Journal of Neurology

, Volume 253, Issue 4, pp 500–506 | Cite as

Treatment of phobic postural vertigo

A controlled study of cognitive-behavioral therapy and self-controlled desensitization
  • J. HolmbergEmail author
  • M. Karlberg
  • U. Harlacher
  • M. Rivano–Fischer
  • M. Magnusson


In balance clinic practice, phobic postural vertigo is a term used to define a population with dizziness and avoidance behavior often as a consequence of a vestibular disorder. It has been described as the most common form of dizziness in middle aged patients in dizziness units. Anxiety disorders are common among patients with vestibular disorders. Cognitive–behavioral therapy is an effective treatment for anxiety disorders, and vestibular rehabilitation exercises are effective for vestibular disorders. This study compared the effect of additional cognitive–behavioral therapy for a population with phobic postural vertigo with the effect of self–administered vestibular rehabilitation exercises.

39 patients were recruited from a population referred for otoneurological investigation. Treatment effects were evaluated with the Dizziness Handicap Inventory, Vertigo Symptom Scale, Vertigo Handicap Questionnaire, and Hospital Anxiety and Depression Scale. All patients had a self treatment intervention based on education about the condition and recommendation of self exposure by vestibular rehabilitation exercises. Every second patient included was offered additional cognitive behavioral therapy.

Fifteen patients with self treatment and 16 patients with cognitive– behavioral treatment completed the study. There was significantly larger effect in the group who received cognitive behavioral therapy than in the self treatment group in Vertigo Handicap Questionnaire and the Hospital Anxiety and Depression scale and its subscales.

Cognitive–behavioral therapy has an additional effect as treatment for a population with phobic postural vertigo.A multidisciplinary approach including medical treatment, cognitive–behavioral therapy and physiotherapy is suggested.

Key words

dizziness anxiety disorders posture vestibular disorders 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Asmundson GJ, Larsen DK, Stein MB (1998) Panic disorder and vestibular disturbance: an overview of empirical findings and clinical implications. J Psychosom Res 44:107–120CrossRefPubMedGoogle Scholar
  2. 2.
    Asmundsson GJ, Stein MB, Ireland D (1999) A factor analytic study of the dizziness handicap inventory: does it assess phobic avoidance in vestibular referrals? J Vestibular Res 9:63–68Google Scholar
  3. 3.
    Barlow DH (2001) Clinical handbook of psychology. New York, Guilford PressGoogle Scholar
  4. 4.
    Beidel DC, Horak FB (2001) Behaviour therapy for vestibular rehabilitation. J Anxiety Disord 15:121–130CrossRefPubMedGoogle Scholar
  5. 5.
    Brandt T (1996) Phobic Postural Vertigo. Neurology 46:1515–1519PubMedGoogle Scholar
  6. 6.
    Brandt T, Huppert D, Dieterich M (1994) Phobic Postural Vertigo: a first follow up. J Neurol 241:191–195CrossRefPubMedGoogle Scholar
  7. 7.
    Brown TA, Antony MM, Barlow DH (1995) Diagnostic comorbidity in panic disorder: Effect on treatment outcome and course of comorbid diagnosis following treatment. J Clin Consult Psychol 63:408–418CrossRefGoogle Scholar
  8. 8.
    Godemann F, Linden M, Neu P, Heipp E, Dorr P (2004) A prospective study on the course of anxiety after vestibular neuronitis. J Psychosom Research 56:351–354CrossRefGoogle Scholar
  9. 9.
    Goldberg C (1998) Cognitive–behavioural therapy for panic: Effectiveness and limitations. Psychol Q 59:23–44CrossRefGoogle Scholar
  10. 10.
    Holmberg J, Karlberg M, Fransson PA, Magnusson M (2003) Phobic postural vertigo: body sway during vibratory proprioceptive stimulation. Neuroreport 14:1007–1011CrossRefPubMedGoogle Scholar
  11. 11.
    Jacob RG, Furman JM, Durrant JD, Turner SM (1997) Surface dependence: a balance control strategy in panic disorder with agoraphobia. Psychosom Med 59:323–330PubMedGoogle Scholar
  12. 12.
    Jacob RG, Moller MB, Turner SM, Wall C (1985) Otoneurological examination in panic disorder and agoraphobia with panic attacks: a pilot study. Am J Psychiatry 142:715–720PubMedGoogle Scholar
  13. 13.
    Jacob RG, Whitney SL, Detwailer– Shostak G, Furman JM (2001) Vestibular rehabilitation for patients with agoraphobia and vestibular dysfunction: a pilot study. J Anxiety Disord 15:131–146CrossRefPubMedGoogle Scholar
  14. 14.
    Jacobson GP, Newman CW (1990) The development of the dizziness handicap inventory. Arch Otolaryngol Head Neck Surg 116:424–427PubMedGoogle Scholar
  15. 15.
    Kapfhammer HP, Mayer C, Hock U, Huppert D, Dieterich M, Brandt T (1997) Course of illness in phobic postural vertigo. Acta Neurol Scand 95:23–28PubMedCrossRefGoogle Scholar
  16. 16.
    Krafczyk S, Schlamp V, Dieterich M, Haberhauer P, Brandt T (1999) Increased body sway at 3. 5–8 hz in patients with Phobic Postural Vertigo. Neurosci Lett 259:149–152CrossRefPubMedGoogle Scholar
  17. 17.
    Lisspers J, Nygren A, Soderman E (1997) Hospital anxiety and depression scale (HAD): some psychometric data for Swedish sample. Acta Psychiatr Scand 96:281–286PubMedGoogle Scholar
  18. 18.
    Mendel B, Bergenius J, Langius A (1999) Dizziness symptom severity and impact on daily living as perceived by patients suffering from peripheral vestibular disorder. Clin Otolaryngol Allied Sci 24:286–293CrossRefPubMedGoogle Scholar
  19. 19.
    Perna G, Dario A, Caldirola D, Stefania B, Cesarani A, Bellodi L (2001) Panic disorder: the role of the balance system. J Psychiatr Res 35:279–286CrossRefPubMedGoogle Scholar
  20. 20.
    Querner V, Krafchyk S, Dieterich M, Brandt T (2000) Patients with somatoform Phobic Postural Vertigo: the more difficult the balance task, the better the balance performance. Neurosci Lett 285:21–24CrossRefPubMedGoogle Scholar
  21. 21.
    Querner V, Krafczyk S, Dieterich M, Brandt T (2002) Phobic Postural Vertigo. Body sway during visually induced roll vection. Exp Brain Res 143:269–275CrossRefPubMedGoogle Scholar
  22. 22.
    Shepard NT, Telian SA, Smith, Wheelock M (1990) Habituation and balance retraining. Neurol Clin 8:459–475PubMedGoogle Scholar
  23. 23.
    Sklare DA, Stein MB, Pikus AM, Uhde TW (1990) Dysequilibrium and audiovestibular function in panic disorder: symptom profiles and test findings. Am J Otology 11:338–341PubMedGoogle Scholar
  24. 24.
    Staab JP, Ruckenstein MJ (2003) Which comes first? Psychogenic Dizziness versus Otogenic Anxiety. Laryngoscope 113:1714–1718CrossRefPubMedGoogle Scholar
  25. 25.
    Staab JP, Ruckenstein MJ, Solomon D, Shepard NT (2002) Serotonin reuptake inhibitors for dizziness with psychiatric symptoms. Arch Otolaryngol Head Neck Surg 128:554–560PubMedGoogle Scholar
  26. 26.
    Stein MB, Asmundson GJ, Ireland D, Walker JR (1994) Panic disorder in patients attending a clinic for vestibular disorders. Am J Psychiatry 151:1697–1700PubMedGoogle Scholar
  27. 27.
    Strupp M, Glaser M, Karch C, Rettinger N, Brandt T (2003) The most common form of dizziness in middle age: Phobic Postural Vertigo. Nervenarzt 74:911–914 (In German)CrossRefPubMedGoogle Scholar
  28. 28.
    Williams SL, Falbo J (1996) Cognitive and performance–based treatments for panic attacks in people with varying degrees of agoraphobic disability. Behav Res Ther 34:253–264CrossRefPubMedGoogle Scholar
  29. 29.
    Yardley L, Beech S, Zander L, Evans T, Weinman J (1998) A randomized controlled trial of exercise therapy for dizziness and vertigo in primary care. Br J Gen Pract 48:1136–1140PubMedGoogle Scholar
  30. 30.
    Yardley L, Bourgneay J, Andersson G, Owen N, Nazareth I, Luxon L (1998) Feasibility and effectiveness of providing vestibular rehabilitation for dizzy patients in the community. Clin Otolaryngol Allied Sci 23:442–448CrossRefPubMedGoogle Scholar
  31. 31.
    Yardley L, Luxon L (1994) Treating dizziness with vestibular rehabilitation. BMJ 308:1252–1253PubMedGoogle Scholar
  32. 32.
    Yardley L, Luxon L, Lear S (1994) Vestibular and posturographic test results in people with symptoms of panic and agoraphobia. J Audiol Med 3:48–65Google Scholar
  33. 33.
    Yardley L, Masson E, Versschuur C, Haacke N, Luxon L (1992) Symptoms, anxiety and handicap in dizzy patients: development of the vertigo symptom scale. J Psychosom Res 36:731–741CrossRefPubMedGoogle Scholar
  34. 34.
    Yardley L, Owen N, Nazareth I, Luxon L (1998) Prevalence and presentation of dizziness in a general practice community sample of working age people. Br J Gen Pract 48:1131–1135PubMedGoogle Scholar
  35. 35.
    Yardley L, Putman J (1992) Quantitative analysis of factors contributing to handicap and distress in vertiginous patients: a questionnaire study. Clin Otolaryngol Allied Sci 17:231–236PubMedGoogle Scholar
  36. 36.
    Zigmond AS, Snaith RP (1983) The hospital anxiety and depression scale. Acta Psychiatr Scand 67:361–370PubMedGoogle Scholar
  37. 37.
    Öst LG (1987) Applied relaxation: Description of a coping technique and review of controlled studies. Behav Res Ther 17:111–124Google Scholar

Copyright information

© Steinkopff-Verlag 2006

Authors and Affiliations

  • J. Holmberg
    • 1
    Email author
  • M. Karlberg
    • 1
  • U. Harlacher
    • 2
  • M. Rivano–Fischer
    • 2
  • M. Magnusson
    • 1
  1. 1.Department of Otorhinolaryngology, Head and neck surgeryLund University HospitalLundSweden
  2. 2.Lund–Orup Rehabilitation CentreLund University HospitalLundSweden

Personalised recommendations