Persistent Postural-Perceptual Dizziness (PPPD)

What is PPPD?

PPPD is a chronic condition characterized by persistent feelings of chronic subjective dizziness, phobic postural vertigo and related disorders. PPPD is triggered by an initial episode of vertigo or dizziness. Following this, individuals experience persistent sensations of movement, dizziness, or light-headedness, lasting for hours or days. Symptoms are almost constant but may fluctuate in severity. These symptoms can also occur without any specific trigger or underlying vestibular disorder, leading to a sensation of being off-balance or swaying, even when standing or sitting still. PPPD can significantly impair a person’s ability to perform routine activities and negatively impact their quality of life.

The symptoms of PPPD can vary from person to person but often include: 

• Persistent feeling of dizziness, lightheadedness and/or rocking, swaying, floating without vertigo lasting 3 months or more (even in the absence of any movements) 
• Increased sensitivity to visual stimuli, such as busy environments or moving objects 
• Difficulty concentrating or focusing 
• Anxiety or panic attacks triggered by dizziness 
• Fatigue or difficulty with balance-related activities, such as walking or standing for extended periods 

The symptoms get worse when 

• In upright posture (standing or sitting) 
• Looking at moving objects 
• Walking in crowd/crowded places (supermarkets, movies) 
• Looking at complex patterns, pictures, wall paintings 

The exact cause of PPPD is not fully understood, but it’s believed to involve a combination of factors, including: 

• Vestibular and sensory mismatch: Discrepancies between sensory inputs from the vestibular system, vision, and proprioception (sensory feedback from muscles and joints) may lead to feelings of dizziness and instability. 

• Anxiety and psychological factors: Stress, anxiety, or past experiences of dizziness can contribute to the development and perpetuation of PPPD symptoms. 

• Central nervous system dysfunction: Alterations in the brain’s processing of sensory information may play a role in maintaining symptoms of PPPD over time. 

PPPD is usually triggered by a first episode of vertigo or unsteadiness. This first episode may be caused by many different things that disrupt the balance system, including BPPV, Meniere’s Disease, Vestibular Neuritis, Vestibular Migraine and other vestibular or balance disorders.

Diagnosing PPPD can be challenging due to its overlapping symptoms with other vestibular and neurological disorders. A comprehensive medical history, physical examination, and evaluation of symptoms are essential for ruling out other potential causes of dizziness. Diagnostic criteria established by organizations such as the Barany Society and the International Headache Society may be used to guide the diagnosis of PPPD. 

The healthcare specialist may order a few tests like vestibular function tests, balance tests and imaging studies (CT/MRI scans) to rule out the other possible causes or coexisting conditions.

Managing PPPD typically requires a multi-faceted approach for “retraining” the brain by combining vestibular rehabilitation with strategies to manage anxiety, including medication and cognitive-behavioural therapy (CBT).

Vestibular Rehabilitation Therapy (VRT) : Specialized form of physical therapy that focuses on exercises to improve balance and reduce dizziness. VRT aims to retrain the brain to process signals from the vestibular system more effectively. 

Cognitive Behavioral Therapy (CBT) : CBT can help patients address negative thought patterns and develop coping strategies to manage their symptoms. 

Medications : In some cases, medications may be prescribed to alleviate symptoms such as anxiety or depression, which worsens the condition. 

Lifestyle Modification  : Avoiding triggers such as caffeine, alcohol, and certain medications may help reduce symptoms. Additionally, maintaining a regular sleep schedule and practising stress-reduction techniques like mindfulness or relaxation exercises can be beneficial. 

Education and Support : Understanding the condition and learning how to manage symptoms is crucial. Support groups or counselling can provide valuable support and resources for patients and their families. 

Optimizing General Health : Maintaining a healthy lifestyle through regular exercise, balanced nutrition, and managing other medical conditions can help improve overall well-being and may indirectly reduce PPPD symptoms.