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Anxiety & Dizziness: Chicken or the egg?

Many of my patients who experience dizziness, especially chronic forms of dizziness such as Vestibular Migraine or Persistent Postural-Perceptual Dizziness (PPPD), also experience some level of anxiety. Some of these patients may have been anxious initially and the onset of dizziness makes their anxiety worse. Others have no history of anxiety, but start to experience symptoms of anxiety because of their dizziness. Some level of anxiety when you have a new experience of dizziness is normal. Let me say that again...it is normal to feel anxious when you suddenly experience dizziness. However, in people with dizziness symptoms lasting months or years, sometimes their anxiety worsens to the point where it can actually make them more dizzy, or be the sole cause of their chronic symptoms. Let's talk about why this may be.

Women with hands on head and distressed look

The Autonomic Nervous System

To understand the intricate relationship between dizziness and anxiety, we have to understand the basics of the autonomic nervous system. This autonomic system automatically controls basic life-sustaining functions such as blood flow, heart rate, sleep cycles, and digestion. There are two parts of the autonomic nervous system: the sympathetic nervous system and the parasympathetic nervous system.


Fight, Flight, or Freeze - The Sympathetic Nervous System

The sympathetic nervous system is known as our fight, flight, or freeze response. I like to refer to the sympathetic nervous system as our body's alarm system. When our body senses danger, a threat, or stress, our brain activates this alarm system, the sympathetic nervous system. Our pupils dilate, blood vessels constrict, heart rate and blood pressure increase, and we may start sweating. This is a normal physiological response in the presence of danger enabling our body to protect us by either fending off the threat (fight), running from the danger (flight), or stopping and taking stock of the situation (freeze). In a normal response, once the danger is addressed or removed, our alarm system de-activates and our nervous system returns to a normal level of excitation, or activation of our parasympathetic system.


Rest and Digest - The Parasympathetic Nervous System

When we are in a sympathetic state (our alarm is sounding), we are more vigilant of everything going on around us. When we are in a parasympathetic state (or our alarm is off), our heart rate and blood pressure decrease, we are less vigilant because we are not in fight/flight/freeze mode and our body can focus on resting and digesting. So while the sympathetic nervous system helps protect us in moments of danger, our parasympathetic nervous system keeps us alive in moments of peace and calm, so we can eat and digest food, and rest and restore our brain and body.


A balancing act

Infograph of the central nervous system and the parasympathetic and sympathetic branches

Our bodies are meant to go between these two systems throughout our day and throughout our lives. We are not meant to be in a sympathetic state for most of the day or for prolonged periods of time. This happens when we have chronic stress in our lives (hmmm…pandemic?) or perpetual worrying thoughts or anxiety (chronic dizziness?). When this happens, our brain interprets this as there constantly being a threat or danger. Because of this, our brain adapts and our alarm system becomes more and more sensitive. This is a physiological response, meaning actual chemical and hormonal changes in our brain! Sometimes this alarm can become so sensitive that, the littlest thing will set it off -- an unexpected loud noise, bright lights, or routine activities like driving or going to the store. AND THIS CAN PRODUCE DIZZINESS!


Neuroplasticity...the good and the bad

Furthermore, our brains are sooooo good at learning and making new connections. They do this through lots of repetition. The more repetition, the stronger the connection. This is known as neuroplasticity. There is positive neuroplasticity and negative neuroplasticity. Positive neuroplasticity results in changes in the brain that improve our overall wellbeing. For example, let's say after a stressful day you've made a habit of taking a few minutes to do deep breathing, gentle yoga, or a mindfulness exercises to help alleviate your stress. Doing this over and over again, you will become more proficient or skilled at reducing your stress levels with these simple activities. The more you do it, the stronger the association between these activities and reduced stress. On the other hand, negative neuroplasticity results in changes in the brain that do not contribute to your wellbeing, and actually make you feel physically and/or mentally worse. An example of this can be as simple as a single thought. One of my patients would get dizzy when walking in an open field. Unfortunately, she lived on a farm and had to do this activity daily. She would get so anxious before going out in the field, worried she would get dizzy, that she soon started to get dizzy just thinking about going out in the field. Her brain made such a strong connection between dizziness and that field that just thinking about it would produce symptoms of dizziness.


Anxiety-Dizziness-Autonomic function: A love triangle

Numerous studies have demonstrated a multitude of connections between parts of the brain that process anxiety, dizziness, and the autonomic nervous system (1). The limbic system is a region of the brain responsible for processing emotions, and thus anxiety. It includes the cingulate gyrus and parahippocampal gyrus, the amygdala, hippocampus, and hypothalamus. The vestibular system consists of a peripheral organ in our inner ear, as well as central projections to various parts of our brain including the brainstem, cerebellum, thalamus, and cerebral cortex. Functional MRI studies have shown that activating the vestibular system, simultaneously activates areas of the limbic system. Likewise, the autonomic system is linked to the vestibular system via the vestibular-sympathetic reflex (1, 2). This reflex is responsible for regulating blood pressure when changing positions, like getting out of bed . Therefore, we can see various anatomical and possibly chemical links between vestibular, emotional, and autonomic processing centers of the brain. So, activation or stimulation of one, can lead to activation of the other. This possibly explains why the patient described above starts feeling dizzy when just thinking about going out in the field. She is activating her limbic system via an anxious thought, and as a result, activating the vestibular centers of her brain. So, if this is true, can we reduce sensations of dizziness by reducing our anxiety or calming our sympathetic nervous system? Absolutely!

Diagram of the brain identifying structures of the thalamus, hypothalamus, cingulate gyrus, cerebellum, and hippocampus


Calming the nervous system

So we talked about the sympathetic nervous system as our alarm system. People with chronic dizziness and/or chronic anxiety have an alarm system that is more sensitive than people without these conditions. Well, what keeps that alarm so sensitive? Lots of things, and all unique to you. More worry, regular stress, poor eating and sleeping habits, poor hydration, limited physical activity, not understanding why this is happening to you can all keep that alarm extra sensitive. So, how can we desensitize our alarm? Many of the things keeping your alarm sensitive are in your control to change!


Reduce Worry and Anxiety

While we may not be able to change much of what may cause us stress, we can change how we react to that stress. This is where Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT) can be of huge importance. CBT helps us recognize patterns of anxiety and identify those patterns that do not serve us. ACT helps us behave in ways that align with our values and accept our responses to situations out of our control. Psychology Today is a great starting place for finding a local therapist that specializes in these areas.


Healthy brain habits

Healthy brain habits include proper nutrition (avoiding processed food, refined sugars, possibly gluten and dairy), good hydration (drinking at least half your body weight in ounces of water), adequate oxygen and blood to the brain through via aerobic exercises, and rest and relaxation in the form of good sleep habits and stress-reduction strategies (see below).


Education and understanding

Understanding the connection between dizziness and anxiety can help people feel better immediately. Oftentimes, patients with chronic dizziness will report significantly less dizziness after just a session of talking about these anxiety and dizziness connections in the brain.


Self-calming strategies

This can take the form of doing an activity you enjoy (knitting, reading, listening to music), getting some exercise, meditation and mindfulness, or breathing exercises. Here are a few of my favorites:

  • Headspace: Headspace is mindfulness meditation app which provides easy to follow instruction and guided audio meditations. Both general meditations and situation-specific meditations like sleep enhancement, anxiety reduction, and calming oneself after a crisis are available. The app has both a free version as well as a premium service.

  • Insight Timer: Insight Timer for sleep, anxiety, and stress. The app features guided meditations, music and talks posted by contributing experts.

  • Calm: Calm provides guided meditations of various lengths which incorporate soothing music, nature scenes/sounds, and breathing exercises to help reduce anxiety and ensure a restful night of sleep. The app has a free version as well as a premium version.

  • Rainy Mood: Rainy Mood provides soothing audio of rainfall to assist with sleeping, working, and relaxing. It is available for free on the web and as a smart phone app, with optional premium version.

  • Do Yoga With Me: Do Yoga With Me is a website that offers high quality streaming yoga instruction for all levels 100% for free. On the site you will find a wide variety of classes offered by a diverse team of skilled instructors.

  • Box Breathing: This is a simple strategy that can be employed anywhere. It is actually used by the Navy Seals to remain calm in stressful situations. And if this is too much, you can always just make your exhale longer than your inhale which has shown to activate the parasympathetic (rest and digest) system.



The right amount of stimulation

This is the core principle of vestibular therapy for people dealing with chronic dizziness and anxiety. If we avoid all activities that bring on our symptoms, we will make our alarm system even more sensitized. On the other hand, if we push through our symptoms until we are so symptomatic that we can’t do anything, we will keep setting off that alarm and continue to keep it sensitized. We need to find the sweet spot by doing activities that specifically tease our symptoms out, touch those symptoms, nudge them a little bit further. I use the term "tease it, touch it, nudge it", borrowed from Adriaan Louw and his work with chronic pain. While we are doing this, we are avoiding setting off the alarm by employing our self-calming strategies and connecting to our body in space. Doing this throughout that day, every day will teach your brain to connect your specific symptom triggers to feelings of calm and relaxation. Your brain will learn that these normal activities are safe and there is no need to trigger the alarm...positive neuroplasticity!


The sooner the better

If you are experiencing symptoms of dizziness lasting months or years, do not wait to get help. The sooner you get expert help, the sooner your symptoms will improve all resolve. A skilled vestibular therapist will be able to assess the health and function of your vestibular system, and link you to other providers and resources critical in your recovery.


References

  1. Rajagopalan A, Jinu KV, Sailesh KS, Mishra S, Reddy UK, Mukkadan JK. Understanding the links between vestibular and limbic systems regulating emotions. J Nat Sci Biol Med. 2017;8(1):11-15.

  2. Holstein GR, Friedrich VL, Martinelli GP. Projection neurons of the vestibulo-sympathetic reflex. J Comp Neurol. 2014;522(9):2053-2074.


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