Persistent Postural-Perceptual Dizziness: A New Diagnosis

Persistent Postural-Perceptual Dizziness (PPPD) is a new diagnosis that is unfamiliar to many health care providers and patients alike. The diagnosis is new in name only, as the primary physical symptoms of this disorder have been reported in medical literature dating back to the 1800s. These core physical symptoms include persistent, non-spinning dizziness and/or unsteadiness that are worsened by complex visual environments, as well as by active or passive movement.

A complex visual environment that may be bothersome to someone with PPPD could include a grocery store aisle or flooring that has a complex or intricate pattern. Examples of passive motions include riding as a passenger in a vehicle or riding an elevator or escalator.

What is Persistent Postural-Perceptual Dizziness (PPPD)?

The Committee for the Classification of Vestibular Disorders of the Barany Society created a consensus document for PPPD in 2017 to allow for greater standardization in diagnosis.

The consensus document for PPPD also allowed for the combination of several conditions which share similar primary symptoms including: phobic postural vertigo, space motion discomfort, visual vertigo, and chronic subjective dizziness. The consensus document requires that all five of the criteria be met in order to make the diagnosis of PPPD.

The recommended criteria for diagnosis include:

1. One or more symptoms of non-spinning dizziness or unsteadiness that are near constant for ≥ 3 months.
2. The symptoms are spontaneous and persistent, but should be exacerbated by an upright posture, active or passive motion, and exposure to complex visual patterns or visual motion.
3. The disorder is precipitated by conditions that cause vertigo, unsteadiness, dizziness, and imbalance including: vestibular disorders, psychological distress, and neurologic or medical illnesses
4. The symptoms cause significant distress or functional impairment.
5. Symptoms are not better accounted for by another disease or disorder.

What Causes PPPD?

PPPD is thought to be a central (brain) maladaptation, most often following an acute episode(s) of dizziness. As the symptoms associated with the acute episode(s) resolve, the more persistent symptoms of PPPD become evident. Rarely does PPPD occur in isolation without a precipitating event.

Dizziness symptoms can be caused by a multitude of pathologies, but peripheral (ear) vestibular disorders are common, accounting for around 30-40% of all dizziness seen clinically. Vestibular migraine is thought to be the second most common cause for dizziness, also making it extremely prevalent.

The most common precipitating conditions for one developing PPPD are vestibular disorders, accounting for 25-30% of cases, followed by episodes of vestibular migraine, which accounts for 15-20% of cases.

Other common precipitating conditions include anxiety or panic attacks with dizziness symptoms, traumatic brain or whiplash injury, and autonomic disorders. This does not encompass all possible precipitating events that could lead to PPPD, but rather those that are most common.

How Common is PPPD?

Long-term epidemiologic studies do not currently exist for PPPD and it is not known how prevalent PPPD is in the general population.

PPPD is thought to be fairly common in those who have suffered from vestibular disorders with studies showing PPPD-like symptoms in up to 25% of patients at 3-12 months follow-up.

At Risk Populations

Those with anxiety-related personality traits seem to be at an increased risk for developing PPPD following a dizziness event.

Overall, it seems that women are slightly more likely to develop PPPD than males and the average age of symptom onset is likely to be between 40 to 60 years old.

Assessment and Treatment of PPPD

Assessment by multiple specialties may be required to reach a diagnosis and could include but are not limited to: Otolaryngology, Neurology, Psychiatry, and Physical Therapy. It often takes time to reach a diagnosis of PPPD due to the multitude of potential precipitating events, as well as the need to rule out other potential causes for the symptoms to reach a diagnosis.

As long at there is not a high clinical suspicion for a potentially life-threatening cause of one’s dizziness, it seems logical to complete vestibular assessment early on, as vestibular disorders are relatively common and are the most frequent precipitating event for PPPD. (For more on comprehensive vestibular assessment click here .)

Due to the association between PPPD and one’s level of pre-existing anxiety, it would seem appropriate to measure the level of anxiety early in assessment so treatment for anxiety can be sought if necessary, with the goal of reducing the likelihood of developing PPPD.

The treatment of PPPD should be multidisciplinary just like the assessment for this condition. Appropriate education and treatment for the precipitating event should occur. Vestibular rehabilitation with a physical therapist should be completed. A physician may also prescribe medications such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). Lastly, cognitive behavioral therapy with a therapist can help to reduce the stress and anxiety associated with PPPD.

The consensus document can be reached here for those interested in learning more about the diagnosis, assessment, and treatment of PPPD.

Brady Workman, AuD, is an audiologist in the Balance Disorders program at Wake Forest Baptist Health Center. He has authored several articles relating to balance and vestibular disorders as a regular contributor and co-editor of the Dizziness Depot at Hearing Health & Technology Matters. Brady received his doctorate of audiology from East Tennessee State University in 2018 and is licensed by the North Carolina Board of Examiners for Speech Language Pathologists and Audiologists and is a fellow of the American Academy of Audiology.