Persistent Postural Perceptual Dizziness - What You Need To Know

Article Summary

Persistent Postural-Perceptual Dizziness (PPPD) causes dizziness and unsteadiness that crowds or other busy places can trigger, but it doesn’t involve spinning (vertigo). This condition usually starts after an event that causes dizziness or balance issues, but it can also occur for no apparent reason. Treatment options include medication, balance therapy, and counseling. 

History 

PPPD was first identified in 1986 by German doctors who called it phobic postural vertigo (PPV). They noticed symptoms like dizziness without spinning and unsteadiness, often triggered by stress or crowded places. At the time, the signs of PPV were thought to include having an obsessive-compulsive personality, feeling a little depressed, and experiencing anxiety. 

However, further research on PPV found that it isn’t considered a mental health disorder. Instead, it’s seen as a condition of the inner ear that also involves behavioral aspects. Researchers are also starting to understand how PPPD affects the brain. Studies suggest there are changes in how balance and sight are processed.

In the early 2000s, American researchers updated their understanding of this condition and coined the term chronic subjective dizziness (CSD). This included similar symptoms, such as feeling dizzy when moving or in complex environments. By 2014, experts agreed on the main features of these conditions and named it Persistent Postural-Perceptual Dizziness (PPPD), which was officially recognized by the World Health Organization (WHO) in 2017.

Symptoms 

The main symptoms of PPPD include feeling unstable or dizzy, without vertigo, for at least three months. These feelings happen most days, and often get worse throughout the day. Also, symptoms are typically worse when standing or moving, especially in busy or visually complicated places. PPPD usually starts after specific events like a vestibular disorder (like BPPV or Meniere’s disease), panic attacks, mild head injuries, or other health issues. It’s rare for it to develop slowly without a clear cause. Keeping a log of symptoms can help doctors make a diagnosis.

Comorbid Symptoms of PPPD

People with PPPD might also have mild anxiety or depression, but these aren’t the main symptoms of the condition. Studies show that having anxiety disorders can make it more likely to develop PPPD. 

Fatigue is significant because it can worsen symptoms such as dizziness and difficulty concentrating. PPPD is a condition where the brain stays sensitive to motion and things happening around it, and tiredness makes it harder for the brain to handle these feelings, causing a cycle of more dizziness and fatigue. 

PPPD can also occur with other balance disorders, which can make it hard to diagnose. Patients often avoid situations that might make them feel worse because they don’t want to experience increased dizziness or fear that something bad will happen. This highlights how PPPD affects both the body and mind.

Diagnosis

Doctors use physical exams and tests to check for other conditions, but not specifically for diagnosing PPPD. To diagnose PPPD, all five of the following criteria must be met:

1. One or more symptoms of dizziness, unsteadiness, or non-spinning vertigo are present on most days for 3 months or more.
   1. Symptoms last for prolonged periods of time (hours) but may wax and wane in severity.
   2. Symptoms need not be present continuously throughout the entire day.
2. Persistent symptoms occur without specific provocation, but are exacerbated by three factors:
   1. Upright posture
   2. Active or passive motion without regard to direction or position, and
   3. Exposure to moving visual stimuli or complex visual patterns.
3. The disorder is precipitated by conditions that cause vertigo, unsteadiness, dizziness, or balance problems, including acute, episodic, or chronic vestibular syndromes, other neurologic or medical illnesses, or psychological distress.
   1. When the precipitant is an acute or episodic condition, symptoms settle into the pattern of criterion #1 (above) as the precipitant resolves, but they may occur intermittently at first, and then consolidate into a persistent course.
   2. When the precipitant is a chronic syndrome, symptoms may develop slowly at first and worsen gradually.
4. Symptoms cause significant distress or functional impairment.
5. Another disease or disorder does not really account for the symptoms.

Behavioral Factors

Many people with PPPD show signs of anxiety or depression. Healthy coping can be hard when anxiety is high. About 60% of PPPD patients have significant anxiety, and 45% have significant depression. Behavioral factors influence PPPD in three main ways: 

1. People who are anxious or already struggle with anxiety may be more likely to develop PPPD after a stressful event. 
2. Those who feel a lot of anxiety during dizziness episodes may have a higher chance of getting PPPD. 
3. If someone has a bad dizziness episode and feels very anxious and cautious, this can prevent them from recovering well. 

Treatment 

As of 2014, there weren’t many large studies on treatments for PPPD, but some smaller ones existed. 

Medication

 In studies with SSRIs and SNRIs (types of antidepressants), about 60-70% of patients had their main symptoms cut in half, and 80% who completed 8-12 weeks saw improvement. Some people had side effects, but those who don’t respond to one SSRI may do better with another. Treatment usually needs to last at least a year to prevent coming back. 

Vestibular Balance Rehabilitation Therapy (VBRT)

VBRT helps patients regain their sense of motion. A 2014 study showed that VBRT can reduce symptoms by 60-80%. It might also help with anxiety and depression, and patients should stick with it for 3-6 months to see full benefits. 

Counseling 

Talking therapies alone may not work well for serious PPPD, but starting early might help prevent it. Cognitive Behavioral Therapy (CBT) showed some benefits, particularly when given soon after dizziness begins. Recent research has shown that combining CBT, VBRT, and medication can improve overall symptoms.

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