
This article originally appeared in the Summer 2024 issue of On The Level.
Persistent postural-perceptual dizziness (PPPD) is a debilitating condition that involves persistent dizziness, a feeling of unsteadiness, and imbalance, which impacts daily functioning and quality of life. The average PPPD patient is in their mid-40s, with this condition predominately affecting women. As of now, an exact cause has not been identified, but it is thought to be worsened with postural (body) movement and exposure to intense visual stimulus (e.g., busy patterns, objects in motion). The complexity of this condition, as well as the symptoms, presents a challenge for clinicians with regards to diagnosis and treatment interventions. The authors of this review paper explore the disorder etiology along with the commonly encountered clinical challenges with PPPD.
The authors discuss the diagnostic criteria developed by the Bárány Society. The diagnosis of PPPD requires (1) symptoms of dizziness, unsteadiness, or non-spinning vertigo that are present on most days for several hours and lasting for ≥ 3 months; (2) symptoms exacerbated by postural or directional movements or visual/moving stimuli; (3) disorder that is precipitated by conditions that cause vertigo or dizziness; (4) symptoms that result in functional impairment or distress; (5) symptoms not accounted by another disease process. When all five criteria are met, a PPPD diagnosis can be rendered.
Though the exact mechanism as to what causes PPPD is not fully understood, research has linked it to dysfunction of the body’s sensory and nervous systems. For example, being in an environment that requires visual and auditory input or processing (i.e., watching screens or crowded places) can lead to the brain struggling to integrate these signals from the environment. This sensory overload can lead to symptoms such as dizziness. Other potential causes involve neurotransmitter dysfunction. However, this remains an area of ongoing research. It is important to note that beyond the symptoms that result from the condition, other comorbid conditions can also exist, such as anxiety and depression. Therefore, treatment requires clinicians to provide holistic, patient-centered care addressing both the physiological and psychological aspects of this condition.
The authors go on to explore the controversies surrounding PPPD in the scientific community. Clinicians and researchers have differing opinions as to whether the persistent symptoms seen in PPPD should have a predefined duration or whether the chronic nature of the condition should be recognized irrespective of the duration. Another point of contention is the overlap between PPPD and other vestibular disorders and psychological conditions. The shared symptomatology and physiological process at play makes clearly distinguishing PPPD from other conditions a significant challenge for the scientific and medical community. Lastly, treatment approaches to PPPD such as weighing the risks and benefits for the use of pharmacotherapy agents like selective serotonin reuptake inhibitors remain a point of ongoing discussions.
The authors then delve briefly into some challenges with PPPD. For example, medications may only provide partial amelioration of symptoms with a lack of a sustained response among a highly variable patient population. Some medications can also potentially cause adverse events such as drowsiness or cognitive impairment. Therefore, balancing the benefits and drawbacks of medications poses a challenge. Other challenges that the authors discuss include treatment variability, subjectivity of symptoms present, diagnostic complexity, as well as the impact of daily functioning.
To better understand PPPD, the authors discuss several proposals for the future. One proposal is a collaborative and interdisciplinary approach that integrates neurology, otolaryngology, psychiatry, and rehabilitation sciences. Doing so, the authors suggest will lead to transformative breakthroughs in better understanding the complexities of PPPD as well as the elevate the standard of care provided to patients with PPPD. The authors also suggest that additional longitudinal studies need to be carried out to understand how this debilitating condition evolves over time and to observe if any patterns exist. The authors also advocate for telemedicine, educational initiatives, and global patient support networks for PPPD care. The authors note that this will enhance access to care among patients, create a more inclusive patient-centered environment, help patients cope with their condition, and connect with other patients through shared experiences.
In summary, the authors recognize that PPPD is a complex condition with the interplay of many factors. The authors recommend additional research to enhance diagnostic accuracy, provide effective treatment interventions, and improve quality of care for patients with PPPD.
Summary by Saishravan Shyamsundar