Persistent Postural-Perceptual Dizziness (PPPD) is a functional neurological disorder defined by chronic symptoms of dizziness, unsteadiness, or non-spinning vertigo that are present most days for three months or more. The condition stems from a problem in how the nervous system functions, rather than from structural damage. These sensations are the result of the brain improperly processing information from the senses related to balance and spatial orientation.
PPPD develops after an event that initially causes vertigo or dizziness. The brain then fails to return to its normal state, remaining on high alert. This creates a persistent mismatch between what the eyes see, what the inner ear’s vestibular system senses, and what the body feels. This sensory conflict generates the ongoing symptoms that can interfere with daily activities.
Core Symptoms of Persistent Postural-Perceptual Dizziness
The main feature of PPPD is a persistent sensation of unsteadiness and dizziness that is not true vertigo. Individuals describe the sensation as rocking or swaying, similar to being on a boat. These feelings can last for hours and are present most days, with fluctuating intensity.
Symptoms are made worse by an upright posture, such as standing or walking, and may be lessened by sitting or lying down. Simple movements like turning the head or walking can also provoke or intensify the dizziness. This sensitivity to one’s own motion can make everyday activities challenging.
Another symptom is a heightened sensitivity to complex visual environments. Places with a lot of movement or intricate patterns, like a busy supermarket aisle or scrolling on a phone, can be overwhelming. This occurs because the brain becomes overloaded by the complex visual input, which exacerbates the feelings of dizziness.
Common Causes and Precipitating Events
PPPD is triggered by an event that disrupts the body’s balance system, such as acute vertigo or imbalance. Common triggers include peripheral vestibular disorders like benign paroxysmal positional vertigo (BPPV) or vestibular neuritis, an inflammation of the inner ear.
Other medical conditions can also precipitate PPPD, such as a mild traumatic brain injury like a concussion or whiplash. Medical illnesses, psychological distress like a panic attack with dizziness, or vestibular migraine can also serve as the initial trigger.
Following the triggering event, the brain enters a state of heightened alert, becoming overly sensitive to motion and visual stimuli. Even after the original problem has resolved, the brain’s postural control system fails to re-adapt. This failure to recalibrate is why the dizziness continues long after the initial cause has passed.
The Diagnostic Process
Diagnosing PPPD is a clinical process based on a patient’s symptoms and history, as no single test can identify the condition. Healthcare providers use diagnostic criteria from the Bárány Society. These criteria require that a patient experiences dizziness or unsteadiness on most days for at least three months.
The nature of the symptoms is a part of the diagnosis. The reported dizziness must be a non-spinning sensation that lasts for extended periods. The symptoms must also be aggravated by three specific factors: an upright posture, active or passive self-motion, and exposure to moving or complex visual stimuli.
To confirm the diagnosis, physicians rule out other conditions that could cause similar symptoms. This process may involve tests like a brain MRI to exclude neurological diseases or a video-nystagmography (VNG) to assess inner ear and eye movement coordination. Unremarkable results from these tests help support a PPPD diagnosis by showing no other identifiable cause for the dizziness.
Treatment and Management Approaches
Treatment for PPPD aims to help the brain relearn how to process sensory information correctly. A primary treatment is Vestibular Rehabilitation Therapy (VRT), a specialized physical therapy. VRT uses exercises to gradually habituate the brain to the movements and visual stimuli that trigger dizziness. These exercises help desensitize the vestibular system and improve balance by retraining the integration of eye, head, and body movements.
Medication is another component of treatment, used in conjunction with VRT. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are commonly prescribed. These medications are not used primarily for anxiety or depression but are prescribed at low doses to help modulate the brain’s dysregulated neural circuits, reducing the intensity of dizziness.
Cognitive-Behavioral Therapy (CBT) can also be an effective part of the management plan. CBT helps patients change patterns of thinking and behavior that perpetuate the cycle of dizziness and anxiety. By addressing the fear of falling and avoidance of activities, CBT helps break the cycle where anxiety worsens symptoms and vice versa. A combination of VRT, medication, and CBT is an effective strategy for managing PPPD.