Persistent Postural-

DISORDERS Perceptual Dizziness

Based on an article written by Dr. Jeffrey P. Staab

HISTORY
NOT Psychiatric
PPPD typically starts In 1986, German neurologists Thomas Brandt and Marianne Dieterich
shortly after an event first described a condition that they called phobic postural vertigo (PPV).
that causes acute vertigo, Symptoms included postural dizziness without vertigo and fluctuating
unsteadiness, dizziness, unsteadiness provoked by environmental or social stimuli (e.g. crowds),
or disruption of balance. which could not be explained by some other neuro-otologic disorder.
Triggers included a pre-existing vestibular disorder, medical illness or
psychological stress.

Behavioral criteria of PPV included the presence of an obsessive-

ARTICLE compulsive personality, mild depression, and anxiety. Studies on PPV
showed that it was NOT a psychiatric disorder, but rather a neuro-otologic
condition with behavioral elements.

In the early 2000s, the American team of Jeffrey Staab, Michael

049 Ruckenstein, & their colleagues performed studies to update the concept
of PPV and described the clinical syndrome of chronic subjective dizziness
(CSD). The symptoms of CSD included non-vertiginous dizziness and
unsteadiness that was increased by a person’s own motion, exposure
to environments with a complex or
DID THIS ARTICLE moving stimuli (e.g., stores, crowds), and
HELP YOU? performance of tasks that required precise
visual focus (e.g., reading, using a computer).
SUPPORT VEDA @
VESTIBULAR.ORG Other vestibular experts described space-
motion discomfort and visual vertigo,
symptoms that overlapped to some extent
with PPV and CSD.

5018 NE 15th Ave. In 2010, scientists from around the world

Portland, OR 97211 began a process of identifying the most
1-800-837-8428 important features of these syndromes. In
info@vestibular.org early 2014, they reached a consensus on
vestibular.org the key symptoms and defined a diagnosis
of Persistent Postural-Perceptual Dizziness
(PPPD).

VESTIBULAR.ORG :: 049 / DISORDERS 1

 Other medical problems, such as dysrhythmias and
adverse drug reactions that manifest with acute
THE PRIMARY bouts of vertigo, unsteadiness or dizziness are less
SYMPTOMS OF PPPD common triggers of PPPD.

ARE PERSISTENT PPPD rarely starts slowly and gradually without a

SENSATIONS OF triggering event, although it is not always possible
to sort out the cause.
ROCKING OR SWAYING
UNSTEADINESS AND/ Anxiety or mild depression may be present as
comorbidities. However, they are not symptoms of
OR DIZZINESS WITHOUT PPPD, as they were with PPV.
VERTIGO LASTING 3
PPPD may coexist with other vestibular disorders,
MONTHS OR MORE. which can confuse the diagnosis since patients may
exhibit other symptoms, including vertigo.

Patients with PPPD may have a history of vertigo,

suggesting a previous vestibular dysfunction.
The World Health Organization has included Patients typically exhibit chronic symptoms due to
PPPD in its draft list of diagnoses to be added the accumulated exposure to motion stimuli, making
next edition of the International Classification of them more susceptible to recurrence of symptoms.
Diseases (ICD-11) in 2017.
Patients with PPPD avoid situations that may
Symptoms exacerbate symptoms because they don’t want to
feel worse physically. Some patients also avoid
• The primary symptoms of PPPD are persistent these situations because they are afraid that
sensations of rocking or swaying unsteadiness something terrible might happen. Thus PPPD is a
and/or dizziness without vertigo lasting 3 physiological disorder that can have psychological
months or more; consequences.
• Symptoms are present on more days than not
DIAGNOSIS
(at least 15 of every 30 days); most patients
have daily symptoms.
Physical exams, laboratory tests, and neuroimaging
• Symptoms are typically worse with: are NOT used to diagnose PPPD itself, but to
οο Upright posture (standing or sitting identify potentially comorbid conditions, which
upright) can lead to a suspected diagnosis of CSD.
οο Head or body motion Physical examination and laboratory testing are
often normal or may show a current or previous
οο Exposure to complex or motion-rich vestibular problem that does not fully explain the
environments patient’s symptoms.
• PPPD typically starts shortly after an event
that causes acute vertigo, unsteadiness, What to look for:
dizziness, or disruption of balance such as: • Primary symptoms (unsteadiness &/
οο A peripheral or central vestibular or dizziness, present 3 months or more);
disorder (e.g., BPPV, vestibular neuritis, fluctuate in severity depending on triggers;
Meniere’s disease, stroke) • Primary symptoms are related to body
οο Vestibular migraine posture – symptoms are most severe when
οο Panic attacks with dizziness walking or standing, less severe when sitting,
and minor or absent when lying down.
οο Mild traumatic brain injury (concussion
or whiplash)
Factors that provoke or exacerbate symptoms:
οο Dysautonomia (disease of the
• Active or passive motion of self not related to
autonomic nervous system)
specific direction or position;

2 VESTIBULAR.ORG :: 049 / DISORDERS

 • Exposure to moving visual stimuli or complex Medication
visual patterns; performance of precision
visual tasks (e.g. reading, computer). In clinical trials for the use of SSRIs (selective
serotonin reuptake inhibitors) and SNRIs (serotonin
Triggering events: norepinephrine reuptake inhibitors) on patients with
• Acute or recurrent peripheral (more common) CSD:
or central (less common) vestibular disorder; • Primary symptoms were reduced by at least
• Medical problems or psychiatric disorders that half in 60%-70% of patients to entered the
produce unsteadiness or dizziness. trials and 80% of patients who completed at
least 8-12 weeks of treatment;
BEHAVIORAL FACTORS • Dropout rates due to medication intolerance
averaged 20% (adverse effects included
Behavioral assessment of PPPD patients may nausea, sleep disturbance, and sexual
be normal and/or show low levels of anxiety and dysfunction).
depression. Other psychiatric disorders may also
present. Patients who do not respond to one SSRI have
a good chance of responding to another one.
Behavioral factors contribute to PPPD in three Increased dizziness was rarely observed, and
ways: comorbid anxiety and depression were improved.
• Individuals with anxious, introverted Treatment must be maintained for at least one year
temperaments or a pre-existing anxiety or more to minimize relapse.
disorder may be predisposed to PPPD after a
precipitating event; Benzodiazepines and other vestibular suppressants
are NOT effective as a primary treatment for PPPD.
• Individuals who exhibit a high level of anxiety
while they are experiencing vestibular
symptoms may be more likely to develop
PPPD;
• A primary predictor of PPPD is when a patient
who first experiences an acute vestibular
episode displays high levels of anxiety and
caution, coupled with expectations for a
negative outcome. This heightened anxiety is
like a self-fulfilling prophesy, in that the result
is generally a poor rate of recovery.

High anxiety intensifies postural instability and

reactivity to motion stimuli during acute vestibular
trauma and slows recovery by preventing the
patient from developing adaptive strategies.

Anxiety and depression can increase the likelihood

of developing PPPD. Vestibular Balance Rehabilitation Therapy
• 60% of patients with PPPD had clinically (VBRT)
significant anxiety;
Vestibular/balance rehabilitation therapy works to
• 45% of patients had clinically significant
desensitize or habituate patients to motion stimuli.
depression;
• 25% of patients had neither. In 2014, the first small study on the efficacy of
VBRT specifically for PPPD patients was completed.
TREATMENT Its results support previous clinical experience and
suggest the following:
By 2014, no large scale, randomized, controlled
• VBRT reduces the severity of vestibular
trials of therapeutic interventions for CSD had been
symptoms by 60%-80%, resulting in
conducted, but several smaller studies have been
increased mobility and enhanced daily
completed around the world.
functioning;

VESTIBULAR.ORG :: 049 / DISORDERS 3

 • VBRT may be effective in reducing anxiety 2. World Health Organization, International
and depression in PPPD patients; Classification of Diseases, ICD-11 beta draft,
• Patients should continue VBRT for 3-6 http://apps.who.int/classifications/icd11/
months to receive maximum benefit from the browse/l-m/en#/http%3a%2f%2fid.who.
treatments. int%2ficd%2fentity%2f2005792829

©2014 Vestibular Disorders Association

VeDA’s publications are protected under copyright.
For more information, see our permissions guide at
vestibular.org. This document is not intended as a
substitute for professional health care.

Counseling

Psychotherapy is not a very successful treatment

for fully established, longstanding PPPD, but it may
be able to reduce the chances of developing PPPD
if used early. Older trials showed that cognitive
behavioral therapy (CBT) had a moderate effect
for reducing dizziness in patients with PPPD, but,
unfortunately the benefits did not last after therapy
was finished. More recent trials showed that just
three CBT sessions resulted in significantly reduced
dizziness and dizziness-related avoidance symptoms
when treatment was started within 8 weeks of
the triggering event (i.e., as PPPD symptoms were
starting, but before they were fully established).
Under those circumstances, the benefits seemed to
last.

MECHANISMS

Research studies are beginning to uncover

physiologic processes associated with PPPD.
Investigations have provided hints about alterations
in postural control, visual perception of space, and
processing of vestibular and visual stimuli in the
brain. More details should be forthcoming over the
next few years.

REFERENCES

1. Staab JP. Chronic Subjective Dizziness.

Continuum (Mineapp.Minn.). 2012 Oct; 18(5
Neuro-otology):1118-41.

4 VESTIBULAR.ORG :: 049 / DISORDERS

NOTES:

VESTIBULAR DISORDERS ASSOCIATION

5018 NE 15th Ave. Portland, OR 97211
1-800-837-8428 info@vestibular.org vestibular.org

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