Balance disorders: causes and therapy

Balance disorders are common. There are many reasons for this, and therapy requires an exact diagnosis, because doctors quickly misinterpret the symptoms. Hearing and balance tests are just as much part of the diagnosis as blood tests.

The organ of balance

Our organ of balance is in the inner ear and is called the vestibular apparatus. Together with eyes, it registers changes in position and movements. This enables us to orientate ourselves in space. There are also receptors on the surface of the body that sense temperature, touch, vibrations and pain.

There are three arches in the equilibrium organ. These are at 90 degrees to each other and thus recognize the three dimensions of the room. The two atrial sacs hold the sensory fields with which we estimate speeds.

The sensory fields perceive the linear velocities, through hairs that protrude into a jelly-like mass. On it are the otoliths, crystals of calcite. If the zempo changes, the jelly moves, causing the hairs to bend and stimulate the sensory cells. The sensory cells then pass the information on to the cerebellum. This implements the information, for example by changing the direction of the eyes. This process cannot be controlled at will.

In the arcades, on the other hand, there are sensory cells that recognize rotational speeds. The hairs also protrude into a jelly mass here. If we turn, the position of the jelly changes and the sensory hairs bend; this is transferred to the sensory cells and they also pass the signals on to the cerebellum. This reacts reflectively, for example by moving your eyes quickly.

By perceiving rotational movements, we can see a hitchhiker on the roadside, for example, when driving a fast car.

Balance disorders

If the balance organ is damaged, these reflexes no longer work. Balance disorders appear as dizziness, confusion, or dissociation. The person concerned cannot keep on his feet, he stumbles and falls, he does not know where is up and down. The triggers are often harmless: someone has drunk too much alcohol, the ground sways on a ship, or traveling in a roller coaster disrupts the interaction between body, nerves and brain.

If such factors fail, serious illnesses can be behind the balance disorder:

- High blood pressure

- Metabolic disorders and low blood sugar

- cardiovascular diseases

- Low blood pressure

- concussion and trauma

- sunstroke

- inner ear infection

- hyperventilation

- Inner ear disease

- Side effects of antibiotics

- eye diseases

- meningitis

- stroke

- Tumors in the ear and eye

- neurological diseases

- Parkinson's

- Multiple sclerosis

The physical balance is influenced by the integration of sensual information into the nervous system. Every conflict between this information, i.e. every blockage, causes changes in the physical balance.

With age, the sensory systems suffer from an accumulation of degenerative, infectious and traumatic processes that hinder their functioning. Although an isolated change in part of the nervous system does not result in overall instability, a combination of these neurological disorders is the key factor in balance problems in the elderly.


Dizziness is one of the most common ailments that people go to the doctor for. This includes apparent movements of the environment as well as problems standing and walking, the feeling of passing out, but also swaying, stumbling and falling.

These dizziness have a variety of causes: disorders of the balance organ as well as visual disturbances, circulatory problems, inflammation of the nervous system, diseases of the metabolism, and, very often, psychological problems.

The dizziness significantly affects those affected, even if the trigger is harmless. They can no longer do a lot of physical work, for example not climbing scaffolding and driving certain vehicles, and mental workers suffer from their concentration.

Persistent dizziness can also anchor itself psychologically, which is also difficult to define diagnostically. Balance disorders are generally difficult to detect with modern methods such as computer tomography, ultrasound and magnetic resonance - in 80% of all dizziness symptoms.

So the doctor himself is asked: his knowledge of the symptoms of equilibrium disorders, his precise analysis of the symptoms and the patient's history determine the correct diagnosis.

Further studies show functional disorders of the sensory organs that carry the balance system, i.e. the balance organ, the eyes, the cerebellum and the nervous system, more precisely, the movement, strain and pressure sensors that are located in the joints, tendons and muscles, especially in the arms and legs.

Physical balance is important because a weakened balance increases the risk of falling and contracting brain injuries or broken legs. Keeping the balance while sitting or standing is necessary for daytime activity, and this includes elementary things like body care or walking. A weak balance disrupts many physical activities such as sports, driving and working.

Medications affect the balance organ as well as infections of the inner ear, head injuries or anything else that affects the inner ear and cerebellum. For example, low blood pressure can cause dizziness if someone gets up quickly. In this case, the cerebellum is not supplied with blood quickly enough. Bone diseases such as rickets or eye diseases such as weakness of the eye muscles can also upset the balance. In the case of arthritis, the information in the cerebellum no longer reaches the bone nerves; in the case of weakness in the eye muscle, the information reaches the eye, but it can no longer implement it. Unfortunately, many balance disorders start suddenly and with no apparent cause.

Balance disorders are generally associated with problems with the vestibular system in the inner ear. However, they can also be related to the cerebellum, the eyes or the skeleton. A lack of vitamin B 12 can lead to balance problems.

Balance problems caused by alcohol

Everyone who has ever drunk too much alcohol knows the loss of balance due to alcohol: the glass falls out of his hand, if he wants to sit on a chair, he sits next to it, he stumbles, and when he is very drunk , he can no longer walk. He sees things twice, cannot estimate distances and loses his bearings. When he arrives at the front door, he does not manage to put the key in the lock, and when he is finally in bed, his head "drives carousel".

Alcohol causes two different types of dizziness. First, drunks suffer directly from the acute disorder outlined, which is directly associated with the intoxication. Second, there are permanent balance disorders in alcoholics and people who chronically abuse alcohol.

The acute disorder caused by a high intoxication is that the alcohol briefly disrupts the interplay of the structures in the balance system. “Carousel driving” in bed, however, is also part of the acute alcohol intoxication and is called “alcoholic vertigo”.

The semicircular canal responds to rotational movements of the head because its hairs are bent. These hairs usually have the same weight as the endolyps that activate them and only react to rotational movements.

However, alcohol is lighter than water, the hairs are now lighter, and the organ reacts to changes in the static position of the head - from a blood alcohol content of 30 mg per 100 ml. The alcohol first lams into the hairs. If the drunk now lowers or lifts his head, he becomes dizzy.

However, this goes away when the alcohol reaches the endolymph and the weight adjusts itself again. But with the "hangover" the second alcoholic vertigo sets in. The alcohol in the inner ear sinks, first in the cupula.

Now the initially lighter cupula becomes heavier than the endolymph, it bends downwards and the drinker again feels dizzy.

Chronic alcoholics, on the other hand, permanently damage their balance system. The nerves no longer work as they should, and this also applies to the nerve pathways and nerve centers that regulate balance. Even without drinking, the patient now stumbles, has “blackouts” again and again, that means problems in orienting himself in the room, forgets important things, stumbles and falls.


Sunstroke is a disorder caused by excessive sun heat. The meninges are exposed to strong stimuli and the person suffers from nausea, headache and dizziness.

If we move in too strong solar radiation for too long, we run the risk of getting a sunstroke. In contrast to sunburn, it is not the whole body that is the "problem area", but the uncovered neck, neck, and especially the head. The wide-brimmed sombrero of the Mexicans is suitable to protect this problem zone because it covers the entire head, neck and shoulder area.

While the sunburn damages the skin with first degree burns, the sunstroke hits the meninges. If you walk around the Sonoran Desert without a hat or uncovered “tan” on the beach of the Persian Gulf, the risk increases, and those who are naturally light-skinned and have little scalp hair should consider a heat stitch as a serious danger.

Anyone who suffers from a sunstroke will feel it, unlike a sunburn, only hours after sun exposure. The sunstroke usually disappears when we cool our heads, put ourselves in the shade or cover our heads.

In a few cases, however, a sunstroke has serious consequences: The worst is cerebral edema, which increases the pressure in the brain, which can lead to respiratory arrest, cramps and even coma. An emergency doctor is required - and he is rarely on hand in risk regions such as the inner Sahara or inland Tanasania.

Other symptoms of a “normal” sunstroke are taken by themselves for outdoor travelers, but are not life-threatening, but can trigger a dangerous domino effect. Orientation problems and dizziness are typical for a sunstroke. The person concerned loses orientation in the room for a short time, and short-term means that until they find shade.

The thirst very quickly joins the sunstroke. Lack of water also causes the person concerned to go black, throbbing pain in his temple, feeling dizzy, finally getting stomach cramps and collapsing. Sunstroke and thirst are not the same, but often occur together and show the same symptoms.

These orientation problems can cost life in an emergency. In the Grand Canyon, for example, there is blazing heat on the ground in midsummer, which in the USA is probably only surpassed by Death Valley. In addition, only one of several paths leads through the bottom of the canyon past a water point.

Anyone who suffers a sunstroke here, secondly does not find a place in the shade, thirdly loses orientation due to the sunstroke, and fourthly cannot seek water or help, is a candidate for death.

In desert areas, there are therefore two brazen laws: first, carry enough water with you, and second, at least wear headgear, but it is better to carry a shade, such as a poncho, blanket or tent wall.

Small children also easily contract meningitis during a sunstroke. Therefore, small children should always be protected from direct and long exposure to the sun.

Psychologically caused dizziness

Many dizziness attacks are psychological in nature, and this is the most common dizziness complaint in young adults.

These are not easy to recognize because they often “imitate” the vestibular vertigo, that is, they act like a disturbance to the balance organ: a tendency to fall, the feeling that everything is turning and disorientation.

However, most psychological dizziness symptoms are clearly undirected, so they are more diffuse than disorders of the balance organ: they do not occur regularly, they cannot be limited in time, or they occur in specific situations such as getting up or rapid head movements.

Rather, it is characterized by a general feeling of falling or sinking, "losing ground", accompanied by sweating and rapid heartbeat, anxiety attacks, a general feeling of being overwhelmed, and, above all, a feeling of drowsiness.

While disturbances of the balance organ are typically triggered by movements of the head, dizziness caused by psychological disorders usually occurs in anxious situations: in crowds, in conversations, in confined spaces, i.e. wherever the person concerned is particularly afraid. Doctors therefore speak of situation-phobic dizziness.

These dizziness attacks have nothing to do with simulantism: They range from a disorderly feeling of unwell to severe fainting spells.

Psychological dizziness complaints have negative consequences for those affected as well as purely physical ones. Often, those affected no longer trust themselves out of the house, they can no longer practice their profession, and the vertigo can develop into a full-blown depression.


Psychological dizziness requires treatment other than an imbalance in the balance organ. If there are everyday problems, such as the fear of an existing exam, it helps the person concerned if the doctor explains the reason for the physical symptoms.

Exercise, and especially endurance sports, always helps with mental dizziness. Although the symptoms are psychological, physical training strengthens the psyche and helps to overcome the challenges that dizziness can act as an “emergency brake”.

If there is a serious problem, the person concerned should consult a neurologist. If dizziness is the cause of mental illness, psychotherapy is also appropriate.


Balance disorders can also be part of a traumatization and / or an underlying mental disorder. Post-traumatic stress syndrome and borderline disorder characterize phases in which the affected person dissociates.

Then he loses the feeling for space and time and his own identity. In these phases, post-traumatized people are reminiscent of drunks. They have problems standing up straight, they have to be out in the fresh air to breathe in oxygen, their head “drives carousel”.

On the one hand, traumatized people experience a flashback, which means that the memories of the traumatizing event return uncontrollably. This includes palpitations, sweating and muscle tension. The person affected looks as if "he stands next to himself". The dizziness is just one of many symptoms that the sufferer suffers from.

Benign paroxysmal positional vertigo

This disorder manifests itself in vertigo attacks. The crystals in the inner ear have come loose due to external violence or chemical processes in the body. Because the crystals are now moving freely in the liquid, the brain perceives a pseudo movement.

An ear, nose and throat doctor makes the diagnosis by checking the position of the crystals. In therapy, the crystals are returned to their previous position.

Those affected feel disturbances in their balance, especially when they turn around in bed, climb into bed or get out of bed, climb stairs or bend their heads back in the shower.

When they get out of bed, their eyes go black, they stumble and even fall. Sometimes they feel extra and have to vomit. For this reason, those affected often confuse the inner ear disease with a flu-like infection.

The symptoms are often abrupt and frighten the patients. Whenever they move their heads or tap their temples, they feel irritated and often even fall out of bed.

When they stand and move their heads forwards or backwards, they often fall to the floor. Symptoms usually decrease in a few weeks or months, but sometimes last for years.

The most common cause of this disease is a head injury. In older people, on the other hand, the equilibrium system in the inner ear often degenerates, and the crystals then dissolve without external influence. This is the case in half of all cases in which the doctors then diagnose: cause unknown.

Meniere's disease

In Meniér's disease, tinnitus, hearing problems and spinning sensation usually occur together, and these symptoms can last for hours, after which the patient is completely exhausted. The fluid in the inner ear is insufficiently formed in this disease, and the function of the membranes that connect the spaces of this fluid is slowed down. The affected person usually has no symptoms between the individual attacks. This condition can lead to permanent hearing loss. In addition to ear, nose and throat doctors, neurologists, ophthalmologists and internal medicine specialists are also consulted.

French physician Prosper Meniere discovered Meniere's disease in the early 1860s. The cause of the disease is as unknown today as it was in his day, doctors suspect allergies that affect the inner ear. It is also unclear why the disease sometimes progresses and often does not. The disease runs in three stages.

The first stage is characterized by sudden phases of dizziness. The patient feels dizzy in these seizures and vomits. Such a phase lasts from 20 minutes to 24 hours. In the meantime, the person affected has difficulty hearing, but the hearing then returns to its normal level. The ear hurts and feels blocked, as if pressure is on it.

In the second stage, dizziness worsens, but hearing loss gets worse. Some sufferers think the disease will stop completely, but then the symptoms will come back after months.

In the third stage, dizziness almost stops, and sometimes it ends forever. But the balance disorders remain. Those affected feel restless when it is dark and can hardly translate visual signals into poor orientation in the room. The hearing deteriorates more and more.

Vestibular neuropathy and labyrinthitis

Neuropathia vestibularis overrides the equilibrium organ without doctors knowing the exact cause. The sufferer suffers from a spontaneous spinning sensation that lasts for days or even weeks.

So-called labyrinthitis is usually caused by a viral infection, for example by herpes. Bacterial labyrinthitis often begins with untreated inflammation of the middle ear or as a result of meningitis.

Once identified, the infections can be treated in a few weeks. However, if the inner ear is permanently damaged by the infection and the cerebellum cannot fix this damage, the symptoms become chronic. These include: chronic confusion, exhaustion, disorientation, tinnitus and hearing loss.

Fistulas of the perilymph fluid

A fistula of the perilymph (English PLF) is an abnormal opening in the fluid of the inner ear. A tear or defect in the small, thin membranes between the middle and inner ear. These membranes are called oval windows and round windows.

We know the change in air pressure that weighs on the middle ear as the “plop” when we take to the skies in an airplane. Usually these have no effect on the inner ear. However, if a fistula affects the inner ear, such changes in the middle ear directly affect the inner ear, stimulating balance and hearing.

Most of the symptoms caused by PLF are similar to those of Meniere's disease. That is why the difference between the two disorders is important: there are two different fluids in the inner ear, the endolymph and the perilymph. Meniere's disease develops when the endolymph fluid comes under pressure and blocks the membranes in which it is located. This pressure shifts the perilymph fluid.

With PLF, however, the perilymphatic fluid flows into the middle ear. This also leads to an uneven pressure between the two fluids and therefore to similar symptoms, even if the cause of the imbalance is different.

Various tests distinguish the two diseases. A fistula can be recognized, for example, by noting the eye movements while at the same time exerting pressure on each ear canal - for example with a small piece of rubber.

Head trauma is the most common cause of PLF, usually caused by a direct blow to the head or ear. But PLF also arises from a rigid change in the pressure of the atmosphere, be it through free diving, acrobatic flight maneuvers, childbirth or bungee jumping. Such fistulas are very rarely congenital.

“Spontaneous PLFs” are controversial - without an obvious trigger. Doctors who deny such "inexplicable" fistulas assume that a head trauma or a rapid change in atmospheric pressure is the cause, but the person concerned does not associate it with the disease.

Vascular dementia

Vascular dementia shows, by way of example, that in many illnesses the disturbance of the balance is only one symptom among many. With this multi-infarct dementia, the brain is no longer adequately supplied with blood. The person concerned loses most of the mental faculties that he previously developed.

In addition to balance disorders, dementia suffer from memory gaps, orientation problems, difficulty concentrating, speech disorders, emotional disorders and constipation.

Twenty percent of all dementia patients suffer from the vascular form of the disease. Their forgetfulness is characteristic, especially in short-term memory. This dementia primarily affects elderly people who have previously suffered from diseases that damage the brain, in particular heart problems or arteriosclerosis. The narrowed blood vessels in the brain no longer supply the organism with the oxygen it needs. The cells die.

Atherosclerosis as a pre-existing condition of vascular dementia is triggered by smoking as well as by too much cholesterol, increased blood levels, diabetes or cardiac arrhythmias.

Dementia begins slowly, so the patient often does not recognize it or perceives it as a normal side effect of aging. It starts with the person concerned forgetting things. What looks like "dodgy" at first - sometimes he doesn't know where the car key is, sometimes he forgets that his grandchildren wanted to visit him - soon affects essential parts of everyday life, and the forgetful one becomes so forgetful that he no more than forgetfulness Perceives problem: He forgets that he is forgetful, and forgets what he has forgotten. In the ongoing process, he no longer recognizes his friends and relatives, his intellectual competence deteriorates - he falls back to the level of an infant.

As with a disturbance of the balance organ, the person concerned has problems orienting himself in the room. The patient loses his motor skills, the limbs become stiff, he taps, shuffles and walks with wide legs.

He keeps falling over and over, he gets optical hallucinations that confuse him. He becomes dizzy, feels threatened by his environment and reacts aggressively to it.

If older people become forgetful, they should definitely see a doctor. The clarifies the cause after an in-depth questioning on the past. If detected early, vascular dementia can at least be slowed down by taking medication that inhibits blood clotting and thus improves blood flow.

An underlying cardiac arrhythmia can be curbed with vitamin K antagonists that force blood thinning.

The consequences of progressive dementia, on the other hand, are dramatic: the sick lose their social contacts, they also lose feelings about the people who are close to them. They can no longer practice their profession or pursue their hobbies because they forget the patterns of thought and action that are stored as memories. This is also why they are becoming increasingly apathetic.

Dementes wander around aimlessly, they also eat inedible because they lose their memory of tasty food, they suffer from sleep disorders, they are irritated and depressed at other times, anxiety attacks are accompanied by delusions, they are as euphoric as they are uninhibited.

You become indifferent. Even going to the toilet doesn't matter, going for a walk loses its appeal, and even basic hygiene has to be taken care of by nurses.

Creutzfeldt-Jakob disease

Creutzfeldt-Jakob disease (CJD) damages the brain. More specifically, it changes its protein structure to a spongy mass. This very rare disease is easily mistaken for dementia because the symptoms are similar. The disease is incurable.

It is triggered by prion proteins, which to some extent put on healthy proteins. The healthy proteins take over the structure of the infectious ones and, to put it loosely, the brain is perforated like a Swiss cheese.

Sometimes the disease occurs without an external cause, namely in the elderly. This form is the most common of this extremely rare condition. Creutzfeldt-Jakob can also be hereditary or triggered by an infection. Human growth hormones that were injected into the patient in particular promoted the disease; the transplantation of human brain and cornea is also a safe suspect.

Young people suffered Creutzfeldt-Jakob in a form that corresponds to the bovine disease BSE.

The disease is characterized by memory gaps, orientation problems, balance problems, difficulty concentrating, tremors, paralysis, depression and anxiety attacks.

As with dementia, the patient first loses slowly, then rapidly his mental and physical abilities. He complains of depression as well as dizziness, then he gradually loses his memory-

Involuntary muscle twitches are typical. The person affected can no longer control his movements, he stumbles and falls and at the same time no longer knows where he is. Not the balance organ, but the brain is damaged here and can no longer process information from the balance system. The disease leads to death after a few months. It cannot be braked or treated.

Only the symptoms can be treated to give the patient a little quality of life in his recent time. Antidepressants for depression, neuroleptics for hallucinations and antiepileptics for muscle twitches are suitable. (Somayeh Ranjbar, Dr. Utz Anhalt)

Author and source information

This text corresponds to the specifications of the medical literature, medical guidelines and current studies and has been checked by medical doctors.


  • Arneborg Ernst; Dietmar Basta: Balance disorders: diagnosis and therapy for the key symptom of vertigo, Georg Thieme Verlag, 2016
  • Institute for Quality and Efficiency in Health Care (IQWiG): (accessed: August 12, 2019), How does the sense of balance work?
  • German Society for Neurology (ed.): "Vertigo - Diagnosis", in: Guidelines for Diagnostics and Therapy in Neurology, 2012, Vertigo - Diagnosis
  • Dee Unglaub Silverthorn, Physiologie, Pearson Deutschland GmbH, 2009
  • Wolfgang Stoll; Eckhard Most; Martin Tegenthoff: dizziness and balance problems, Georg Thieme Verlag, 2004
  • Thomas Lempert: Effective help for vertigo: what is behind it and how to get rid of it, TRIAS, 2003
  • Rudolf Schweitzer; Michael Schröder: The Naturopathic Academy. Legal Studies, Emergency Medicine and Pharmacology, Urban & Fischer Verlag, 2018
  • Alexander Eckhardt et al .: "Dizziness and Anxiety Diseases - Results of an Interdisciplinary Study", in: Laryngo-Rhino-Otologie, Volume 75 Issue 9, 1996, Thieme
  • Hans Peter Zenner: Practical Therapy for Ear, Nose and Throat Diseases, Schattauer, 2008
  • Helmut Schaaf: Meniere's Disease: Dizziness - Hearing Loss - Tinnitus A Psychosomatic Orientation, Springer, 2009
  • Joseph B. Nadol; Michael J. McKenna: Surgery of the Ear and Temporal Bone, Lippincott Williams & Wilkins, 2005

Video: A Clinical Review of Balance Disorders. UPMC (January 2022).