Holistic Medical-Psychological Treatment Principles for Audio-Vestibular Disorders - The Copenhagen Audio-Vestibular Approach (CAVA)

Some of the most challenging disorders to treat are seen in patients with severe tinnitus or dizziness. The diagnoses are often difficult to investigate and thus treat the patients for. Medication or surgery is far from always a solution. Ear doctors therefore often face frustrated and bewildered patients who are mentally burdened by both the uncertainty and the experience that their symptoms from the inner ear are neither understood nor believed, and symptoms that can also have significant consequences for the patient both socially and in terms of the patient’s work. Similarly, this is seen in motion sickness, where the anxiety of being exposed to diseaseinducing transportation triggers dizziness-like symptoms and anxiety. Anxiety activates the Amygdala, a central part of the brain’s fear center, which in turn releases stress hormones (so one can flee or fight against the danger), resulting in an increased experience of symptoms. This often leads to a persistent focus on/fear of the symptoms, with resulting fatigue, difficulty concentrating, physical inactivity, and social withdrawal - often leading to social decline as a consequence. These patients thus pose a particular problem in the healthcare system.

To address the treatment-resistant more severely affected audio-vestibular patients, we have had success in Copenhagen over the past 25 years with consultations where a psychologist with specialized knowledge and interest in audio-vestibular disorders also participates. The idea has been to help patients with the challenges they face both physiologically, socially, and mentally.

Experience shows that one of the most important things is simply listening to the patient’s complaints. It is important for the patient to feel taken seriously. What matters most to the patient mentally is only found out by taking the time to listen carefully during the very first consultation.

It is important for the patient to understand what both a possible vestibular diagnosis entails and how this affects the patient mentally. This gives the patient an understanding of the measures needed to improve the situation. This knowledge motivates the patient to do what is necessary for the best possible rehabilitation, such as specialized physiotherapeutic balance training (which often immediately triggers dizziness). It is our experience that the interaction between the doctor and the psychologist is also important here: What one says is supported and elaborated on by the other - but with different words and based on their respective expertise. Through this, there is a greater likelihood that the patient will grasp the messages and experience hope and courage, providing a basis for further treatment. The interdisciplinary collaboration also helps to open up a description of where the symptoms are experienced as challenging in everyday life, perhaps even anxiety-provoking and limiting to the quality of life. Through this, these issues can be addressed and reduced.

This patient group often experiences a sense of isolation and loneliness, especially if there is also a concomitant significant hearing loss. This is seen in the long term in conditions like Meniere’s disease or more suddenly as in Sudden Deafness, where there can also be severe tinnitus. Here, patients also often talk about grief, loss of identity, meaning, direction in life, and thus about a fundamentally reduced quality of life due to the symptoms. Existence is challenged, and it is difficult for the patient to find a way towards a good life. Here too, the interaction between the ear doctor and the psychologist is of great importance.

It is important to provide the patient with information about where to get help to move forward. Unfortunately, this often falls through, and the patient repeatedly seeks out the ear doctor. It is important for the patient to receive specific advice on further assistance based on in-depth questions that uncover any hidden angles in the patient’s disease management. If this does not happen, there is a risk of keeping the patient stuck in their challenges. Is there a need for a referral to physiotherapeutic, specialized balance training, assistance with hearing loss, or the need for psychological help in coping with tinnitus, anxiety, or depression, grief or a sense of meaninglessness? Is there something in the patient’s work life that contributes to maintaining the situation, such as being on sick leave or fearing a lack of understanding of the situation, etc.? Does the patient require professional support or an experienced and hopeful “peer” (former patient) that can provide support and hope to get through the illness crisis? Our experience is that patients in this group often need fairly extensive, interdisciplinary psychosocial support if they are to move forward despite their symptoms.

A small number of patients are so severely affected in their existence that psychological treatment is necessary. An existential phenomenological approach combined with knowledge and understanding of the symptoms is particularly suitable for this patient group. Again, the interaction between the ear doctor and the psychologist is important in helping the patient understand that mental factors can contribute to maintaining symptoms, and perhaps even exacerbating them, and that psychologists can empower the patient to move forward. Less frequently, in patients who have developed actual depression, there may even be a need for referral to a psychiatrist.

The Copenhagen Audio-Vestibular Approach (CAVA) with interdisciplinary psycho-medical consultations ensures that as much as possible of the patient’s complex situation is captured and addressed. Investing time at the patient’s initial consultation ensures that the patient is provided with the right treatment path, which the patient is also motivated for. Experience from our many years of interdisciplinary psycho-medical consultations in Copenhagen also shows that a holistic approach helps patients find a way back to a normal, active social life despite episodes of dizziness, balance problems, and tinnitus [1-4].

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No conflicts of interest.

1. Dauman N, Erlandsson S I (2012) Learning from tinnitus patients' narratives: A case study in the psychodynamic approach. Int J Qual Stud Health Well-being 7(1).
2. la Cour P (2025) Introducing Existential Health: The Four-Dimensional Model. Routledge. SOMECAM. (n.d.). Sense of coherence and meaning in life.
3. Spinelli E (2014) Practising Existential Therapy: The Relational World (2^nd). SAGE Publications Ltd.
4. van Deurzen E (2010) Everyday Mysteries: A Handbook of Existential Psychotherapy (2^nd). Routledge.