REFERENCE · RECOVERY TECHNIQUE
Working With Worry and Attention During Vestibular Rehabilitation
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When this may fit: When symptom-related worry, constant monitoring or an assessed avoidance pattern makes rehabilitation harder and the person wants help with it. [Emerging CBT-informed package evidence; not proof of psychological causation]
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For the Person With FND
After enough frightening episodes, it is understandable to wonder whether the next movement will go badly. You might hold yourself very stiffly, watch your balance constantly or avoid an activity you still want to do. Those experiences deserve care without being blamed for the whole condition.
What does psychologically informed mean?
It means bringing agreed psychological strategies into physical rehabilitation. Cognitive behavioural therapy (CBT) explores relationships between interpretations, feelings and actions. In a dizziness programme, that might mean noticing a prediction about falling and designing a safe, supported task to explore it.
The aim is not to persuade you that dizziness is imaginary. Psychological distress is not required for PPPD, and treatment benefit would not prove that thoughts caused it. A real fall risk must be addressed before calling a concern excessive. [1]
What a session could look like
- Describe one difficulty in your own words, including what you expect, what actually happens and which supports you need.
- Agree whether attention, worry or avoidance seems relevant. If it does not, choose another target rather than forcing this explanation.
- With the therapist, select a low-risk activity and keep the agreed physical supports. For example, practise a familiar turn with guarding while attending to the destination rather than repeatedly judging every sensation.
- Discuss both useful and difficult results. Stop an experiment that becomes repeated self-testing, increases distress or undermines safety.
This example illustrates collaborative therapy; it is not the INVEST trial protocol. Psychological work should remain within the professional’s training and your consent.
Where does ACT fit?
Acceptance and commitment therapy (ACT) helps people make room for difficult experiences while taking steps towards what matters. It may be discussed as part of care, but the CBT-informed trial cited here does not establish ACT-specific benefit for PPPD. Acceptance does not mean tolerating an unsafe task or giving up on medical care.
During a familiar flare
Use a simple agreed phrase, an accessible plan or help from someone you trust if that is useful. You do not have to analyse your thoughts while overloaded. If this approach makes you feel blamed, tell the team and ask for the formulation to be reconsidered.
When to stop and seek assessment
Stop unsafe activity. Sudden or distinctly different dizziness with new weakness, double vision, speech trouble, inability to walk, severe headache, fainting or chest pain needs urgent assessment. Sudden hearing loss, head injury or persistent vomiting also needs prompt medical attention. Increasing falls or progressive loss of function warrants reassessment. Existing PPPD does not explain every new symptom. See the diagnostic and differential-assessment page.
For the Person With FND
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For Family, Friends, and Other Supporters
Listen before offering reassurance or encouragement. Ask whether the person wants help with a coping strategy, practical assistance or simply company. Do not use therapy language to dismiss symptoms or withhold aids.
During a familiar flare, follow the agreed support and safety plan. Ask before taking over. New or substantially different symptoms need their own assessment; an exercise should never delay that care.
For the Person With FND
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For Clinicians and the Care Team
Use a shared formulation and consent for behavioural experiments. Establish actual vestibular, visual, cardiovascular and fall constraints first. The INVEST programme used CBT-informed vestibular physiotherapy rather than generic psychotherapy. Its eligibility restrictions, including frequent migraine and active competing conditions, limit generalization to complex patients. Assess burden and adverse effects and preserve access support.
Agree an accessible next step and review point. Consider meaningful activity, safety, access, effort and delayed effects alongside dizziness severity. Limited improvement is not grounds to withdraw assistance or infer lack of effort.
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Research and Sources
This page expands original entry 8, Psychologically informed vestibular rehabilitation. Examples and practical prompts are educational adaptations, not patient quotations or a reproduced treatment protocol. Original-entry numbering does not imply thirteen independently validated treatments.
INVEST randomized 40 adults to six sessions of integrated CBT-VRT or time-matched VRT, with four-month outcomes. Findings supported feasibility and suggested possible benefit; it was not powered for definitive efficacy. No intervention-related serious adverse events were reported, which does not establish universal safety. Neither component efficacy nor ACT efficacy can be inferred.
| Citation | Source | What it supports and its limits | Figure |
|---|---|---|---|
| 1 | FND-CIT-0192 — Herdman D, Norton S, Murdin L, Frost K, Pavlou M, Moss-Morris R. The INVEST trial: a randomised feasibility trial of psychologically informed vestibular rehabilitation versus current gold standard physiotherapy for people with Persistent Postural Perceptual Dizziness. Journal of Neurology. 2022;269:4753–4763. DOI. | Small feasibility comparison of treatment packages; does not establish component efficacy or ACT benefit. | — |
| 2 | FND-CIT-0040 — Webster KE, Kamo T, Smith L, et al. Non-pharmacological interventions for persistent postural-perceptual dizziness (PPPD). Cochrane Database of Systematic Reviews. 2023;3:CD015333. DOI. | Strict comparator and follow-up criteria left very limited evidence; not proof that rehabilitation cannot help. | — |
Sources checked: September 22, 2026 · Vestibular, neurological, lived-experience and accessibility review pending
For the Person With FND
For Family, Friends, and Other Supporters
For Clinicians and the Care Team
Research and Sources
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