It's All in Your Head: A Case Report of Persistent Postural-Perceptual Dizziness and Chronic Anxiety Treated Simultaneously With Osteopathic Cranial Manipulative Medicine.

Persistent postural-perceptual dizziness is a chronic functional vestibular disorder characterized by persistent dizziness, imbalance, motion sensitivity, and significant psychological distress, frequently including anxiety. Symptoms often persist despite normal imaging and multidisciplinary evaluation, contributing to diagnostic uncertainty and misattribution to psychiatric causes. Osteopathic cranial manipulative medicine is not routinely incorporated into the management of persistent postural-perceptual dizziness despite osteopathic principles, emphasizing the interrelationship between cranial structure, autonomic regulation, vestibular function, and psychological well-being. A 30-year-old female patient with a longstanding history of anxiety, depression, and post-traumatic stress disorder presented with a greater than two-year history of persistent postural-perceptual dizziness, recurrent falls, and imbalance that began following a motor vehicle accident. Her psychiatric symptoms had been refractory to psychotherapy and pharmacologic treatment, while her imbalance remained refractory to physical therapy and neurologic evaluation. The chronic persistence of vestibular symptoms coincided with worsening psychological distress and functional decline. Magnetic resonance imaging demonstrated a suprasellar pituitary lesion without a definitive explanation for her symptoms. Osteopathic structural examination identified decreased cranial rhythmic impulse amplitude, increased dural tension, and superior sphenoid strain at the sphenobasilar synchondrosis (SBS). Osteopathic manipulative treatment was performed, including osteopathic cranial manipulative medicine techniques directed at reducing dural tension and restoring balanced motion at the cranial base. Two treatment sessions were performed one week apart. Following the first treatment session, the patient reported mild improvement in balance and substantial reduction in anxiety symptoms. Following the second session, she reported further improvement in balance, anxiety, and ambulatory confidence compared with pretreatment baseline. Generalized Anxiety Disorder-7 scores improved to below the screening threshold for generalized anxiety disorder, while Patient Health Questionnaire-9 score improved from 11, consistent with moderate depression, to 5, consistent with mild depressive symptoms. The patient additionally reported fewer falls, improved confidence with ambulation, and immediate subjective relief following treatment. This case suggests a potential role of osteopathic cranial somatic dysfunction in persistent postural-perceptual dizziness and associated psychological distress refractory to conventional management. Identification and treatment of superior sphenoid strain were temporally associated with clinically meaningful improvements in vestibular symptoms, anxiety, depressive symptoms, and functional capacity. These findings support further investigation into osteopathic cranial manipulative medicine as a potential adjunctive treatment approach for persistent postural-perceptual dizziness and related neuropsychiatric symptomatology. This case also highlights the importance of comprehensive, multidisciplinary evaluation in patients whose physical symptoms may be prematurely attributed solely to psychiatric diagnoses.