Peer Reviewed

Is Vestibular Care Off-Balance?

How a biopsychosocial approach can help improve outcomes for people with dizziness

Dr. Yonit Arthur, AuD, CCC-A, Board-Certified Audiologist & Coach

Your cheeks flush. Your hands get cold and your palms start to sweat. You feel your heart start to race and your breathing speed up. You notice tightness in your chest and fluttering in your stomach.

What’s happening? Is there a wild animal running after you? Are you nervous about making a big presentation? Are you embarrassed? Are you coming down with the flu? Or perhaps you’re excited about seeing a long-lost friend?

Did you notice that all these explanations make sense? Physical symptoms can mean many different things because all experiences are the result of an ongoing, two-way conversation between the brain and the senses. Our physical experiences aren’t purely biological, one-way responses to something happening to us. As in this example, our physical experiences always occur through the lens of the brain’s processing, which is affected by thoughts, beliefs, feelings, social context and past experiences. 

In this article, we’re going to be talking about why that is, what it tells us about standard biomedical care of vestibular disorders, and why dizziness should be treated using an approach that addresses all these factors, known as the biopsychosocial model. 

Before we dive into this topic, it is important to note that the “bio” component of the biopsychosocial model means that the first stop for any person experiencing dizziness needs to be a physician or other expert medical provider who specializes in diagnosing and treating dizziness. While we will be exploring the importance of psychosocial factors in this article, we must be sure we are addressing existing biological factors (diseases, injuries, etc.) first.

When a nail isn’t a nail

Over the last 40 years, cognitive neuroscience has reshaped how we understand sensory perception. In the past, it was assumed that sensing something – say, dizziness – was a simple “bottom up” process; that is, if your sensory organs weren’t working properly, your brain would perceive dizziness. We now know that this is not accurate, and there are many examples that demonstrate this in the vestibular world. Some people with debilitating symptoms have physical changes in sensory processing areas of the brain, often without damage to the ear (as in persistent postural perceptual disorder, or PPPD). Yet others have physical damage but don’t have symptoms (as in compensated vestibular neuritis or even asymptomatic hydrops or swelling in the ear). How can that be? It’s because the brain is in charge of our physical experiences. 

Far from being a passive organ, the brain is affected not only by biological factors like genes and hormones but also by psychosocial factors. Psychosocial factors include thoughts, learning, beliefs, feelings, social context, life stress, trauma and past experiences. They affect both the way your brain processes information as well as how your brain and body respond to information. The influence these factors have on the brain helps explain why someone might have physical damage and no symptoms, whereas someone else might have no physical damage and have symptoms. Having had a lot of anxiety and catastrophic thoughts, for example, increases the likelihood that someone will develop chronic symptoms after a benign paroxysmal positional vertigo (BPPV) or vestibular neuritis (VN) episode (Trinidade et al, 2021; Sun et al, 2023, Waterston et al, 2021; Godemann et al, 2004; Tschann et al, 2011). 

The brain is powerful, and the way it processes information can dramatically change physical symptoms even without a biological reason. One example that illustrates this concept from the British Medical Journal describes a construction worker who had a huge nail go through his boot at his worksite. He was screaming in pain and taken to the nearest emergency room, where he was given morphine so the doctors could cut off his boot. When they did, they found that the nail had gone right in between two of his toes without causing tissue damage at all (Fisher et al, 1995). He experienced real, physical pain, but it wasn’t from tissue damage, rather from his brain making an incorrect interpretation of his experience. 

Research in the field of psychoneuroimmunology is also showing how psychosocial factors affect the biology of the brain and body. A study on subjects’ hormonal responses to a milkshake, for example, showed that the subjects’ beliefs about the content of the milkshake affected their hormonal response to it (Crum et al, 2011). Other astonishing studies on belief effects have shown that beliefs change the chemistry and electrical patterns of the brain’s response to various substances that subjects consume (Gu et al, 2015; Zunhammer et al, 2021; Kirsch et al, 2023). These studies and many others demonstrate that psychosocial factors have important effects on the biology of the body and the function of the immune and nervous systems.

What this means for people with vestibular disorders is that the severity of symptoms, effectiveness of treatment and even in some cases people’s vulnerability to disorders are affected by psychosocial factors. The most dramatic cases described in research are from studies on people who have undergone adverse childhood experiences, who are more likely to have chronic pain and migraines (Brennenstuhl & Fuller-Thompson, 2015), as well as disorders that involve physical disease processes like heart disease (Deschenes et al, 2021). Research on migraine, PPPD, post-concussion syndrome, and unilateral hypofunction have all demonstrated that psychosocial factors affect both symptom severity and treatment outcomes, regardless of the severity of an initial causal event (Nachman-Averbuch, et al 2020; Herdman et al, 2020; Trinidade et al, 2023; Faulkner & Snell, 2022; Clarke et al, 2022).

A biopsychosocial approach for vestibular disorders

While everyone who has dizziness should have biological factors such as disease or damage addressed by a medical provider, it should be clear by now that regardless of the origin of your vestibular symptoms, they are affected by factors other than your sensory organs or genes. The model that takes these other factors into account is called the biopsychosocial model. It states that what determines someone’s symptoms is not just biological damage or a disease process, but also the person’s psychology (e.g. background, trauma history, psychiatric disorders, feelings, mental well-being and thought patterns), and social context (beliefs about illness, socioeconomic status, social support and identity). 

Since we have already established that these things have a direct impact on the brain and how it processes information, it should be clear why a biopsychosocial approach is potentially more effective in addressing chronic symptoms than one that only addresses one of these factors. This has been well-illustrated in chronic pain research. For example, a recent study (Ashar et al, 2022) looked at 151 people who had had chronic pain for many years despite having gone through many conventional and alternative treatments. Most of those past treatments had focused on the identified physical cause of the pain (herniated discs, postural issues, etc.) but these participants were still in pain. Some of these participants were put through a program that addressed their beliefs about their pain as well as their feelings about certain life experiences. A stunning 73% of the people who completed the treatment had complete or almost complete resolution of their pain. That wasn’t all. The researchers showed via fMRI imaging that the subjects’ brains actually changed how they processed sensory information in response to the program. These changes corresponded to reductions in the experience of pain.

While research at this scale has not been done in the field of vestibular disorders yet, ongoing research into post-concussion syndrome and PPPD are showing that biopsychosocial treatments (including psychoeducation and cognitive-behavioral therapy as well as physical therapy and medications, if needed) are more effective than one-dimensional, biological ones (physical therapy and medications alone) (Waljas et al, 2015;  Waterston et al, 2021; Axer et al, 2020, Trinidade et al, 2023). Even disorders with physical origins like ear weakness have better outcomes when someone is given cognitive-behavioral therapy at the same time (Johanssen et al, 2001; Andersson et al, 2006; Naber et al, 2011). This should come as no surprise given what we have discussed so far. Migraines, too, are affected by psychosocial factors, and addressing thoughts, emotions and beliefs have shown remarkable effects on symptoms (Balottin et al, 2014; Kropp et al, 2017; Bae, 2022).

Ok, so why is it not being used in the mainstream?

One major obstacle is that there are not enough counselors available to perform psychosocial assessments, and the majority of those providers are often not covered by insurance. Adding to the difficulty is the fact that the patients struggling the most with vestibular disorders are on disability, making access to healthcare tenuous at best. In addition, doctors themselves, whether MD or DO, do not have extensive training in counseling. One exception is psychiatrists, and even that varies between residency programs and schools of thought. All of those factors lend to the limited exposure patients end up getting to the holistic biopsychosocial model, regardless of country or healthcare system.

Another barrier is that the research evidence is not clear yet on ideal interventions. While it’s quite clear that our current interventions are inadequate and unsatisfactory to many people who are suffering with vestibular disorders (Dornhoffer et al, 2020; Kisabay, 2022; Knapstad et al, 2019), it is expensive and difficult to study whole-person interventions. Many clinicians may feel uncomfortable changing their approach to treating dizziness without having ideal protocols with a lot of research behind them. 

Finally, sometimes there is a misunderstanding from people who are suffering from vestibular disorders that taking a biopsychosocial approach means thinking that symptoms are “all in their heads.” Dizziness symptoms are never your fault or something you’re just making up, and vestibular disorders are not “just anxiety.” The biopsychosocial model seeks to optimize and customize your treatment by acknowledging that factors other than your ears, nerves, hormones and genes are affecting your symptoms. By looking at you as a whole person, it allows you to identify which factors in your life might be contributing to nervous system sensitivity and brain processing that make symptoms occur. This allows you to have the best possible outcomes.

I want to take a biopsychosocial approach to my disorder. How do I do that?

From the get-go, it might be helpful to reframe some of your goals in seeking treatment for your vestibular disorder. First, it would be important to be open to psychosocial factors potentially playing a role in your symptoms. This doesn’t mean “it’s just anxiety,” of course (and feel free to leave and never go back to any providers who tell you this), but it means that it’s important for you to understand and recognize that your life stress, emotions, thought patterns, beliefs and background are playing a role in how your brain is responding to and interpreting your symptoms. This is true regardless of whether your symptoms have a disease cause (such as neuritis, Meniere’s and third window syndrome) or not. 

Second, in this context, it makes sense to address your symptoms via a multidisciplinary, “whole person” oriented team, consisting of medical providers as well as therapists, coaches and/or support groups. Different providers have different roles in your treatment, and being open to psychosocial factors affecting your outcomes means that you have access to more comprehensive treatment. Your medical providers’ jobs are to rule out and treat disease or physical damage causes of your illness, whereas therapists, coaches and support groups can address stress, thoughts and other important psychosocial factors. 

Third, be open to options beyond physical treatment (medication, diet, physical therapy, medical procedures, chiropractic care) and consider interventions that target thoughts, beliefs, feelings, social context, stress, and other life experiences. This is particularly important if you have already tried physical treatment approaches and they have not worked. In these cases, it would make sense to explore how psychosocial factors may be playing a role in how your brain is responding to your environment and to symptoms. These can be done with a therapist or a coach who specializes in vestibular disorders, or on your own using some of the resources listed at the end of this article.

Fourth, on a related note, given that we know the brain responds powerfully to beliefs and thoughts, it may be helpful to work with providers who view their role as more than just helping you “cope with” symptoms. Your provider’s negative beliefs about your ability to recover or regain function can have a direct effect on your ability to do so (Rossettini et al, 2020; Klinger et al, 2017). Working with someone who understands how psychosocial factors (including his or her authority as a clinician!) can have an influence on your well-being and symptoms is critical.

And finally, remember that whatever psychosocial factors may be contributing to your symptoms, addressing your symptoms via a biopsychosocial approach does not mean “thinking positive,” pretending that everything is ok, thinking your symptoms aren’t real, or blaming yourself for your symptoms. In fact, a great deal of the current research on chronic symptom recovery is focusing on teaching people emotional awareness and expression. What this means for you is that learning to work through your emotions (grief, frustration, anger, guilt) without blaming yourself for having them is an important part of the process. Many of the factors that may have influenced you to develop symptoms were out of your control, but the biopsychosocial approach seeks to help you find and take charge of what will help you most. Learning new skills for working with stress, thoughts, emotions, anxiety and relationships can be empowering and life-changing, and from my own work, lead to dramatic reductions in symptoms.

Final notes & easy first steps

It can feel overwhelming to think about taking these steps when you’re already not feeling well. Here are some immediate suggestions to help you on your way.

  • Read or listen to the audiobook of “The Way Out” by Alan Gordon & Alon Ziv. This book explains how thoughts, beliefs and feelings can influence your experience of chronic symptoms, and it provides practical tips for how to make changes in the way you’re addressing your symptoms.
  • I have hundreds of free videos on my YouTube channel about dizziness through a psychosocial lens. Visit my channel at https://youtube.com/@thesteadycoach.
  • Consider working with a coach or therapist who specializes in vestibular disorders or other chronic physical symptoms like chronic pain. You can find one through the Vestibular Disorders Association (use filters: psychologist, social worker, and certified health coach) or the Psychophysiologic Disorders Association at ppdassociation.org.



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