LET’S TALK ABOUT . . .

PPPD
can be vague and hard to describe, so it may not
Key points be diagnosed for some time. PPPD can interfere
with work, school, leisure and family life.
• PPPD is a common cause of long-lasting PPPD was defined as a disorder in 2015. Before
dizziness. that, several different names were used for
conditions with similar symptoms, including phobic
• The brain over-reacts to normal signals from postural vertigo (PPV), space-motion discomfort
the eyes, inner ear, and muscle and joints. (SMD), visual vertigo (VV) and chronic subjective
dizziness (CSD).
• Anxiety often develops about things that
trigger dizziness. Researchers are not sure how many people have
PPPD. But some studies suggest that as many as 1
• It is not a psychiatric disorder. in 4 people who have a vestibular problem such
as vestibular neuritis, Ménière's disease or benign
• PPPD can overlap with other vestibular postural positional vertigo (BPPV) may go on to
disorders. develop PPPD.

• It is usually treatable, especially if diagnosed PPPD can happen at the same time as another
vestibular disorder. For example, someone can
early.
have both Ménière's disease and PPPD. And some
people with Ménière's disease may never develop
PPPD.
What is PPPD?
PPPD seems to be more common in women, and
Persistent postural-perceptual dizziness (PPPD, often develops between the ages of 30 and 50.
pronounced "three-P-D" or "triple-P-D") is a
common cause of chronic (long-lasting) dizziness. What causes PPPD?
It is usually treatable, especially if it is diagnosed
early. The brain's balance system combines information
from many sources, including:
Usually, PPPD is triggered by an episode of vertigo
or dizziness. After that first episode, the person • the vestibular system (the semicircular canals
continues to have feelings of movement, dizziness, and otoliths in the inner ear), which senses
unsteadiness or light-headedness that can last for when your head tilts, turns or changes speed
hours or days at a time. These symptoms are • the visual system, which lets you see
present nearly all the time, but they can be better or
worse at times. Things like sitting or standing • the proprioceptive system, which sends signals
upright and seeing busy patterns or movement about position, pressure, movement and
often make the symptoms worse. As a result, vibration from the legs and feet and the rest of
people with PPPD often become anxious about the body
losing their balance or falling. They may avoid Normally, you don't consciously notice all these
situations that make their symptoms worse, to the different sources of information. The balance
point where it can start to interfere with their lives. system combines them for you in the background,
and you can stand, walk or turn your head without
PPPD can be very frustrating for people who have needing to think about keeping your balance. But
it. Many health care professionals are not very with PPPD, the experience is no longer seamless.
familiar with dizziness, and the symptoms of PPPD You start to notice the different signals, especially if

SUPPORTING, INSPIRING AND EDUCATING THOSE AFFECTED BY BALANCE AND DIZZINESS DISORDERS
BC Balance and Dizziness

they do not all agree with each other. This can Symptoms of PPPD
make you feel like you are moving when you are
standing still, or like you are about to fall. PPPD can cause various symptoms, including:
If the brain thinks you might be in danger of falling, • non-spinning vertigo (feeling as if you are
it reacts automatically to protect you. Think about swaying or rocking, even though you are sitting
how you feel when you are walking on ice or or standing still)
standing on a ladder: your body gets stiff, you take • unsteadiness (feeling as if you are about to
shorter strides and you focus on staying upright. At fall)
the same time, the balance system uses less
• light-headedness (feeling woozy or as if you
information from the vestibular system and more
from the visual system. Normally, when the risk of are going to pass out)
falling is over, the balance system goes back to • mild dissociation (feeling "spaced out" or as if
normal. But in PPPD, the brain stays in "high-risk" you are floating)
mode instead. This causes a vicious circle:
These symptoms happen on most days for at least
• you worry about falling and pay more attention three months. They may last for hours at a time.
to keeping your balance They may not happen every day.
• the brain stays on the alert and relies more on
visual input Many people with PPPD find it hard to describe
• visual input like busy patterns and movement their symptoms. People often feel "off" or not like
suggests you might be in danger of falling themselves.

This description may make it sound as if PPPD is People with PPPD often feel worse when:
"all in your head," but the symptoms are real. PPPD • they are standing or sitting upright
has some things in common with anxiety disorders,
but it is not a psychiatric disorder. Some studies • they see movement, such as when they are
have found differences in brain activity in people scrolling on a phone, watching TV, looking at
with PPPD, compared with people who do not have traffic or seeing many people walking around
PPPD. These differences may make it harder for • they see complex patterns, such as a busy
the brain to integrate different sources of carpet, wallpaper or a supermarket aisle
information and assess threats properly. • they are walking or riding in a car
PPPD is usually triggered by a first episode of The symptoms sometimes get worse if the person
vertigo or unsteadiness. This first episode may be is tired or paying more attention to the symptoms
caused by many different things that upset the and better if the person is distracted. They are
balance system, including: usually persistent (they continue for a long time).
• a vestibular problem such as Ménière's
disease, vestibular neuritis or benign postural The pattern of symptoms may be slightly different
positional vertigo (BPPV) depending on what originally caused the PPPD:
• vestibular migraine • If it was caused by an acute problem (one that
lasts for a short time and then goes away) or
• mild concussion an episodic problem (one that goes away and
The first episode of vertigo or unsteadiness can comes back from time to time), PPPD
also be caused by a psychological event, such as symptoms may start as the initial problem gets
anxiety or a panic attack. Panic attacks and anxiety better. They may come and go at first and then
can have physical symptoms, including dizziness, become persistent.
light-headedness, fast heartbeat, shortness of • If it was caused by a chronic problem (one that
breath, sweating, shaking, muscle tension, does not go away), PPPD symptoms may
tiredness or nausea. develop slowly and gradually get worse.

2
balanceanddizziness.org
BC Balance and Dizziness

People with PPPD may develop other related Clinical criteria for PPPD
problems, including:
To be diagnosed with PPPD, a person must have
• neck stiffness all of the following:
• problems with how they walk (their gait) • One or more symptoms of dizziness,
• fatigue (tiredness) unsteadiness or non-spinning vertigo on most
days for at least three months. Symptoms last
• fear of falling for hours-long periods, but may wax and wane
• anxiety or avoidance about things that trigger in severity. Symptoms do not need to be
dizziness for them, such as crowded places or present continuously throughout the entire day.
even going outside • Persistent symptoms happen without specific
provocation, but are exacerbated (made
How PPPD is diagnosed worse) by three factors: upright posture, active
or passive motion without regard to direction or
PPPD may be diagnosed by a primary care position, and exposure to moving visual stimuli
doctor or a specialist, such as a neurologist, an or complex visual patterns.
otolaryngologist, an otologist or a psychiatrist.
• The disorder is triggered by events that cause
There is no test that is specific for PPPD. But vertigo, unsteadiness, dizziness, or problems
PPPD is not a diagnosis of exclusion, which is a with balance, including acute, episodic or
diagnosis made when no other cause for the chronic vestibular syndromes, other
symptoms can be found. Diagnosis is based on neurological or medical illnesses, and
clinical criteria. psychological distress.
Your doctor will ask about your symptoms. • Symptoms cause significant distress or
Symptoms like dizziness and vertigo are not always functional impairment.
easy to describe. Try to be as specific as possible • Symptoms are not better accounted for by
about your symptoms and when they get better or another disease or disorder.
worse.
Your doctor will also ask about your medical Treatment and management
history, including any medications you are taking.
Once you have a diagnosis, the first step in
Side effects from medication or dose changes can
treatment is helping you understand what causes
sometimes cause symptoms similar to PPPD.
PPPD and how the brain is responding to normal
You may have some of the following diagnostic signals as if you were in danger. Knowing what is
tests: going on will help you feel more in control and able
to take part in treatment.
• general physical exam
• vestibular function tests Treatment for PPPD usually involves "retraining"
your brain through a combination of vestibular
• balance tests
rehabilitation, strategies to address anxiety, such
• blood tests as medication and cognitive-behavioural therapy
• imaging (CT or MRI scans) (CBT). You may also benefit from relaxation for
your neck and shoulders.
PPPD can overlap with other vestibular disorders,
Ideally, you will have a treatment team of health
such as Ménière's disease. So your doctor will also
care professionals who work together to help you.
look for signs of any related conditions, including
Remember that both vestibular rehabilitation and
conditions that might have triggered PPPD and
CBT take practice and effort. Your therapists will
problems that PPPD might have caused (also
teach you the skills you need, but you are the one
called secondary conditions).
who puts them to use.

3
balanceanddizziness.org
BC Balance and Dizziness

Vestibular rehabilitation It is important to start at a low dose and increase

the dose gradually. Let your doctor know if you are
Vestibular rehabilitation is an exercise-based having any side effects. It usually takes 8 to 12
treatment program for dizziness. Its goal is to help weeks for medication to start working. If you find a
your brain relearn how to balance and how to medication that helps with your symptoms, you may
respond to signals from the visual and vestibular need to take it for several months. Do not stop
systems. A vestibular therapist with experience in taking your medication or change your dose without
PPPD can help you set treatment goals and design talking to your doctor.
an appropriate program.
Some medications that are used to treat other
Vestibular rehabilitation for PPPD may include: forms of dizziness, including dimenhydrinate
(Gravol®), betahistine (Serc®), sedatives and other
• Habituation, a type of rehabilitation that antidepressants, have not been shown to be
involves getting the brain used to signals that effective to treat PPPD. In fact, some of them may
trigger dizziness. This is done through slow down your recovery. Be sure to discuss all
repeated, controlled exposure to signals such medications with your doctor, including over-the-
as complex patterns, busy environments and counter and natural products.
head movements. You may do exercises
indoors and outdoors. You may go on short Cognitive-behavioural therapy
trips to places that trigger symptoms, such as
Cognitive-behavioural therapy (CBT) is a type of
grocery stores or shopping malls.
psychotherapy. It usually lasts for a relatively short
• Breathing and relaxation exercises, which help time and is focused on a specific goal.
to regulate the autonomic nervous system.
CBT is focused on the relationship between your
• Walking and other aerobic activities. thoughts (cognition) and behaviour. Cognition
includes your conscious thoughts (which are under
your control), your automatic thoughts (which may
It is very important to start exercises gradually and
not be under your control) and your core beliefs
increase them slowly and steadily. If you start doing
(known as schemas). CBT teaches you how to:
too much, too soon, it can make the symptoms of
PPPD worse. Treatment may last for several • notice and identify your thoughts and beliefs
months.
• consider your thoughts and beliefs from
Medication different viewpoints
• change your behaviour patterns
Your doctor and you may decide to use medication
in your PPPD treatment. Note that usually For PPPD, the goals of CBT are to help you:
medication alone does not fully address PPPD
symptoms. Two types of antidepressants may be • manage anxiety
used:
• cope with symptoms when they happen
• SSRIs (selective serotonin reuptake inhibitors),
including fluvoxamine (Luvox®), paroxetine • stop avoiding situations that could trigger
(Paxil®) and sertraline (Zoloft®) symptoms

• SNRIs (serotonin norepinephrine reuptake • gain confidence

inhibitors), which are usually tried if two SSRIs Some studies have found that even 3 sessions of
have not worked CBT help to improve symptoms in as many as 3 in
4 PPPD patients.
These medications are used to treat depression
and anxiety, but they can also help to treat PPPD. Other forms of anxiety management, such as
All of them work in slightly different ways. If the first mindfulness-based stress reduction may also be
medication does not work or if it has too many side beneficial in PPPD treatment.
effects, your doctor may suggest trying a different
one.
4
balanceanddizziness.org
BC Balance and Dizziness

What to expect in the future

So far, there is not much research about recovery
from PPPD. Vestibular rehabilitation seems to help
many people with PPPD, especially if it is combined
with patient education and/or anxiety management.
PPPD may never go away completely, but the skills
you learn in vestibular rehabilitation and CBT
should make the symptoms better and help you go
back to your normal activities.

Sources
View sources used for this handout:
https://bit.ly/372yJoi
Handout updated August 2019

If you find the information in this handout valuable, we ask you for your help. The cause of
supporting those affected by balance and dizziness disorders with up-to-date, evidence-based
information written for Canadians, needs you.
Will you consider becoming its champion by making a gift online or by mail?

This handout is intended as a general introduction to the topic. As each person is affected differently, speak with your
health care professional for individual advice. Copyright © BC Balance and Dizziness. Individuals may print a copy for
their own use. Professional members of BC Balance and Dizziness may distribute copies for their own clients. Written
permission is required from BC Balance and Dizziness for all other uses.

Contact BC Balance and Dizziness:

325-5525 West Boulevard info@balanceanddizziness.org Lower Mainland: 604-878-8383
Vancouver, BC V6M 3W6 Toll free:1-866-780-2233

5
balanceanddizziness.org