Neuroticism and functional burden in chronic dizziness: A clinical cross-sectional observational study using the Eysenck Model and Dizziness Handicap Inventory

Introduction

Dizziness ranks among the most frequent complaints in both primary care and specialist settings and has been associated with significant impairment in quality of life, work productivity, and psychological well-being. ¹ Patients may use the term ‘dizziness’ to describe a spectrum of sensations – including vertigo, light-headedness, disequilibrium, or general imbalance – reflecting both peripheral and central vestibular disorders, as well as non-vestibular causes such as cardiovascular, psychiatric, or functional aetiologies. ² This diversity complicates diagnosis, often leading to extensive investigations, fragmented referrals, and prolonged periods of uncertainty before an accurate clinical interpretation is achieved. ³

An emerging body of evidence suggests that for a subset of patients, particularly those with persistent or medically unexplained dizziness, psychological factors may play a pivotal role in symptom maintenance and perceived disability. ⁴ Functional vestibular disorders represent an important subgroup within this population. Persistent postural-perceptual dizziness (PPPD), for example, is a well-defined chronic functional vestibular disorder characterized by persistent non-vertiginous dizziness and hypersensitivity to motion and visual stimuli. ⁵ While PPPD is considered a subtype within the broader category of functional dizziness, the term ‘functional dizziness’ is often used more broadly to describe conditions in which symptoms are not fully explained by structural vestibular pathology but are influenced by central processing and psychological mechanisms. ⁶ Emotional vulnerability, cognitive misattribution of bodily sensations, and maladaptive coping strategies have been associated with chronic dizziness conditions, including persistent postural-perceptual dizziness (PPPD), functional dizziness, and somatoform vertigo.^5,6

The Dizziness Handicap Inventory (DHI) is a widely used, patient-reported outcome measure designed to quantify the impact of dizziness on physical, emotional, and functional aspects of daily life. The DHI has demonstrated strong internal consistency and satisfactory test–retest reliability for both the total score and its subscales. Its validity is supported by findings that higher DHI scores are associated with more frequent dizziness and greater functional impairment. ⁷ While the DHI captures the emotional consequences of dizziness, it does not assess underlying psychological traits or personality dimensions that may influence symptom perception. Previous studies have shown that high DHI scores often correlate with comorbid anxiety and depression, regardless of vestibular test findings. ⁸ This suggests that psychological factors may mediate the degree to which dizziness affects patients’ lives, highlighting the need for complementary measures that specifically assess psychological traits.

Personality dimensions, particularly neuroticism, have been shown to influence how individuals interpret, respond to, and manage health-related symptoms. ⁹ Neuroticism, characterized by heightened emotional reactivity and a tendency toward negative affect, is associated with increased somatic symptom awareness, health anxiety, and poorer outcomes across a range of chronic conditions. ¹⁰ Emerging evidence also suggests that personality traits may play a role in chronic dizziness and PPPD, with higher levels of neuroticism linked to increased symptom persistence, distress, and disability.^5,11–15 Despite this, much of the existing literature has predominantly focused on state-based measures of anxiety and depression rather than stable personality dimensions.

The Eysenck Personality Questionnaire-Revised (EPQ-R), grounded in a biologically based model of temperament, offers a structured means of assessing personality across three major dimensions: neuroticism, extraversion, and psychoticism. ¹⁶ However, relatively few studies have investigated the relationships between personality traits and dizziness -related handicap using both the EPQ and DHI. Existing work combining these measures remains limited, with most studies focusing on psychiatric comorbidity using instruments such as the Hospital Anxiety and Depression Scale (HADS), rather than trait-based personality constructs.^17–19

To date, there remains a gap in understanding how stable personality traits interact with perceived disability in patients with dizziness. Addressing this gap may have important clinical implications, as individuals with certain personality profiles may benefit from early psychological screening, targeted counselling strategies, and more integrative rehabilitation approaches.

This study aimed to investigate the relationships between psychological factors (neuroticism), functional impact (dizziness-related handicap), and physical and behavioural aspects (fall history and healthcare consultation behaviour) within a biopsychosocial framework. By exploring the associations between DHI scores, EPQ findings, and clinical characteristics, this study sought to enhance the understanding of psychological contributors to dizziness severity and to support earlier identification of patients at risk for chronicity or functional disability.

Methods

Sample

All adult patients (≥18 years) who completed both the DHI and the EPQ as part of their clinical evaluation were eligible for inclusion. A total of 247 patients met the inclusion criteria and their clinical data were included in the analysis.

Measures

Data analysis

The primary analysis focussed on the relationship between neuroticism and perceived dizziness-related handicap. Secondary exploratory analyses were conducted to examine associations between neuroticism and selected clinical characteristics, including consultation behaviour and fall history, to provide broader clinical context. These included group comparisons, correlation analyses, cluster identification, and regression modelling. Patients with combined central and peripheral diagnoses (n = 2) were excluded from subgroup analyses due to insufficient sample size. Subgroup analyses were therefore limited to diagnostic categories with sufficient sample sizes to ensure meaningful interpretation.

Results

The final dataset included 247 adult patients with complete DHI and EPQ-R neuroticism scores. The mean age of patients was 52.4 years (SD = 16.8; range 18–85), with 64% being female (n = 158) and 36% (n = 89) being male. The mean DHI score was 35.8 (SD = 18.3), indicating a mild-to-moderate functional burden overall. The mean EPQ-R neuroticism score was 9.4 (SD = 4.7), reflecting mild to moderate levels of emotional reactivity in the sample. Visual inspection of the data indicated no substantial deviations from normality for the main outcome variables, supporting the use of parametric analyses.

Discussion

Findings from the current study identified three clinically meaningful patient subgroups. One group, characterized by high DHI and neuroticism scores, frequently reported comorbid memory problems and anxiety treatment but had a relatively low fall history. This may reflect a subgroup experiencing high psychosomatic distress with limited objective imbalance. Conversely, another cluster with moderate DHI and low neuroticism showed a 100% fall history and frequent memory complaints, possibly indicative of physiologically driven impairment. The third, low-burden cluster reported few comorbidities and had the lowest DHI and neuroticism scores. These findings emphasize the clinical utility of multidimensional assessments in dizziness, supporting a biopsychosocial model of care. ²³

Neuroticism was found to be a significant predictor of dizziness-related handicap, with meaningful association between neuroticism and DHI scores. This aligns with previous research indicating that psychological factors, particularly trait anxiety and emotional instability, play a substantial role in modulating dizziness perception and disability.^14,24 This association suggests that individuals with higher neuroticism may experience increased emotional distress in response to somatic symptoms, potentially amplifying their perceived impairment even when objective vestibular findings are mild or absent.

Regression analyses confirmed that neuroticism significantly predicted DHI scores, whereas diagnostic category, symptom duration, and anxiety treatment were not significant predictors. However, the explained variance was modest (R² = 0.140), indicating that neuroticism accounts for approximately 14% of the variability in dizziness-related handicap. Hence, although emotional reactivity is a significant contributor, the majority of variance in DHI scores remains unexplained by the variables included in the analysis. These findings suggest that additional factors, such as vestibular impairment severity, visual dependence, cognitive load, coping strategies, illness perceptions, and environmental or contextual influences, likely contribute to dizziness-related disability. Similar findings have been noted in previous literature demonstrating that chronic dizziness is influenced by a complex interaction of vestibular, psychological, and behavioural factors rather than a single determinant.^5,10,14 Taken together, these findings reinforce that dizziness-related disability is multifactorial and cannot be attributed to a single psychological construct alone, supporting a biopsychosocial framework for assessment and management.

The significant association between neuroticism and diagnostic category observed in this study highlights the complex interplay between psychological traits and vestibular symptom presentation. In particular, patients with functional dizziness demonstrated a higher proportion of moderate-to-high neuroticism levels compared to other diagnostic groups. This is consistent with the conceptualization of functional vestibular disorders, including PPPD, as conditions in which persistent symptoms are shaped not only by vestibular mechanisms but also by maladaptive postural control, heightened threat appraisal, and altered sensory processing. ⁵

In contrast, patients with peripheral and non-vestibular conditions were more frequently represented within the mild neuroticism category, suggesting a comparatively lower contribution of enduring psychological traits to symptom perception in these groups. Patients with central vestibular disorders showed a more heterogeneous distribution across neuroticism levels, which may reflect variability in clinical presentation and individual psychological responses to neurological dysfunction. This interpretation is supported by evidence showing that psychiatric comorbidity differs across organic vertigo syndromes rather than occurring uniformly across diagnoses, and that persistent dizziness after vestibular disorders is associated with psychological strain as well as vestibular factors. ¹¹ One possible explanation for this heterogeneity in central vestibular disorders is the variability in lesion location, symptom unpredictability, and the involvement of neural systems linked to emotional regulation and sensory integration. Although this remains speculative in the present study, the broader dizziness literature supports the view that psychosocial factors such as stress, depression, and related emotional processes are meaningfully associated with chronic dizziness. ¹³

Importantly, while higher neuroticism was more prevalent in functional presentations, very high neuroticism scores were relatively uncommon across all diagnostic categories. This suggests that, although emotional reactivity contributes meaningfully to perceived disability, extreme personality profiles are not characteristic of the broader dizziness population. These findings support a biopsychosocial framework in which stable psychological traits interact with vestibular and neurological factors to influence symptom severity and functional impact. ⁵

Fall history and duration of symptoms were not significantly associated with neuroticism, nor did symptom duration predict DHI scores. The lack of association between symptom duration and perceived handicap may reflect adaptation over time or variability in individual coping mechanisms. This finding is consistent with some previous reports suggesting that chronicity alone does not necessarily predict perceived disability, although it contrasts with other studies that have demonstrated increasing handicap with prolonged symptom duration.^25,26 This discrepancy may reflect differences in patient populations, measurement approaches, or the influence of moderating psychological variables such as coping style and resilience. Notably, there was a relationship between fall history and DHI scores, suggesting that physical factors contribute to perceived disability, although this relationship appears to be modulated by psychological variables.

Overall, these findings highlight the importance of integrating psychological screening, especially for trait neuroticism, into the assessment of patients with dizziness. The results support targeting emotional processing and maladaptive coping styles in management strategies, particularly for patients with functional or centrally mediated dizziness. The limited predictive value of diagnosis category and symptom duration further underscores that psychological factors may, in some cases, supersede structural findings in determining patient outcomes. Although not central to the primary research question, exploratory analyses examining consultation behaviour and fall history were included to contextualize how personality traits may influence healthcare utilisation and symptom interpretation. These analyses should be interpreted cautiously, as hypothesis-generating rather than confirmatory findings.

Our study contributes to the growing evidence base advocating for multidisciplinary, person-centred approaches in vestibular rehabilitation. ²⁷ The integration of psychological constructs such as neuroticism into clinical dizziness research is not only timely but necessary. Current study findings align with a growing body of literature that suggests chronic dizziness cannot be comprehensively managed using only biomedical models.^4,28,29 Patients with similar objective vestibular test outcomes may report markedly different levels of disability due to variations in emotional and cognitive responses. This is particularly evident in individuals with high neuroticism, who may demonstrate increased vigilance toward bodily sensations, health-related anxiety, and catastrophizing – all of which are known to influence symptom perception and distress. Given the cross-sectional design, these findings should not be interpreted as indicating that neuroticism causes increased dizziness-related disability, but rather that these variables are significantly associated.

Limitations

This study has several limitations that should be considered. Firstly, the cross-sectional design precludes any conclusions regarding causal relationships between neuroticism and dizziness-related handicap. While higher neuroticism was associated with increased perceived disability, the direction of this relationship remains unclear. It is plausible that neuroticism represents a predisposing vulnerability; however, it is equally possible that persistent or severe dizziness contributes to increased emotional distress and elevated neuroticism scores over time. Secondly, the relatively small sample sizes within certain diagnostic subgroups may have limited statistical power to detect more subtle between-group differences. Thirdly, in more recent literature, different cut-off values have been used for the DHI, with a cut-off of 30 being frequently applied.^31–35 Findings from this study and other literature need to be viewed in light of these differences due to the absence of a universally accepted classification system. Fourthly, the regression model accounted for only a modest proportion of the variance in DHI scores, suggesting that additional factors – such as vestibular impairment severity, visual dependence, coping strategies, and contextual influences were not captured in the current study. Furthermore, the use of K-means clustering with mixed variable types represents a methodological limitation, as Euclidean distance may not optimally capture similarity when binary variables are included. Alternative approaches, such as Gower distance-based clustering or k-prototypes, may provide more robust modelling of mixed data. As such, the identified clusters should be interpreted as exploratory and hypothesis-generating rather than definitive classifications. Finally, the reliance on self-report measures may introduce response bias, particularly in the assessment of psychological constructs and perceived functional burden. Future research should employ longitudinal designs and incorporate a broader range of clinical and psychosocial variables to better elucidate the complex and potentially bidirectional interactions underlying dizziness-related disability.

Conclusion

This study contributes to the understanding of how personality domains, specifically neuroticism, interact with dizziness-related handicap and clinical features in chronic dizziness. Findings underscore the need to incorporate personality profiling and psychosocial support into the diagnostic and management framework for patients with chronic dizziness. Future research should investigate whether interventions targeting emotional regulation and maladaptive illness beliefs can reduce symptom persistence and improve quality of life in this population.