This article originally appeared in the Spring 2026 issue of On The Level.
People with a vestibular disorder often experience a sense of lost control and an inability to complete daily activities. In some instances, this loss of control also poses a danger to their physical well-being, such as when they are driving a car or walking down a flight of stairs.
When people become acutely aware of the sensations associated with an oncoming vestibular episode, they also become increasingly aware of the circumstances in which these episodes occur, such as in settings with high-volume sound, uneven walkways, or quick head turns.
Unsurprisingly, these people actively work to limit or eliminate these triggers from their daily life and sometimes find themselves “on the lookout” for scenarios they strongly associate with their symptoms.
This phenomenon of increased avoidance and high cognitive effort in identifying nearby triggers is known in neuroscience as hypervigilance and is strongly associated with disorders involving the vestibular system1.
When Fear Becomes the Trigger
Neuroscience suggests that physical symptoms are connected to what we’re aware of and afraid of. In simple terms, when two things happen together often, our brains start linking them. This is known in lay terms as “things that fire together, wire together.”2
This concept explains how neurons that perform completely different functions in the brain can become strongly associated with each other through synapse formation when they are consistently “fired together.”2
Take hyperacusis (high sensitivity to sound), for example: The neurons that integrate the perception of heightened sound are not necessarily anatomically synapsed strongly with the neurons that perceive the symptoms of a vestibular episode or the fear associated with those episodes.
However, if a person initially suspects, rightly or wrongly, that their symptoms are directly triggered in settings involving loud noises, they will actively work to avoid these settings and, when unable to do so, will adopt a seemingly unavoidable fear response that occurs without the presence of, or could even directly lead to, a vestibular episode.
This creates a confusing cycle of fear that isn’t caused by the actual triggers of their vestibular system but instead comes from how they see and connect their surroundings to their disorder.
Likewise, every time they find themselves in these settings, the neurons responsible for fear fire, and, whether the symptoms occur or not, they become wired to the neurons that perceive that specific environment. From then on, that environment will almost always trigger a fear response, regardless of whether the symptoms follow.
A personal reflection
Karen Mizrach, longtime “Tips & Tricks” columnist for On the Level, shares a personal reflection on hypervigilance, plus she offers her quick tips at the end of this article.
About five years into my vestibular experience, I started seeing a mental health counselor to help me cope with my health challenges. As I explained my journey to him, and how I was managing, he repeatedly said, “You are hypervigilant.” Once he explained what that meant, I repeatedly said, “No, I’m just careful.” It took me a while to understand that being constantly on guard, always anticipating symptoms, and being overly cautious, was actually a huge part of my problem. What a stunning insight, and one I am still learning from.
He explained over and over that keeping my brain on constant alert for danger could intensify my symptoms, and not allow my nervous system to reset or relearn. Now I still catch myself being hypervigilant, but I can back off, relax and just breathe. I now don’t expect disaster at every moment and at times even forget all about my crazy vestibular system.
Impact on Daily Life
Many people with a vestibular disorder cite the disruption of their daily life as the single most difficult symptom of these disorders. Ironically, hypervigilance in some people becomes even more disruptive than the disorder itself.
Not only will they find themselves actively avoiding activities or settings they once fully enjoyed, but they will do so with the misguided belief that not doing so would lead to more symptoms.
The main issue with this strategy is that it only reinforces the association between those conditions and their vestibular disorder, thereby strengthening the perceived threat associated with those activities or settings.
Even if a hypervigilant person were hypothetically “cured” of their vestibular disorder, their fear response would likely remain, as it was directly wired to the perception of the environment rather than the disorder itself.
Hypervigilance in Research
This phenomenon was directly observed in orthopedic patients with “acute lower back pain” who qualified as hypervigilant, developing into “chronic lower back pain” without any anatomic or physiologic changes.3 Researchers from this study were even able to “predict” which acute-state patients would develop into chronic-state solely based on their vigilance level.3
Although under-researched, the disorders of the vestibular system play by the same rules. It’s not necessarily about the disorders themselves; it’s the person’s fear of their symptoms that disrupts their daily life.
The Stoplight Method
There are many techniques utilized by neuroscience to alleviate hypervigilant behaviors. For example, using the “stoplight method,” a person identifies settings or stimuli they experience regularly. They then identify which settings and stimuli are “green lights” (unlikely to trigger symptoms), “yellow lights” (moderately likely to trigger symptoms), and “red lights” (most likely to trigger symptoms). The key is not to eliminate red lights from their daily life; it is to recognize their existence and have the capacity to narrow down the instances in which vigilance is moderately warranted.
Additionally, patients who have completed this “categorization” process can strategically implement slow, incremental, and safe exposures to red lights, so they do not strengthen the association between those lights and their symptoms. In this method, hypervigilance serves as a tool for exposure therapy rather than a means of fear-based hyperfocus on their condition.
Karen’s Quick Tips
Expect to be ok sometimes – There is a fine line between awareness of your body and constant monitoring of symptoms. Definitely know your body, and learn about your triggers, but accept that those situations will not always be a problem.
Show your brain there is other stuff going on in the world – When you catch yourself obsessing on what could happen, slow your breathing and focus on something else. Notice your surroundings that are safe – like a beautiful view or interesting people or music that is upbeat/soothing, or try to think about an upcoming task (not vestibular related) and brainstorm options.
Talk to your brain – “Hey, we’re going to be fine. This is safe. We’ve got this. Let’s just try this a different way and see what happens.”
Exercise – Find a safe space – whether it’s in a chair, or a gym, or a pool, or on a track, get your body moving. Show your brain that you can move and get stronger. Instead of letting your brain convince you everything is scary and dangerous, flip it and tell your brain what’s what. Yes, it’s a bit of a mind game.
And, as always, eat right, sleep well, spend time with other people, take care of your body and mind as best as you can.
Final Thoughts
Hypervigilance is often overlooked and unaccounted for. People with vestibular conditions are typically instructed to identify their triggers, but ironically, will sometimes feel they need to “live inside of” the constant awareness of those triggers. Recognizing the concept of hypervigilance and understanding when this methodology becomes destructive is paramount to the person’s ability to live a fulfilling, minimally limited life while taking decision-making power away from their disorder.
Author: Sam Tunney, M.D. Candidate University of South Carolina School of Medicine Columbia
References
- Ellmers TJ, Kal EC. Exploring the role of attention towards balance in chronic dizziness: Development of the Balance Vigilance Questionnaire. Eur J Neurol. 2024 Mar;31(3):e16148. doi: 10.1111/ene.16148. Epub 2023 Nov 28. PMID: 38015469; PMCID: PMC11235928.
- Keysers C, Gazzola V. Hebbian learning and predictive mirror neurons for actions, sensations and emotions. Philos Trans R Soc Lond B Biol Sci. 2014 Apr 28;369(1644):20130175. doi: 10.1098/rstb.2013.0175. PMID: 24778372; PMCID: PMC4006178.
- Zhang W, Löffler M, Usai K, Mišić M, Nees F, Flor H. Hypervigilance to Pain May Predict the Transition from Subacute to Chronic Back Pain: A Longitudinal Observational Study. J Pain Res. 2025 Jun 25;18:3141-3158. doi: 10.2147/JPR.S512911. PMID: 40584771; PMCID: PMC12206421.
