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 1. WHAT IS PERSISTENT POSTURAL PERCEPTUAL DIZZINESS (PPPD)?

 2. Information and support
 3. Vestibular Disorders

Persistent Postural-Perceptual Dizziness (PPPD) is one of the most common causes
of chronic dizziness. PPPD stands for:

 * Persistent, the symptoms are there most of the day, most days of the week.
 * Postural, because symptoms tend to be worse when patients are upright or
   moving, and better when lying down in bed.
 * Perceptual, because it is something that is felt by the patient, but not
   necessarily obvious to others.
 * Dizziness, as this is the term that most patients use to describe the
   sensation.

Who is affected by PPPD?

PPPD can affect anyone, regardless of age and gender. It is more common in
younger (<50yrs) individuals but data on the prevalence is lacking. A UK
population-based study of primary care found that 4% of all patients registered
with a general practitioner experience persistent symptoms of dizziness, and
most of those were severely affected by their symptoms.

Symptoms of PPPD

Patients with PPPD often describe a sense of internal motion (even without
objective movement of the body), akin to a feeling of ‘rocking or swaying as if
on a boat’, a sense of unsteadiness, vibrations inside the body, and walking ‘as
if drunk’. Symptoms tend to be worse in busy or visually rich environments but
can also persist even when the patient is lying in bed at night. There may be
accompanying symptoms such as difficulty concentrating, short-term memory loss,
and a sensation of derealisation (feeling detached from the world) or
depersonalisation (feeling detached from oneself).

One of the most frustrating aspects of PPPD for patients is that others cannot
see the problem, and so often patients report feeling ‘mis-understood’ by
friends, family, or work colleagues, and dismissed by doctors as being ‘just
anxious’.  

What causes PPPD?

Patients most often develop PPPD following an insult or injury to the balance
system (such as vestibular migraine, vestibular neuritis, or BPPV), a medical
issue (such as a severe episode of low blood pressure causing dizziness), or
trauma (both physical or psychological).

Although we may feel we are still at times, in fact our bodies are in constant
motion, particularly when we are upright (try balancing a pen on a tabletop). In
PPPD, the normal ‘filters’ that the brain uses to suppress feelings of movement
that we need not be conscious of, go wrong. Instead of the brain being able to
balance everything up and give you a nice smooth feeling when you are moving,
the person can feel a sense of movement that they shouldn’t. Balance is, after
all, an automatic process.

After a while, because the person notices it a lot, they start to wonder what it
is going on, and this causes ‘hypervigilance’ - thinking about dizziness or
balance or worrying about it “turns up the volume knob” on the sensation. That
makes it even stronger – and so a vicious circle begins. We now know that PPPD
causes changes in how the brain processes information related to movement (our
own and that of the world around us), a bit like a malfunctioning computer
software.

How is PPPD diagnosed?

There is no diagnostic test for PPPD and because it is a ‘software’ disorder,
routine examinations and tests are normal, because these focus on ‘hardware’
problems in the nervous system (like stroke, or Parkinson’s disease). However,
patients with PPPD tend to experience similar symptoms, and because the physical
examination is normal, it is possible to make a diagnosis based on the types of
symptoms, how they change over time, and what they are triggered by.

See image, right (click to enlarge) or follow this link to the ‘diagnostic
criteria’ that doctors or practitioners will refer to in order to make a
diagnosis of PPPD.

How is PPPD treated?

Specific treatment of PPPD takes time and there is no ‘quick fix’ but good
recovery is certainly possible even after months or years of symptoms. The
recipe for success includes:

A clear positive diagnosis and explanation that you can work with. An
understanding of how the nervous system has become sensitised can help you work
to desensitise it.

Recognition that many of the symptoms may go along with your PPPD including
dissociation, neck pain, anxiety, fatigue and poor concentration. Some of these
problems may have treatments of their own.

Physiotherapy/ Desensitisation. As symptoms of PPPD build up, most people begin
to avoid moving their eyes, neck and body as much as they used to that may the
brain’s (subconscious) approach to try to reduce symptoms. Physiotherapy and
specific vestibular physiotherapy can be useful to help desensitise the nervous
system and start to overcome ingrained patterns of movement.

Medication. Medications, mostly based on so-called antidepressants, have been
successfully used to manage PPPD symptoms, independently of any low mood or
anxiety. More studies are needed to be confident of this.

Psychological treatment. Anxiety, whilst rarely a trigger for the symptoms of
PPPD, can be a common consequence of this disorder, and often perpetuates the
symptoms. Psychological approaches such as CBT, counselling and mindfulness can
be helpful in addressing understandable fears of falling, or other sources of
anxiety. Treatment from a therapist who understands PPPD can help break bad
habits that many patients with PPPD get into with respect to their symptoms, and
also help with

Additional Links

Functional Dizziness (PPPD) – Functional Neurological Disorder (FND)
(neurosymptoms.org)

Persistent postural-perceptual dizziness (PPPD): a common, characteristic and
treatable cause of chronic dizziness (bmj.com)

Further information about PPPD

Please contact us for further information about PPPD or to chat with a member of
our team. 

The Ménière's Society can provide general information, but is unable to provide
specific medical advice. You should always check with your medical professional
for information and advice relating to your symptoms/condition.

 

Support our work

If you have found our information helpful, why not become a member. As well as
supporting our work, we'll keep you informed about the latest
management/treatment options for vestibular disorders and what research is
taking place. Find out more about membership.

If membership isn’t for you, please consider making a donation towards our work
so we can continue supporting people affected by PPPD and other vestibular
disorders, as well as funding vital research into these conditions. Donate Now!

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IN THIS SECTION

 * Vestibular Disorders
   * Non-vestibular causes of dizziness and imbalance
   * Superior Semicircular Canal Dehiscence Syndrome
   * What is BPPV?
   * What is Bilateral Vestibulopathy?
   * What is Endolymphatic Hydrops?
   * What is Labyrinthitis?
   * What is Mal de Debarquement Syndrome (MdDS)?
   * What is Ménière’s disease / syndrome?
   * What is Perilymph Fistula?
   * What is Persistent Postural Perceptual Dizziness (PPPD)?
   * What is Vestibular Migraine?


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