Phobic Postural Vertigo

Phobic postural vertigo (PPV) (Brandt and Dieterich 1986; Brandt 1996) has been described as a syndrome that is distinguishable from panic disorder, agoraphobia, and the pseudo-agoraphobia syndrome “space phobia” (Marks 1981). Since we began diagnosing it as a clinical entity, PPV has become the second-most common cause of vertigo in our dizziness unit (p. 23). Closely connected with gait and posture, PPV is characterised by a combination of non-rotational vertigo with subjective postural imbalance and unsteadiness, normal neuro-otological tests, and phobic avoidance behaviour mainly in patients with an obsessive-compulsive personality. The monosymptomatic subjective disturbance of balance manifests with superimposed attacks that occur with and without recognisable provoking factors in one and the same patient. The patient experiences them with and without accompanying excess anxiety, misleading both patient and physician to make a false diagnosis of organic disease. Although an association of PPV with anxiety disorders is evident, not all patients present with symptoms of anxiety or panic during attacks of vertigo. However, most patients develop a disabling “phobic/avoidance pattern” (Kapfhammer et al. 1997). These patients contact neurologists or otolaryngologists first and foremost and not psychiatrists or psychotherapists, since their prevailing complaint is distressing postural imbalance and vertigo.