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 us 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 (feeing 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

Further information about PPPD

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)