Anxiety-Related Functional Dizziness: A Systematic Review of the Recent Evidence on Vestibular, Cognitive Behavioral, and Integrative Therapies

Background: Functional dizziness and persistent postural-perceptual dizziness (PPPD) involve mutually reinforcing vestibular symptoms and anxiety. Non-pharmacological interventions, such as vestibular rehabilitation therapy (VRT) and cognitive behavioral therapy (CBT), aim to address both mechanisms, yet their overall effectiveness remains unclear. Methods: We systematically examined randomized controlled trials (RCTs) published between 2000 and 2025 that evaluated VRT, CBT, or multimodal approaches for adults with functional or chronic dizziness (including PPPD and related functional dizziness constructs) accompanied by significant anxiety. Twelve RCTs (513 participants) met the criteria, involving individuals with PPPD, chronic subjective dizziness, chronic vestibular disorders with prominent anxiety, and residual dizziness after benign paroxysmal positional vertigo. Results: Conventional VRT delivered in clinic or as structured home-based programs produced small-to-moderate improvements in dizziness-related disability versus usual care. Combining VRT with CBT or psychologically informed components yielded larger and more consistent reductions in disability and maladaptive dizziness-related beliefs. CBT-based interventions reduced anxiety and dizziness-related distress compared with supportive controls. Emerging modalities, including virtual-reality-based VRT, non-invasive neuromodulation, and heart-rate-variability biofeedback, showed potential, although they were limited by small samples and methodological issues. Most trials had some risk-of-bias concerns and evidence certainty ranged from very low to moderate. Conclusions: Integrated multimodal rehabilitation shows promise, although larger, high-quality RCTs using standardized procedures and outcome measures are required.