What is Persistent Postural Perceptual Dizziness? 
 
After an attack of vertigo or significant disruption to the balance system, the body has the ability to recover with normal balance being restored, although this process can take time. In some people, however, this recovery does not happen fully and dizziness symptoms persist after the initial attack has settled. This condition of a persistent feeling of dizziness is referred to as Persistent Postural Perceptual Dizziness (PPPD). The symptoms of dizziness are usually present on most days and last hours. In fact it is not uncommon for people to report symptoms every day which can be prolonged throughout the day. The dizziness is persistent lasting months and in some cases years.  
 
Key features
 
A specific event triggers this condition. Most conditions that can cause vertigo can trigger PPPD. It is not of gradual onset unless the trigger is a chronic condition. 
Symptoms are worse when upright (postural), are made worse with the individual moving and are worse in environments where there is a lot of surrounding motion. Symptoms are less troublesome when seated and minimal or absent when lying down. 
 
Other features
 
The severity of symptoms can vary over time but it does not get progressively worse. 
Most people with PPPD will notice that the dizziness tends to be worse as the day progresses with few symptoms on wakening in the morning.  
Certain activities are noted to aggravate symptoms. These include crossing bridges, descending stairs, walking in busy streets, supermarkets or in crowds ,watching fast action TV programmes, scrolling on phones and computers. 
It is noted that dizziness symptoms may not occur immediately on standing, moving or in situations with a lot of surrounding motion such as crowds but can develop and then take hours to settle when the provoking factor has been removed. People may avoid situations which they recognise wil worsen their symptoms 
Those with PPPD often have difficulty with precision visual tasks 
 
Previous terms used for similar symptoms were chronic subjective dizziness, visual vertigo, phobic postural vertigo, space-motion discomfort. These terms have now been largely replaced by PPPD which encompasses these conditions.  
 
 
Associated symptoms 
 
Patients with PPPD, may also notice some or all of the following symptoms in association with their dizziness;  
neck stiffness and headache 
tiredness 
poor concentration (brain-fog) 
feeling spaced out or zoned out 
anxiety ranging from mild anxiety to phobic avoidance behaviours  
light and motion sensitivity, smell sensitivity 
 
 
What causes it? 
 
It is triggered by a specific event that causes sudden onset of dizziness symptoms. Such events include viral infections of the balance system, vestibular migraine or following ear surgery. The symptoms can also occur from a much wider range of events that can provoke onest of dizziness symptoms such as a head injury, a stroke, anxiety attack, whiplash, heart rhythmn issues, drug reactions amongst others. 
 
The normal body response after an attack of dizziness is increased reliance on visual information and less dependence on that from the balance system in the ears as it can no longer rely on the accuracy of the infromation from the ears. Along with this is undertandably a greater care with movement- likened to stacking shelves on a beam 10 foot up as opposed to doing the same action standing on the ground. As the vertigo feeling subsides this response settles and everything returns to normal. In PPPD the response persists with associated anxiety and high levels of awareness of the symptoms. Few patients have pre-existing anxiety although it is more common in people who are anxious or prone to worry. 
 
 
How is it diagnosed? 
 
A careful history and thorough examination backed up by relevant investigations as requried will often lead to the diagnosis. Because there is no specific test that can identify the condition (as is the case with many dizziness conditions), there may remain a degree of uncertainty about the diagnosis . In such a case, management is based on the most likely cause of symptoms keeping an open mind that with time the diagnosis may become clearer or need to be reassessed if expected progress is not made.  
 
 
How is it treated? 
 
It often improves gradually without treatment. This is, however, not always the case and patients may have symptoms for years before a correct diagnosis is made and appropriate treatment commenced. 
 
Cognitive Behavioural Therapy (talking therapies) may be helpful for dealing with associated anxiety if this is a major feature but only as part of an overall treatment plan. 
 
Vestibular rehabilitation is the main treatment used. This is a series of exercises that stimulate the balance system with the aim of settling the dizziness. This is a gradual process and takes time. The amount of time is variable and what is looked for is steady improvement rather than a specific target time in the future to be better. Unfortunately if the exercises are pursued too vigorously they will make the symptoms worse and conversely if not pursued enough they will have little benefit . This is perhaps similar to trying to get fit at the gym. If you do too much you feel dreadful and if you do too little you never get fit. It is important that the exercises are monitored by a professional skilled in the administration of these exercises in this condition.  
 
Medication is often used in combination with vestibular exercises. My preference is for patients to start the exercises initially and add medication depending on the response to the exercises although is determined on an individual basis. The medications used specifically for PPPD are in a class of drugs often used to treat anxiety and depression. It has been identified that these medicines are useful fro teh condition and are not being used because they are antidepressant or anti-anxiety drugs, just as ,for example, another common antidepressant is frequently used for pain conditions and migraine prevention. The class of drugs are termed SSRIs and somentimes SNRIs - this medicine is started at a low dose and only slowly increased as needed. It may take 8-12 weeks to observe effect from medications and it is normally recommended for a minimum of 12 months.  
 
Overall expectation is for symptoms to settle and this is the case in the majority of poeple. 
 
 
Recommended Further Information; 
 
Neurology website on PPPD 
 
 
 
 
 
 
 
 
 
 
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