J Neurol

DOI 10.1007/s00415-015-7826-0

LETTER TO THE EDITORS

Functional dizziness: diagnostic keys and differential diagnosis

Thomas Brandt1 • Doreen Huppert1 • Michael Strupp2 • Marianne Dieterich2,3

Received: 12 May 2015 / Revised: 11 June 2015 / Accepted: 11 June 2015

 Springer-Verlag Berlin Heidelberg 2015

Dear Sirs, differential diagnosis for migrainous vertigo, which has the
In the 1990s, 9 % of neurological inpatients were found highest frequency (39 %) in childhood [8].
to have functional (then called psychogenic or somato- The term ‘‘functional dizziness’’ is not a nosological
form) rather than structural neurological disorders of the entity but comprises several diagnoses. To complicate
nervous system as the primary cause of admission [1]. This matters, a functional component enhances, overlaps, or
is a conservative figure, since secondary and minor pseudo- prolongs the symptomatology of vestibular or central ner-
neurological symptoms were not included; other studies vous system disorders in many patients. A typical devel-
later found up to 18–20 % [2]. In a further study, it was opment is, for example, the evolution of vestibular neuritis
reported that 61 % of patients referred to a neurology into phobic postural vertigo, which was documented by
service had at least one medically unexplained symptom, artificial neural network posturography [9]. Therefore, it
and 35 % fulfilled the diagnostic criteria for an ICD-10 was proposed to clinically differentiate between primary
somatoform disorder [3]. and secondary somatoform (now functional) dizziness [10,
Functional dizziness is one of the most frequent func- 11]. This is particularly relevant for unpredictable episodic
tional disorders in adult in- and outpatients. In a tertiary vertigo syndromes (like vestibular migraine or Menière’s
referral dizziness unit, it accounted for 19.5 % of 17,700 disease), especially when they remain undiagnosed or are
adult outpatients; thus, it is the second most common poorly explained to the patient. Sometimes it is clinically
diagnosis after benign paroxysmal positional vertigo [4]. difficult to differentiate primary vestibular from secondary
The frequencies vary for different countries and study functional symptoms.
designs: 2.5 [5], 16 [6], and 23 % [7] have been reported. Many clinicians hesitate to use the diagnostic label
Functional dizziness is also a relevant diagnosis in chil- ‘‘functional’’ because they fear the consequences of a
dren. Its frequency peaks at 21 %, and it is an important potential misdiagnosis and the danger of overlooking a
vestibular, neurological, or psychiatric disorder. In the
following we draw on our experience in the German Center
for Vertigo and Balance Disorders to provide both typical
& Thomas Brandt
thomas.brandt@med.uni-muenchen.de
positive criteria and unlikely signs and symptoms in
patients presenting with functional dizziness syndromes. In
1
Institute for Clinical Neurosciences and German Center for Table 1, we define key signs that may sometimes even
Vertigo and Balance Disorders, University Hospital Munich, uncover deliberate aggravation and malingering.
Ludwig-Maximilians University, Campus Großhadern,
Marchioninistr. 15, 81377 Munich, Germany
With regards to the above features, it is our expert
2
opinion that chronic subjective dizziness [12] without
Department of Neurology and German Center for Vertigo and
associated neurological or otoneurological dysfunction has
Balance Disorders, University Hospital Munich, Ludwig-
Maximilians University, Campus Großhadern, no relevant vestibular or neurological differential diagno-
Marchioninistr. 15, 81377 Munich, Germany sis. Features 2–5 have one characteristic in common––a
3
SyNergy, Munich Cluster for Systems Neurology, Munich, dissociation of subjective complaints and objective find-
Germany ings. Anxiety is a central feature, but it is often revealed

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Table 1 Features typical for a

1. Chronic spontaneous dizziness or unsteadiness lasting for months or longer
functional dizziness syndrome
2. Dissociation between objective balance tests and subjective imbalance
3. Fear of falls without a history of falls
4. Improvement during bodily activity, mental distraction or after alcohol consumption
5. Inappropriate excessive anxiety or fear of impending doom
6. Dizziness combined with non-vestibular or non-balance symptoms
7. Situational or social events as triggers of dizziness and avoidance behavior
8. Rotational vertigo without concurrent spontaneous nystagmus
9. Unusual or bizarre postural and gait patterns
10. Chronic unsteadiness and dizziness following transportation in vehicles

Table 2 Features atypical for a

1. Frequent episodic vertigo/dizziness attacks with symptom-free intervals
functional dizziness syndrome
2. Nausea and emesis
3. Rotational vertigo with directional pulsion or falls
4. Dizziness/vertigo with concomitant auditory symptoms
5. Head rotation or head tilt as specific triggers
6. Spontaneous suspicion of patients that psychological (not physical) stress is causative

only by carefully taking the patient’s history. Vestibular With the Table 2 of unlikely or atypical features [17] we
and neurological dizziness syndromes do not improve with would like to stress their non-functional origin. For
alcohol consumption. The combination of dizziness with example, spontaneous episodic vertigo or dizziness attacks
non-vestibular complaints refers to the association of with symptom-free intervals are rarely functional, but are a
abdominal or heart symptoms, muscle weakness, dyses- criterion of vestibular disorders such as Menière’s disease,
thesia, pain syndromes (except headache), or sleep distur- vestibular migraine, or vestibular paroxysmia. Nausea and
bances. In contrast to causes of chronic dizziness in emesis most often indicate an acute peripheral labyrinthine,
bilateral vestibulopathy or downbeat nystagmus syndrome, vestibular nerve, or vestibular nucleus lesion. Rotational
patients with phobic postural vertigo show a circadian vertigo with a directional pulsion, deviation of gait, and a
rhythm with minimal symptoms in the morning [13]. Sit- tendency to fall also points to vestibular disorders. A
uational or social triggers of dizziness and their avoidance combination of dizziness with hearing loss, tinnitus, or
are not typical for vestibular or neurological disorders. If a fullness of the ear is typical for peripheral vestibular dys-
patient complains about an acute rotational vertigo during function, especially Menière’s disease and less frequent in
the physical examination, but the physician cannot observe vestibular migraine. Head and body movements relative to
a spontaneous nystagmus, then a vestibular cause is unli- gravity indicate benign paroxysmal positional vertigo; head
kely. Finally, a number of functional disorders of posture rotations may indicate vestibular paroxysmia due to neu-
and gait are characterized by unusual and bizarre motor rovascular cross-compression. Patients presenting with
patterns like excessive slowness, hesitation, momentary functional dizziness may spontaneously blame physical
fluctuations, improvement of Romberg test values during (rarely psychological) stress as the cause of their dizziness.
distraction, ‘‘walking on ice’’ gait pattern, or sudden Dizziness or vertigo may be the primary cause of
buckling [14]. Here, ostentatious behaviour such as man- admission of outpatients suffering from a psychiatric dis-
nered posturing of the hands, a facial expression of suf- order. The most frequent of these are listed below
fering, or moaning, supports the suspicion of a functional according to DSM-V and the ICD-10 classification [15,
disorder. Psychiatrically, the functional disorders of stance 16]:
and gait are classified among dissociative disorders and
• Anxiety disorders (specific phobias, panic disorders),
somatic symptom and related disorders [15, 16]. Mal de
• Depressive disorders,
debarquement syndrome refers to a sensation of swinging,
• Somatic symptom and related disorders,
swaying, unsteadiness, and disequilibrium that is prefer-
• Posttraumatic stress disorders.
ably experienced in sea travel (less often other forms of
travel) immediately on disembarking and may persist for Dizziness and vertigo are not keys that help establish a
weeks to years in some individuals. specific psychiatric diagnosis. Here, psychopathological

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Table 3 Differential diagnoses of functional dizziness rare and characterized by spells of vertigo and oscillopsia
1. Vestibular migraine without concomitant headache
induced by coughing, Valsalva maneuver, and sometimes
2. Sensory polyneuropathy
even loud sounds. It is caused by a bony apical defect of the
superior semicircular canal, which can be shown by thin-
3. Bilateral vestibulopathy
slice CT of the petrous bone.
4. Side effects of medication
We would like to encourage those who manage dizzy
5. Alcohol or substance abuse
patients to discuss with the patient the functional genesis of
6. Orthostatic hypotension or hypertensive crises
the mechanisms causing the sometimes frightening dizzi-
7. Major and mild cognitive impairment
ness and subjective postural instability. The readiness of
8. Mild degenerative cerebellar ataxia and downbeat nystagmus
syndrome most patients, who experience much stress as a result of
9. Orthostatic tremor
their suffering, to understand the functional mechanism and
10. Superior canal dehiscence syndrome
to overcome it by desensitization is a positive experience
for both the physician and the patients [4]. However,
symptoms are the main indicators. This is also true for physicians should avoid a dichotomous thinking of func-
specific phobias and panic disorders in which dizziness is tional versus organic disorders for at least two reasons:
mentioned as one among many bodily symptoms. It is well first, both conditions frequently overlap, and second, a
acknowledged that dizziness may be a complaint in many vestibular condition can change into a functional condition.
other psychiatric conditions; however, those patients will Various cognitive, educational, behavioural, physical, and
rarely be seen by physicians who manage dizzy patients. medical therapies have to be applied for the individual
These vestibular and neurological disorders may be patient and the different conditions summarized under the
misdiagnosed as functional (Table 3). umbrella term ‘‘functional dizziness’’.
Attacks of vestibular migraine with dizziness and postural
Acknowledgments We thank Judy Benson for copy-editing the
stability of various durations [18] manifest without con- manuscript. The work was supported by the German Ministry of
comitant headache in about 30 % of patients [19]. Episodic Education and Research (Grant Nos. 01EO0901 and 01EO1401) and
vertigo syndromes in childhood are associated with migraine the Hertie Foundation.
in about 50 % of the cases [20]; the frequent benign parox-
Conflicts of interest The four authors declare no conflict of interest.
ysmal vertigo of childhood—a migraine equivalent—man-
ifests typically without headache. The physical examination
of dizzy patients should include sensory testing for
References
polyneuropathy; it frequently occurs in elderly patients and
is often combined with visual deficits and bilateral vestibu- 1. Lempert T, Dieterich M, Huppert D, Brandt T (1990) Psy-
lopathy. Patients with bilateral vestibulopathy are symptom- chogenic disorders in neurology: frequency and clinical spec-
free if they do not move, but they typically complain of trum. Acta Neurol Scand 82:335–340
oscillopsia with head movements (due to the defective ves- 2. Fink P, Hansen MS, Oxhoj ML (2004) The prevalence of
somatoform disorders among internal medical inpatients. J Psy-
tibulo-ocular reflex) and imbalance during locomotion in chosom Res 56:413–418
darkness or on uneven ground when vision and propriocep- 3. Fink P, Hansen MS, Sondergaard L (2005) Somatoform disorders
tion cannot substitute for the vestibular deficit. Numerous among first-time referrals to a neurology service. Psychosomatics
medications, alcohol, or substance abuse cause dizziness and 46:540–548
4. Brandt T, Dieterich M, Strupp M (2013) Vertigo and dizziness:
numbness; thus, the patient history must clarify this point. common complaints, 2nd edn. Springer, London
Fluctuating alertness, slowing of cognitive processing, and 5. Ketola S, Niemensivu R, Henttonen A, Appelberg B, Kentala E
motor performance, especially postural imbalance and falls, (2009) Somatoform disorders in vertiginous children and ado-
are hints of an abuse. Hypotensive and hypertensive blood lescents. Int J Ped Otorhinolaryngol 73:933–936
6. Lopez-Gentili LI, Kremenchutzky M, Salgado P (2003) A sta-
pressure dysregulation may also cause dizziness, which is tistical analysis of 1300 patients with dizziness-vertigo. Its most
often described as numbness or lightheadedness. Dizziness frequent causes. Rev Neurol 36:417–429
may be the leading complaint of patients with mild cognitive 7. Obermann M, Bock E, Sabev N, Lehmann N, Weber R. et al. (2015)
impairment or dementia. The same is true for beginning Long-term outcome of vertigo and dizziness associated disorders
following treatment in specialized tertiary care—the Dizziness and
degenerative cerebellar ataxias, which can be identified by Vertigo Registry (DiVeR) study. J Neurol (in press)
ocular motor and other cerebellar signs of motor perfor- 8. Batu ED, Anlar B, Topcu M, Turanli G (2015) Vertigo in
mance. Rare orthostatic tremor is characterised by a childhood: a retrospective series of 100 children. Eur J Paed
13–18 Hz body sway which can sometimes be visually Neurol 19:226–232
9. Brandt T, Strupp M, Novozhilov S, Krafczyk S (2012) Artificial
observed but has to be confirmed by posturography or elec- neural network posturography detects the transition of vestibular
tromyography. Superior canal dehiscence syndrome is also neuritis to phobic postural vertigo. J Neurol 259:182–184

123
 J Neurol

10. Huppert D, Kunihiro T, Brandt T (1995) Phobic postural vertigo 16. World Health Organisation (1993) The ICD-10 classification of
(154 patients): its association with vestibular disorders. J Audiol mental and behavioral disorders. Clinical description and diag-
Med 4:97–103 nostic guidelines. WHO, Geneva
11. Eckhardt-Henn A, Best C, Bense S, Breuer P, Diener G, Tschan 17. Brandt T, Strupp M, Dieterich M (2014) Five keys for diagnosing
R, Dieterich M (2008) Psychiatric comorbidity in different most vertigo, dizziness, and imbalance syndromes: an expert
organic vertigo syndromes. J Neurol 255:420–428 opinion. J Neurol 261:229–231
12. Staab JP (2012) Chronic subjective dizziness. Continuum Life- 18. Lempert T, Olesen J, Furman J, Waterston J, Seemungal B, Carey
long Learning Neurol 18:1118–1141 J et al (2012) Vestibular migraine: diagnostic criteria. Consensus
13. Feuerecker R, Habs M, Dieterich M, Strupp M (2015) Phobic document of the Barany Society and the International Headache
postural vertigo: fewer symptoms in the early morning—a com- Society. J Vestib Res 22:167–172
parison with downbeat nystagmus syndrome and bilateral 19. Dieterich M, Brandt T (1999) Episodic vertigo related to
vestibulopathy. J Neurol Neurosurg Psychiatry (in press) migraine (90 cases): vestibular migraine? J Neurol 246:883–892
14. Lempert T, Brandt T, Dieterich M, Huppert D (1991) How to 20. Jahn K, Langhagen T, Schroeder AS, Heinen F (2011) Vertigo
identify psychogenic disorders of stance and gait. A video study and dizziness in childhood—update on diagnosis and treatment.
in 37 patients. J Neurol 238:140–146 Neuropediatrics 42:129–134
15. APA (2013) Diagnostic and statistical manual of mental disor-
ders: DSM-5, 5th edn. American Psychiatric Publishing,
Washington

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