Persistent Postural-Perceptual Dizziness

What is persistent postural-perceptual dizziness (PPPD)?

Persistent postural-perceptual dizziness (pronounced “3-P-D”) is a chronic (long-term) condition that causes frequent dizziness — so much so that it interferes with your quality of life. It typically occurs after a triggering event of acute (short-term) dizziness, vertigo or imbalance.

The words that make up PPPD help explain what’s involved:

• Persistent: You feel dizzy most days for at least three months.
• Postural: The dizziness worsens when you’re in an upright position (sitting or standing).
• Perceptual: You feel dizzy because you perceive yourself or your surroundings as off-balance.
• Dizziness: The dizziness may feel like swaying or rocking (but not spinning, as in vertigo).

When your balance system is working as it should, its parts (including your eyes, muscles, inner ear and brain) coordinate to help you stay balanced within your surroundings. The process is automatic.

But with PPPD, there’s a communication breakdown within the system. Although there’s nothing physically wrong with the individual parts, they’re no longer “syncing up.” As a result, you feel unsteady on your feet.

How common is PPPD?

PPPD is likely a common cause of long-term dizziness. But it’s a new diagnosis, so it’s hard to know just how common it is. It wasn’t until 2017 that experts developed the criteria for defining it as a condition.

There’s still lots to research and learn about PPPD.

What are the symptoms of PPPD?

With PPPD, you’re dizzy more days than you’re not dizzy. The dizziness may last for several hours at a time and worsen as the day progresses, or it may come and go unpredictably.

Dizziness from PPPD feels like swaying or unsteadiness, as if you’re on a boat being rocked by waves. It can occur without any triggers, but it may worsen when:

• You stand, sit upright or change positions.
• You’re moving (walking) or in a vehicle that’s moving (like a car, train or bus).
• You’re taking in a lot of visual information (like scanning the grocery store aisles or scrolling on your phone).

Other PPPD symptoms include:

• Brain fog (having trouble thinking and focusing in general).
• Short-term memory loss.
• Trouble concentrating.

The experience of PPPD may make you feel detached from your body, environment and others. It may cause you to avoid situations or activities you worry may worsen the dizziness.

What causes PPPD?

PPPD usually starts after a “triggering” event, especially an episode or injury that causes a balance issue.

Triggers of PPPD include:

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

With PPPD, your body remembers feeling off-balance even after the event passes. Although you don’t mean to, you remain hyperaware of things that affect balance, like your posture and surroundings. The heightened awareness often leads to anxiety.

Instead of helping, the hyperawareness prevents your brain from processing sensory information from your eyes, muscles and inner ear so you feel steady on your feet. Experts suggest that your brain relies too much on sensory inputs you’re more aware of, like what you see and how you’re positioning your body. Meanwhile, it relies too little on information you’re less aware of, like information about subtle movements you get from your inner ear (vestibular system). As a result, you experience symptoms.

It’s frustrating. The hyperawareness in PPPD is as automatic as maintaining balance is for a person without PPPD.

Risk factors

Some studies show that people assigned female at birth (AFAB) are four times more likely to develop PPPD than people assigned male at birth (AMAB). People with a preexisting condition affecting their balance (vestibular disorder) or a mood disorder, like anxiety or depression, are also more likely to develop PPPD after experiencing a triggering event.

Personality type may play a role, too. Studies show that PPPD is more common in introverts, whose energy and focus are most often directed inward.

How is PPPD diagnosed?

Persistent postural-perceptual dizziness can be challenging to diagnose because it doesn’t involve a problem with any of the individual parts of your vestibular system. So, common tests to check for balance system issues, like vestibular tests, often come back normal.

Instead, your healthcare provider will diagnose you with PPPD based on a set of five criteria related to your symptoms. You meet the criteria if:

• You feel dizzy or unsteady (without the spinning feeling as in vertigo) for most days for at least three months.
• You experience worsening symptoms without specific provocation, but the dizziness can feel even more intense when you’re upright, in motion or processing lots of visual information.
• You experienced a trigger event, either a temporary episode or a chronic condition, that caused the dizziness.
• Your symptoms negatively impact your quality of life.
• Your symptoms aren’t because of another condition.

How is PPPD treated?

There isn’t a cure for PPPD, but there are several treatment options your provider may recommend to help combat the dizziness.

Treatments include:

• Vestibular rehabilitation therapy: Vestibular rehabilitation can help you better understand how your body’s hyperfocus is actually causing your dizziness. Knowing what’s happening can help you learn coping strategies for managing symptoms.
• Talk therapy: Treatments like cognitive behavioral therapy (CBT) can help you manage anxiety that worsens PPPD symptoms. It can also help you develop strategies so you feel more comfortable socializing if you’ve been withdrawing because of your dizziness.
• Medications: Your provider may recommend SSRIs or SNRIs (usually if the SSRIs haven’t helped). While more research is needed to understand how they work in PPPD, they may help ease anxiety and the hyperfocus associated with the condition.

What kind of doctor treats PPPD?

Talk to your primary care provider (PCP) if you have symptoms of PPPD. Depending on your situation, they may refer you to specialty care. Providers who diagnose and treat PPPD include:

• Otolaryngologists (ENTs).
• Otologists (ENTs who specialize in inner ear conditions).
• Neurologists.
• Psychologists or psychiatrists.
• Vestibular physical therapists.

Does PPPD ever go away?

PPPD doesn’t ever completely go away. And it may take some time before you find the right treatment for managing your dizziness.

But most people with PPPD are able to manage their condition with therapy and medications. Experts continue to research how individual therapies and treatment combinations can help people living with PPPD.

How do I take care of myself with PPPD?

If you have PPPD, taking care of yourself means being patient with yourself as you try to find treatments that help. Since this condition is so new, research about the most effective treatments is still in the early stages. You may need to try therapies and medications before you find the right treatment.

Taking care also means allowing yourself some grace as you learn to live with this diagnosis. Many people with PPPD express frustration that they have a hard time explaining to others what they’re experiencing. It may feel as if others just don’t (or won’t) “get it.” You may be told that the condition is “all in your head.”

But that’s not the case. PPPD is a real disorder that disrupts feelings of stability within your body. It’s a condition that you’ll need to work on to manage. But there are providers who are ready to help you.

Can you still drive with PPPD?

Ask your provider whether it’s safe to drive with PPPD. Some people with the condition find that driving makes the dizziness unbearable. It may feel as if your car is tilting. The sense of imbalance may make it difficult to drive safely. Others are able to drive but at speeds well below the speed limit.

Your situation depends on how severe your dizziness is and if you’ve found the right treatment to manage it.

What questions should I ask my healthcare provider?

Questions to ask include:

• What likely caused my PPPD?
• What triggers should I avoid to prevent the dizziness from worsening?
• What activities are unsafe, given my diagnosis?
• What treatments would you recommend?
• What criteria will let us know if treatment is successful?

Is PPPD just anxiety?

PPPD and anxiety are two different conditions. But you may be more at risk of developing PPPD if you already have an anxiety disorder and then experience a triggering event. Living with untreated PPPD can perpetuate a negative feedback loop that makes anxiety worse.

This is why treatments for anxiety are often a part of PPPD treatment.

A note from Cleveland Clinic

Reach out to a healthcare provider if you’re experiencing frequent dizziness and you’re not sure why. It may take a while for your provider to determine that persistent postural-perceptual dizziness (PPPD) is what’s causing your balance issues. The sooner you seek help, the sooner you’ll find the right treatment plan to help you feel steady on your feet again. PPPD is a lifelong condition, but it doesn’t have to diminish your quality of life. You can learn to manage it with the right care.