Dizziness, vertigo and balance disorders may originate in the inner ear, brain, vascular or nervous system and can be mild to debilitating. Learn more about the types, symptoms and causes of balance disorders. Diagnostic and treatment options such as vestibular rehabilitation and cognitive behavioral therapy will be discussed

1. Balance Disorders: Dizziness and
Vertigo
Treatment of Associated Anxiety
Presented by:
Gina Byrnes, MSW, LCSW, ACT
January 30, 2014

2. 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

3. 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

4. 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

5. Anxiety and Dizziness: The Connection
Similar presentation between Anxiety associated with
Vestibular Disorders and Panic Disorder
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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

6. Treatment Approach – Cognitive Therapy
Addresses the Misperception and Overestimation of Threat
Anxious Thinking
Change
Focus on Likelihood of
Serious Threat/Danger
Normalized Thinking
Focus on Realistic Likelihood
Process
Focus on Inability to Cope,
Helplessness & Vulnerability
of Various Outcomes
Focus on Ability to Cope
& Problem –Solve Challenging
Circumstances
Intense Anxiety
Minimal Anxiety
From The Anxiety and Worry Workbook: The Cognitive Behavioral Solutin, David A. Clark and Aaron T. Beck
p. 98, 2012, The Guilford Press

7. 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

8. 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.

9. 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.

10. 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”

11. 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

12. REFERENCES
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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.