Dr Beh is Assistant Professor of Neurology, Director, Vestibular and Neuro-Visual Disorders Clinic, University of Texas Southwestern Medical Center at Dallas.
A 68-year-old woman with symptoms of vertigo had seen her internist, who referred her to an otolaryngologist. She was subsequently sent to a neurologist who ultimately referred her for tertiary neuro-otology evaluation with me.
She had a year-long history of intermittent attacks of vertigo, which she described as feeling like she was “being grabbed and thrown around by the devil.” They occurred episodically and were brief but unpredictable, and so violent that she was terrified that she would die. She was unsure of any specific triggers. There were no associated symptoms whatsoever.
The patient lived in such utter fear of the vertigo that she walked and moved very slowly. She withdrew from any social, family, and leisure activities and became housebound. As a consequence, she became extremely depressed and frequently expressed a preference to die during her visit. “I’m just so afraid of the vertigo that it would be better to be dead than to continue living like this,” she told me. She quickly added that she was not suicidal because that went against her religious beliefs. She had no relevant medical, family, or social history.
Previous laboratory investigations, video nystagmography, caloric testing, and brain magnetic resonance imaging were unremarkable.
I was puzzled by the patient’s description of symptoms, and I proceeded with the examination to see if I could glean any clues. Her neurologic examination only revealed a very cautious gait. I proceeded to examine her ocular movements with infrared video-oculography. In the upright position, no nystagmus was observed. In the right Dix-Hallpike position, she developed upbeat and right torsional nystagmus associated with her typical vertigo, which caused her to scream loudly. She calmed down as the vertigo subsided after 20 seconds.