Persistent Postural-Perceptual Dizziness

Persistent postural-perceptual dizziness (PPPD) is a condition that makes you feel dizzy often. It can get in the way of daily life. PPPD usually starts after a short-term episode of vertigo or balance problems.

The name of the condition gives clues about what it involves:

• Persistent: Dizziness lasts most days for at least three months.
• Postural: Symptoms get worse when you’re upright — that is, sitting or standing.
• Perceptual: You feel off-balance, even if your surroundings are stable.
• Dizziness: The sensation often feels like swaying or rocking, not spinning.

Normally, the parts of your balance system — including your eyes, muscles, inner ear and brain — work together seamlessly to keep you steady. But with PPPD, these parts stop syncing properly. Each part still works, but they stop working together. This makes you feel off-balance.

PPPD is a newer diagnosis and may be a common cause of long-lasting dizziness. Experts only defined it in 2017, so research is still catching up.

Symptoms of PPPD

If you have PPPD, you’re dizzy more days than not. Dizziness can last for hours, come and go, or worsen as the day goes on. It often feels like swaying or rocking — like you’re on a boat.

Other symptoms may include:

• Brain fog (trouble thinking or focusing)
• Difficulty concentrating
• Feeling disconnected from your body or surroundings
• Short-term memory issues

It’s not just in your head — these symptoms have real causes, often rooted in how your body responds to a trigger.

Causes of PPPD

This condition usually starts after a balance-related event. Common triggers include:

• Acute vertigo
• Benign paroxysmal positional vertigo (BPPV)
• Head injury (like a concussion)
• Ménière’s disease
• Panic attack
• Stroke
• Vestibular migraine
• Vestibular neuritis

Once PPPD develops, everyday movements or settings can keep symptoms going. These secondary triggers include:

• Standing, sitting upright or changing positions
• Taking in a lot of visual input, like scrolling on your phone or shopping in a store
• Walking or riding in a moving vehicle

Even after the initial event has passed, your brain stays hyperfocused on balance — especially posture and visual input. This makes it harder to process signals from your ears, eyes and muscles, so you keep feeling off-balance. It’s frustrating because balance is automatic for most people. But this hyperawareness is automatic if you have PPPD.

Risk factors

PPPD is more common in:

• Women (about four times more likely than men)
• Those with a history of vestibular disorders or mood conditions like anxiety or depression
• People with introverted personality traits, who tend to be more inward-focused

Knowing your risk is important — it helps a provider get to the right diagnosis faster.

How doctors diagnose this condition

Diagnosing PPPD can be tricky. The condition doesn’t involve damage to the parts of your balance system, so vestibular tests often come back normal. Instead, your provider will use a specific set of criteria based on your symptoms.

You may get a PPPD diagnosis if:

• You’ve felt dizzy or unsteady (not spinning) most days for at least three months.
• Your symptoms get worse when you’re upright, moving or processing lots of visual input.
• You had a triggering event, either a temporary episode or an ongoing condition, that caused dizziness.
• Your symptoms interfere with daily life.
• No other condition explains the symptoms.

Even without abnormal test results, your symptoms are real — and a clear diagnosis helps guide the right care.

How is PPPD treated?

There’s no cure, but PPPD treatment can help reduce symptoms and improve your quality of life. Your provider may recommend:

• Vestibular rehab: Helps retrain your balance system and reduce dizziness
• Talk therapy (CBT): Eases anxiety and helps you feel more comfortable in daily life
• Medications: SSRIs or SNRIs may reduce anxiety and help with hyperfocus issues

What can I expect if I have PPPD?

PPPD may not go away completely. But the right treatment can help. Many people can manage their symptoms with a combination of therapy and medication.

Ongoing research is exploring which treatments — or combinations — work best for long-term relief.

Is there anything I can do to feel better?

Managing PPPD takes patience. Because it’s a newer diagnosis, treatment may involve trial and error before you find what works for you.

It’s also important to give yourself grace. Many people with PPPD feel frustrated trying to explain it to others. You may hear that “it’s all in your head.” But that’s not true.

PPPD is a real condition that disrupts your sense of balance. And while it takes effort to manage, support is available. The right care can make a big difference.

Can I drive if I have PPPD?

It depends on how severe your symptoms are. Some people find driving unbearable — it may feel like the car is tilting or that you’re constantly off-balance. Others can drive, but only at slower speeds.

Ask your provider if it’s safe for you to drive, especially while you’re still adjusting to treatment.

Is PPPD just anxiety?

No. PPPD and anxiety are different conditions. But having an anxiety disorder may increase your risk of developing PPPD after a triggering event.

Untreated PPPD can also worsen anxiety, creating a feedback loop. That’s why managing anxiety is often a key part of treatment.