Last week, we looked at papers which, using qualitative methods, summarized key themes based on the lived experience of persistent dizziness [1-5]:

• disrupted agency / identity
• invalidation
• difficulties interpreting symptoms
• uncertainty about the future
• emotional distress
• a persistent struggle for control and coherence

We then asked,

Are our current conceptual models and their generative treatments sufficient to integrate and address these complexities?  

Being influenced by de Haan (2020) [6], I have come to believe that an integrative approach to anything is not merely attending to its components  (‘psychosocial barriers’ + ‘vestibular symptoms’), at least without understanding how they fit into the whole situation.  Rather, we need a model or framework “big enough” to hold a whole person (dizzy or not) with all of their complexities. An ‘enactivist’ framework seems to be sufficiently encompassing to help us here. Enactive approach casts the person as an embodied agent, embedded in their environment and engaged in actively making sense of their internal and external “worlds.” [6]

The person with persistent dizziness is struggling to make sense of their internal and external worlds.

• What is happening to me?
• Why doesn’t anyone understand?
• Will I ever recover?
• I used to be so independent…

In a word: Uncertainty

Make it make sense….

The process of resolving uncertainty (sense-making) is well characterized by active inference [7-8]. Active inference is a theory that further elaborates on the sense-making process.  Sense-making is fundamental to the lived experience of (anything like) persistent dizziness, which “makes sense” given that perception itself is a sense-making process. Perception is not a process of assembling our experienced reality “pixel by pixel” from incoming sensory data, rather it’s a process of modeling, predicting, comparing, and updating the model based on how accurate its predictions were.  In active inference, which is a generalization of predictive processing (coding), the person is an autonomous agent “in the game of” actively minimizing the discrepancy between their model of the world, that is their beliefs or predictions (expectations), and sensory inputs. This discrepancy is encoded as a “prediction error,” or simply something unpredicted by the model.  Importantly, this process is hierarchical, linking our subconscious “beliefs” (e.g., “my vision remains stable when I move) with conscious beliefs (e.g., “I have good balance.”).  The more confidence one has in these beliefs, the more the beliefs are supported, meaning evidence to the contrary (prediction errors) is minimized. For example, postural sway is typically not felt, because it’s not relevant to the person whose beliefs are that they are “well balanced.”  This stands in contrast to the experience of the person with persistent dizziness, who has acquired uncertainty about their perceptual stability.  Attempting to resolve this uncertainty, the same degree of postural sway is afforded greater precision (or attention). Thus, the person becomes understandably stuck in a state of unresolved uncertainty. As the uncertainty (prediction errors) ascends the hierarchy to deeper levels of consciousness without resolution, it manifests as emotions (“I don’t know what to do about this”-anxiety or “maybe I’m no longer the kind of person who is in control”-depression) [9]. Thus, unresolved uncertainty seems to be the theme throughout the hierarchy and manifests in accordance with the system involved-perceptual, motor, interoceptive, etc.

What do you think?

Does enactivism, elaborated by active inference offer us an appropriate conceptual model of persistent dizziness?

Is the person with persistent dizziness having a hierarchical crisis of uncertainty?

If not, what’s going on?

If so, then what do we do about it?

Do the factors in bold offer us a signpost for treatment?

I have more questions than answers.

I’d love to hear from you.  If you’d like to engage in this discussion, consider joining our “Integrative Circle” community on Slack.  If that’s not your thing, but you want to chime in, leave a comment in response to the blog post.  

All the best,

Marc

References

1. Gamble, R., Sumner, P., Wilson-Smith, K., Derry-Sumner, H., Rajenderkumar, D., Powell, G.: Using interpretative phenomenological analysis to probe the lived experiences of persistent postural-perceptual dizziness (PPPD). Journal of vestibular research : equilibrium & orientation. 33, 89–103 (2023). https://doi.org/10.3233/VES-220059.

2.  Sezier, A.E.I., Saywell, N., Terry, G., Taylor, D., Kayes, N.: Working-age adults’ perspectives on living with persistent postural-perceptual dizziness: a qualitative exploratory study. BMJ open. 9, e024326 (2019).  https://doi.org/10.1136/bmjopen-2018-024326.

3.  Olsson Möller, U., Hansson, E.E., Ekdahl, C., Midlöv, P., Jakobsson, U., Kristensson, J.: Fighting for control in an unpredictable life – a qualitative study of older persons’ experiences of living with chronic dizziness. BMC geriatrics. 14, 97 (2014). https://doi.org/10.1186/1471-2318-14-97.

4.  Kruschinski, C., Theile, G., Dreier, S.D., Hummers-Pradier, E.: The priorities of elderly patients suffering from dizziness: a qualitative study. The European journal of general practice. 16, 6–11 (2010). https://doi.org/10.3109/13814780903479914.

5.  Mendel, B., Lützén, K., Bergenius, J., Björvell, H.: Living with dizziness: an explorative study. Journal of advanced nursing. 26, 1134–1141 (1997).  https://doi.org/10.1111/j.1365-2648.1997.tb00805.x.

6.  de Haan, S.: Enactive psychiatry. Cambridge University Press. (2020). https://doi.org/10.1017/9781108685214.

7.  Friston, K.J., Daunizeau, J., Kilner, J., Kiebel, S.J.: Action and behavior: a free-energy formulation. Biological cybernetics. 102, 227–260 (2010).   https://doi.org/10.1007/s00422-010-0364-z.

8.  Pezzulo, G., Parr, T., & Friston, K.. Active inference as a theory of sentient behavior. Biological Psychology, 186, 108741 (2024). https://doi.org/10.1016/j.biopsycho.2023.108741

9.  Seth, Anil K., and Karl J. Friston. Active interoceptive inference and the emotional brain. Philosophical Transactions of the Royal Society B: Biological Sciences 371.1708 (2016): 20160007.