The symptom of dizziness represents a nonspecific complaint that has a broad differential diagnosis. Otolaryngologists naturally focus on the inner ear as the source of the complaint. However, if a patient with dizziness is to be diagnosed accurately and treated effectively, then it is incumbent on the clinician to recognize that dizziness can also be a manifestation of underlying neurological, cardiovascular or psychiatric pathology. In addition, it has long been recognized that psychopathology can produce a sensation of dizziness. It is helpful to approach a patient complaining of dizziness in a manner analogous to the approach taken when evaluating a patient presenting with chest pain. Although the initial reflex may be to focus on a cardiac etiology; gastrointestinal, musculoskeletal, and psychologic pathology may also result in chest pain.

It cannot be overemphasized that eliciting a precise description of the dizziness from the patient is the critical factor in delineating the specific diagnosis. The specific symptoms described by the patient allow the clinician to categorize the of dizziness (eg, true vertigo, lightheadedness, presyncope, positional imbalance, ataxia); the severity of the dizziness; factors that provoke or ameliorate the dizziness; and any associated symptoms. At times, this description of dizziness is precise and easy to elicit. There are patients, however, who despite the interviewer’s best efforts can only describe a vague sensation that defies a precise medical definition. Rather than become frustrated with the patient’s inability to articulate a clear description of his or her dizziness, Barber pointed out that such vague symptoms may be evidence, within the first few minutes of the interview, of a psychiatric etiology. Such vague symptoms of chronic heavy headedness, lightheadedness, tightness in the head, and the floor rising and falling are the hallmark of what he and others referred to as “psychogenic dizziness.”

Recognizing that psychiatric factors may have an important role in certain symptoms of dizziness is an important step in counseling patients and avoiding unnecessary medical and surgical procedures. This level of understanding of the disease process, however, has certain limitations. Too often patients are left with the impression that psychogenic dizziness is a diagnosis of exclusion. Simply referring to a process as psychogenic provides no insight as to which of the myriad of potential psychiatric diagnoses are responsible for the symptoms. Furthermore, psychiatric processes may be a cause or consequence of dizziness. They may trigger sensations of dizziness or sustain chronic symptoms following transient medical events. Because successful treatment is predicated on an accurate diagnosis, the need for better diagnostic precision is required.

Approximately 10 years ago the authors set out to better define the entity that was referred to as “psychogenic dizziness.” To that end, they endeavored to (1) provide an accurate and reproducible set of diagnostic criteria; (2) delineate the underlying etiologies for the disorder (eg, provide specific psychiatric and medical diagnoses and understand their potential interactions); (3) establish an effective treatment strategy for these patients; and (4) provide a theoretic framework for understanding this disorder that facilitates future research. Their work has resulted in the definition of a clinical entity they refer to as “chronic subjective dizziness” (CSD).