Why Does Anxiety Make My Dizziness Worse? Understanding PPPD, the Vestibular System and the Brain

Sep 18

12 min read

Balance Awareness Week 2026

It’s Balance Awareness Week, so I thought I’d take the opportunity to talk about something that comes up a lot in my work with people experiencing PPPD and persistent dizziness: the relationship between the vestibular system, the brain, anxiety and the way we respond to our symptoms.

If you’ve ever experienced dizziness, you’ll probably know just how difficult it can be to explain to somebody who hasn’t experienced it themselves. You can look completely fine on the outside while feeling as though the floor is moving, you’re walking on a boat, your balance doesn’t feel quite right, or the whole supermarket has suddenly become far too busy for your brain to deal with. And then, of course, you might have had somebody say, “But your tests are normal.” That can leave you thinking, well, if everything is normal, why on earth do I feel like this?

This is where understanding the vestibular system, the brain and the nervous system can be really helpful. The vestibular system isn’t simply your inner ear. It’s a much bigger network involving the inner ear, the vestibular nerve, the brainstem, the cerebellum, the eyes, information from the rest of your body and different areas of the brain that help you make sense of where you are and what is happening around you. Once we add anxiety, attention, previous experiences and the brain’s threat system into the mix, things become even more interesting.

So, what actually is the vestibular system?

The vestibular system is one of the systems that helps your brain understand movement, balance and where your body is in relation to the world around you. Part of it sits inside your inner ear and includes the semicircular canals and the otolith organs. These structures detect different types of movement, including changes in head movement and position, and send information through the vestibular nerve towards the brain.

That information then travels into areas of the brainstem known as the vestibular nuclei and onwards to other parts of the brain. These pathways are involved in things such as controlling eye movements, maintaining posture, coordinating movement and helping us stay oriented in space. One particularly clever part of this system is the vestibulo-ocular reflex, or VOR, which helps keep your vision stable when your head moves. Thankfully, we don’t have to consciously think about any of this while we’re walking around doing the school run or trying to find the car in a supermarket car park.

The vestibular system also doesn’t work in isolation. Your brain is constantly taking information from your vestibular system and combining it with what you can see, information coming from your muscles and joints, and other sensory information from your body. All of this helps your brain build an ongoing picture of where you are and what is happening around you.

Your brain has a lot more information to work with than just your ears

This becomes particularly important when we start talking about PPPD. Your brain has to decide how much weight to give different sources of sensory information, and this can change depending on what is happening. For example, if the information coming from your balance system feels unreliable, your brain may start relying more heavily on visual information. This is sometimes described as sensory reweighting or increased visual dependence.

This can help explain why environments such as supermarkets, shopping centres, busy streets or places with lots of movement can feel particularly difficult for somebody with PPPD. There is a huge amount of visual information coming towards you, and your brain is having to process all of it while also trying to work out where your body is in space. What might once have been an ordinary trip to the shops can suddenly feel like your brain has been given far too many tabs to keep open at once.

PPPD, or persistent postural-perceptual dizziness, is a recognised functional vestibular disorder. The symptoms are real, and the fact that routine tests may not show a structural abnormality does not mean that nothing is happening. The diagnostic criteria developed by the Bárány Society describe PPPD as a condition involving persistent dizziness, unsteadiness or non-spinning vertigo that is typically made worse by upright posture, movement and exposure to complex or moving visual stimuli.

This is important because PPPD is sometimes misunderstood as simply being anxiety. It isn’t as straightforward as that. Anxiety, attention, threat appraisal and previous experiences can all interact with how the brain processes sensory information, but that does not mean the dizziness is imaginary or that it has simply been caused by somebody worrying too much.

So where does anxiety come into all of this?

Imagine that you first become dizzy in a busy supermarket. Perhaps you were already feeling unwell, had experienced a vestibular problem, were recovering from an illness or had some other trigger. You suddenly feel strange, the floor doesn’t feel quite right and the lights and movement around you make everything feel worse. Understandably, your brain may interpret that experience as something it needs to pay attention to.

The next time you go into a supermarket, your brain may remember what happened previously. You might start monitoring how you feel as soon as you walk through the doors, checking your balance, looking for somewhere to sit, staying close to a trolley or wondering whether you will be able to get through the whole shop. None of this means you are doing anything wrong. In fact, these responses make a lot of sense when your brain believes that something might be dangerous.

The problem is that the more closely we monitor a sensation, the more noticeable it can become. Your attention starts to become focused on your balance, your vision, how your head feels and whether you are becoming dizzy. At the same time, the brain’s threat system can become more alert, particularly when previous experiences have taught it that certain situations might not be safe.

Current thinking around PPPD increasingly recognises the interaction between sensory processing, threat appraisal, attention, hypervigilance and avoidance. This doesn’t mean that anxiety causes every case of PPPD, and people can develop PPPD following a range of different precipitating events. It does mean that once persistent dizziness has developed, the way we attend to and respond to those symptoms can become an important part of the picture.

What do the amygdala and hippocampus have to do with it?

When we talk about anxiety, you’ll often hear the amygdala described as the brain’s “fear centre”. That description is a little too simplistic, but the amygdala is certainly involved in processing emotionally significant information and contributing to the brain’s threat response. It works as part of a much larger network rather than sitting there on its own shouting, “DANGER!” every time somebody walks into a supermarket.

The hippocampus is also involved because it helps with memory and context. Your brain can remember previous experiences and use that information when you encounter something similar in the future. If you have previously felt extremely dizzy in a particular environment, your brain may become more alert when you return to a similar situation, even before anything has actually happened.

This is one reason why people can sometimes feel anxious about dizziness before the dizziness has even properly started. The brain is very good at predicting what might happen next, and sometimes it gets a little overenthusiastic with that particular skill. If only our brains were always as sensible as we would like them to be.

And then the body gets involved

Once the brain detects a possible threat, the body can respond too. Your heart rate may increase, your breathing may change, your muscles may become more tense and you might feel hot, shaky, nauseous or light-headed. You may also become much more aware of sensations that you would normally barely notice.

These are genuine physical responses. They are not something you are imagining and they are not evidence that you are “making yourself dizzy”. The difficulty is that when you already have a sensitive or unpredictable vestibular system, additional physical sensations can make it even harder to work out what is happening.

You might notice your heart beating faster and think something is wrong. You might feel slightly light-headed and immediately check whether your balance is okay. You might notice visual movement and become more alert to every sensation in your head. The more threatening those sensations feel, the more closely you may monitor them, which can keep the whole system switched on.

This is where the CBT cycle can start to develop

This is where CBT can be particularly useful, because we can start looking at what happens around the dizziness rather than simply trying to get rid of the dizziness itself. For example, you might notice a sensation of unsteadiness in a busy environment and immediately think, “I’m going to lose my balance.” That thought can understandably increase fear and alertness, which may then lead to more physical sensations and even greater awareness of the original dizziness.

You might then start doing things to make yourself feel safer. Perhaps you hold tightly onto the trolley, avoid looking around, leave the shop as quickly as possible, only go shopping when somebody else is with you or repeatedly check how steady you feel. These behaviours can be completely understandable and may give you some relief in the moment, but they can also prevent your brain from learning that you are capable of coping with the sensations without needing all of those safety behaviours.

Over time, the brain can learn that the situation was dangerous because you escaped, avoided it or needed a particular safety behaviour to get through it. That can make the next supermarket trip feel threatening before you have even walked through the door. Not everybody with PPPD experiences this cycle in exactly the same way, and PPPD is a complex condition, but for some people these patterns can become an important part of what keeps the symptoms going.

So where does CBT fit?

CBT is not about telling somebody that their symptoms are “just anxiety”. It is certainly not about looking at a person who feels dizzy and saying, “Your tests are normal, so there’s nothing wrong with you.” That would completely miss the point of what the person is actually experiencing.

Instead, CBT gives us a way of looking at the relationship between symptoms, thoughts, attention, emotions and behaviour. We can explore what you are predicting will happen, what you are paying attention to, what you do when you feel dizzy and whether you have gradually started changing your life to avoid situations that feel difficult.

Sometimes the things people do to cope with dizziness make perfect sense. If you feel unsteady, holding onto something feels sensible. If a busy supermarket makes you feel awful, avoiding it feels like a reasonable way of preventing that awful feeling. The difficulty is that something which helps you feel safer in the short term can sometimes stop your brain from learning that the situation is actually manageable.

This is where CBT becomes much more than simply talking about your thoughts. We can begin to test some of the predictions your brain has developed and gradually give it new information.

What can we actually do about it?

One part of CBT can involve looking at where your attention goes. If you spend a lot of time checking your balance, monitoring your vision or scanning your body for signs that dizziness is getting worse, we can start practising a different way of directing your attention. This is not about ignoring your symptoms or pretending they are not there. It is about helping your brain become less consumed by monitoring them.

We can also look at safety behaviours and avoidance. Perhaps you have stopped going to certain shops, stopped driving, avoid busy places, need somebody with you whenever you go out or constantly hold onto things when walking. Rather than suddenly throwing you into the deepest end and telling you to get on with it, CBT can involve gradually working towards situations that have become difficult, at a pace that allows you to build confidence.

Behavioural experiments can also be useful. If your brain is predicting, “If I feel dizzy in the supermarket, I will lose my balance,” we can look at that prediction carefully and consider how we could test it safely. The aim isn't to prove that you will never feel dizzy again. It is to help your brain learn that feeling a sensation does not automatically mean that something terrible is about to happen.

Recovery from PPPD does not necessarily mean reaching a point where you never experience another moment of dizziness. For many people, the bigger change is that dizziness becomes less frightening and less controlling. You can begin doing things again without constantly wondering how your body is going to feel, and your world can gradually become bigger rather than smaller.

What does the research tell us?

The research into psychological approaches for PPPD is growing, although it is important to be honest about where the evidence currently stands. A 2024 meta-analysis found that adding CBT to conventional treatment was associated with additional improvements for people with PPPD, including measures of dizziness and psychological symptoms. However, the authors also highlighted the need for more high-quality randomised controlled trials.

There has also been research looking at psychologically informed vestibular rehabilitation. The INVEST study was a randomised feasibility trial comparing psychologically informed vestibular rehabilitation with standard physiotherapy for people with PPPD. The findings supported the feasibility and acceptability of the approach and showed promising changes, but it was a feasibility study rather than a definitive trial establishing effectiveness.

More recent evidence continues to show that this is an evolving area. A 2026 systematic review and network meta-analysis looking at non-pharmacological interventions for PPPD included 11 randomised controlled trials involving 518 adults. The authors concluded that the evidence base remains limited, with concerns about risk of bias across a number of studies and generally low to moderate certainty around the findings.

Recent clinical reviews have also highlighted the importance of understanding PPPD through mechanisms such as sensory reweighting, visual dependence, threat appraisal, attention and hypervigilance. This fits with the way I think about PPPD clinically: not as a condition that sits neatly inside one box, but as something where the vestibular system, brain processing, attention, emotions and behaviour can all influence the overall experience.

PPPD isn't “just anxiety”

I think this is one of the most important things to understand. PPPD is a recognised vestibular disorder and the dizziness and unsteadiness experienced by people with PPPD are real. At the same time, anxiety, threat processing, attention, avoidance and previous experiences can become involved in the way symptoms are maintained.

We sometimes talk about physical health and mental health as though they are two completely separate things, with a big dividing line between them. The reality is much messier, because our brains and bodies are constantly communicating with each other. Feeling physically unwell can make us anxious, anxiety can change what we notice in our bodies, and our previous experiences can influence how our brains interpret new sensations.

That doesn't mean everything is psychological. It means there can be several things happening at once. Understanding those different parts of the picture can be incredibly helpful because it gives us more options for treatment rather than leaving somebody thinking they simply have to put up with the symptoms.

And this is where recovery can start to feel different

Persistent dizziness can gradually change the way somebody lives their life. You might stop going to places you used to enjoy, reduce your activities, rely more heavily on other people or spend a huge amount of time thinking about how you feel. Before long, the dizziness can become the thing around which the rest of your life is organised.

CBT can help you start to understand those patterns and gradually make changes. We can look at the things your brain has learned to fear, the behaviours that have developed to keep you feeling safe and the ways your attention may have become focused on your symptoms. From there, the aim is to help you build confidence in your ability to cope, rather than constantly needing certainty that you will feel okay.

For some people, that shift can be really significant. The goal isn't to promise that you will never feel dizzy again or that every day will suddenly be perfect. It is about helping you feel that dizziness no longer has quite so much control over what you do.

Final thoughts

The vestibular system is an incredibly clever part of the body, but it is also just one part of a much bigger system. Your brain is constantly combining information from your inner ears, your eyes, your body and your previous experiences to work out where you are and what is happening around you. When persistent dizziness develops, that system can become more sensitive and more reliant on certain types of information, particularly when threat and hypervigilance become part of the picture.

Understanding this can sometimes be a relief. It means we don't have to choose between saying, “This is a physical problem” or “This is an anxiety problem.” We can recognise that the symptoms are real while also looking at the ways attention, threat processing, avoidance and behaviour may be influencing the experience.

And that is really where I see CBT fitting alongside vestibular and medical care. We are not trying to convince your brain that the dizziness isn't real. We are helping it learn that dizziness, movement, busy environments and uncomfortable sensations do not necessarily need to be treated as a threat.

If you are experiencing PPPD or persistent dizziness and feel that anxiety, avoidance or fear of your symptoms has started to take over, CBT may be one part of your recovery plan. At Pondering Therapies, I work with people experiencing PPPD and vestibular-related anxiety, using a tailored CBT approach that looks at the individual rather than simply applying a one-size-fits-all programme.

I offer sessions online, by telephone and in person. If you would like to talk through what you are experiencing and see whether CBT could be appropriate for you, you are welcome to get in touch for a consultation.