the onset of the disease, and a few normal people can also have facial fever, rapid heartbeat, numbness in the hands, and dizziness after hyperventilation.
Diagnostic criteria: In 1986, it was proposed that psychogenic vertigo can be diagnosed when five of the following six items are present.
The patient describes his medical history in a convoluted manner, failing to clearly describe his true feeling of dizziness, or even having an emotional description, which confuses the doctor who asks him or her, or even fails to make a successful diagnosis.
Long duration of dizziness episodes, lasting for weeks or even months or more.
Absence of symptoms of organic vestibular pathology.
symptoms of combined related psychogenic disorders.
normal neuro-otological examination, physical examination and laboratory tests.
causing the patient to hyperventilate may induce similar dizziness or other uncomfortable symptoms.
5. Differential diagnosis
Before diagnosing psychogenic vertigo, it is important to exclude organic diseases such as hyperthyroidism, paroxysmal tachycardia, hypoglycemia, anemia or pheochromocytoma, because the above-mentioned diseases tend to make patients anxious, so thyroid function tests, fasting blood glucose tests and hematocrit tests are very important; CT or MRI of the brain should be performed to exclude intracranial organic lesions; and psychiatry, neurology and internal medicine should be consulted. Neurology, internal medicine and other related departments for consultation. To avoid misdiagnosis.
Treatment
The treatment of psychogenic vertigo is different from other vestibular diseases. It mainly relies on good doctor-patient relationship to reduce patients’ anxiety and anxiety, and uses behavioral therapy, anti-anxiety or antidepressant drugs and biofeedback relaxation method to solve basic anxiety and insomnia problems.
Most patients can be managed in the cerebral dizziness clinic, but for those with definite psychiatric or psychological conditions or who are taking psychiatric medications, a psychiatrist consultation is required to assist in treatment.