Vestibular disorders
Persistent Postural-Perceptual Dizziness (PPPD)
This information is intended as a general introduction to the topic. Since every person is affected differently by balance and dizziness problems, you should consult your doctor for individual advice.
For reasons of readability, the generic masculine form is used and the simultaneous use of the male, female, and diverse (m/f/d) forms is omitted. Unless otherwise specified, the personal designations used in this patient information refer to all genders.
What is persistent postural-perceptual vertigo?
Persistent postural-perceptive dizziness (PPPD) is the most common cause of chronic (long-lasting) dizziness. It is usually treatable, especially if diagnosed early.
PPPD is usually triggered by an attack of vertigo. After this initial attack, the person continues to have feelings of movement, dizziness, unsteadiness or lightheadedness that can last for hours or days. These symptoms almost always occur, but can be better or worse at times. Sitting and standing upright and complex patterns and movements often exacerbate the symptoms. This is why people with PPPD are often afraid of losing their balance or falling. They may avoid situations that exacerbate their symptoms to the point where they begin to severely impact their lives.
PPPD can be very frustrating for sufferers. Many healthcare professionals are not well versed in dizziness and the symptoms of PPPD can be vague and difficult to describe. As a result, the condition often goes undiagnosed for a long time and many sufferers are also given incorrect diagnoses (such as cervical vertigo), leading to even more confusion. PPPD can severely affect work, school, leisure and family life.
PPPD was defined as a disorder in 2015. Prior to this, various names were used for disorders with similar symptoms, including phobic vertigo, functional vertigo, visual vertigo and chronic subjective vertigo.
Researchers are not sure exactly how many people suffer from PPPD. However, some studies suggest that up to 25% of people who have a vestibular disorder such as neuritis vestibularis, Meniere's disease or benign paroxysmal positional vertigo (BPPV) go on to develop PPPD.
PPPD can occur at the same time as another vestibular disorder. For example, someone may have both Meniere's disease and PPPD. And some people with Meniere's disease may never develop PPPD.
PPPD appears to be more common in women and often develops between the ages of 20 and 50.
Summary
- The most common cause of chronic dizziness.
- Can last three months or longer (even decades).
- In some people, it begins after an event that triggers vertigo, e.g. an inner ear disorder.
- Instead of fully recovering and calming down, the brain remains on high alert and hypersensitive.
- The anxiety often begins with movements, situations and stimuli that trigger the symptoms.
- Daily life is usually considerably impaired.
- The disease leads to a vicious circle: as the anxiety increases, so do the symptoms.
- The symptoms are real - NOT imaginary.
- Treatment usually involves "retraining" the brain through a mixture of vestibular rehabilitation, medication and counseling.
- There is no quick fix, but with time, understanding and the right treatment, a cure is possible.
What causes persistent postural-perceptual vertigo?
The brain's balance system combines information from many sources, including:
- the vestibular system (the semicircular canals and macula organs in the inner ear), which perceives head movements and head movement speeds
- the visual system that perceives the movement of your surroundings
- the proprioceptive system, which perceives signals about position, pressure, movement and vibration from the legs and feet and the rest of the body
Normally, you are not consciously aware of all these different sources of information. The balance system combines them for you in the background and you can stand, walk or turn your head without having to think about how to keep your balance. But with PPPD, perception is no longer seamless. You start to notice the different signals, especially if they don't all match up. This can make you feel like you're moving or about to fall even though you're standing still.
Wenn das Gehirn denkt, dass du in Gefahr bist zu fallen, reagiert es automatisch, um dich zu schützen. Denk daran, wie du dich fühlst, wenn du auf Eis gehst oder auf einer Leiter stehst: Dein Körper wird steif, du machst kürzere Schritte und konzentrierst dich darauf, aufrecht zu bleiben. Gleichzeitig nutzt das Gleichgewichtssystem weniger Informationen aus dem vestibulären System und mehr aus dem visuellen System. Normalerweise kehrt das Gleichgewichtssystem in den Normalzustand zurück, wenn die Gefahr eines Sturzes vorüber ist. Aber bei PPPD bleibt das Gehirn stattdessen im “Hochrisikomodus”. Dadurch entsteht ein Teufelskreis:
- You worry that you might fall and pay more attention to keeping your balance.
- The brain remains on alert and relies more on visual stimuli.
- Visual signals such as rapid patterns and movements indicate that you are in danger of falling.
Diese Beschreibung mag den Anschein erwecken, als sei PPPD “nur in deinem Kopf”, aber die Symptome sind real. PPPD hat einige Gemeinsamkeiten mit Angststörungen, ist aber keine psychische Störung. Einige Studien haben Unterschiede in der Gehirnaktivität von Menschen mit PPPD im Vergleich zu Menschen ohne PPPD festgestellt. Diese Unterschiede können es dem Gehirn erschweren, verschiedene Informationsquellen zu integrieren und Gefahren richtig einzuschätzen.
PPPD is usually triggered by a first episode of dizziness or balance disturbance. This first episode can be triggered by many different causes that disrupt the balance system, such as
- a vestibular disorder such as:
- Menière's disease
- Vestibular neuritis
- Benign paroxysmal positional vertigo (BPPV)
- Isolated otolith dysfunction
- Vestibular migraine
- mild traumatic brain injury (TBI)
The first episode of dizziness or gait instability can also be caused by a psychological event, e.g. anxiety or a panic attack. Panic attacks and anxiety can cause physical symptoms such as dizziness, light-headedness, rapid heartbeat, shortness of breath, sweating, trembling, muscle tension, tiredness or nausea.
PPPD can cause various symptoms, including:
- Swaying dizziness (as if you are swaying or rocking, even when you are sitting or standing still).
- Vague, diffuse feelings of lightheadedness (as if slightly intoxicated).
- Postural and gait instability
- Mild dissociative disorder (e.g. the feeling of being "beside oneself" or floating)
These symptoms occur on most days for at least three months. They can last for hours. However, they do not have to occur every day.
Many people with PPPD find it difficult to describe their symptoms. They often feel "not clear-headed", "foggy" or not like themselves.
People with PPPD often feel worse when:
- they stand or sit upright
- they stand or sit upright
- they see complex patterns, such as a patterned carpet, wallpaper or a supermarket aisle
- they are traveling on foot or by car
The symptoms sometimes get worse when the person is tired or pays more attention to the symptoms, and better when the person is distracted. The symptoms are usually persistent and last for a long time.
The pattern of symptoms may vary slightly depending on what originally caused the PPPD:
- If it was caused by an acute problem or an episodic problem, PPPD symptoms may begin when the original problem improves. Symptoms may come and go at first and become chronic in the long term.
- If the cause is a chronic problem, PPPD symptoms can develop slowly and gradually get worse.
People with PPPD may also develop other disorders, such as:
- Neck tension
- Exhaustion and tiredness
- Fear of falling
- Fear or avoidance of situations that trigger dizziness, such as crowded places or leaving the house
Diagnosis of persistent postural-perceptual vertigo
PPPD can be diagnosed by a specialist in dizziness such as a neurologist, an ENT specialist or a psychologist.
There is no test that is specific for PPPD. However, PPPD is not a diagnosis of exclusion: the diagnosis is not made because no other cause for the symptoms could be found. The diagnosis is made on the basis of clinical criteria.
These specialized doctors will take a detailed medical history, perform a neurological examination, and carry out various tests to assess the function of your vestibular system.
You may undergo some of the following diagnostic tests:
- General physical examination
- Vestibular functional examination
- Balance tests
- Blood tests
- Imaging (CT or MRI scans)
PPPD can occur with other vestibular disorders such as Meniere's disease or vestibular migraine. Therefore, your doctor should also look for signs of triggering diseases.
To be diagnosed with PPPD, a person must have all of the following symptoms:
- One or more symptoms of dizziness (not vertigo but rather dizziness or lightheadedness) and unsteadiness on most days for at least three months. Symptoms last for hours but may increase and decrease in severity. The symptoms do not have to be present continuously throughout the day.
- Persistent symptoms occur without specific provocation but are exacerbated by three factors: (A) upright posture, (B) active or passive movement regardless of direction or position, and (C) moving visual stimuli or complex visual patterns.
- The disorder is triggered by events that cause dizziness, lightheadedness, unsteadyness or balance problems. These include acute, episodic or chronic vestibular disorders, other neurological or medical conditions and psychological stress.
- The symptoms cause considerable suffering or functional limitations.
The symptoms cannot be better explained by another disease or disorder.
Treatment of persistent postural-perceptual vertigo
Once diagnosed, the first step in treatment is to understand what is causing PPPD and why the brain is overreacting to normal signals as if you are in danger. Understanding what is causing your symptoms will help you feel in control and able to participate in treatment.
Die Behandlung von PPPD beinhaltet in der Regel eine “Umschulung” deines Gehirns durch eine Kombination aus vestibulärer Rehabilitation, Strategien gegen Angst, wie z. B. Medikamente und kognitive Verhaltenstherapie (KVT). Du kannst auch von Entspannungsübungen für deinen Nacken und deine Schultern profitieren. Im Idealfall hast du ein Behandlungsteam aus Gesundheitsfachkräften, die zusammenarbeiten, um dir zu helfen. Denke daran, dass sowohl die vestibuläre Rehabilitation als auch die KVT viel Übung und Einsatz erfordern. Deine Therapeuten werden dir die nötigen Techniken beibringen, aber du bist die Person, die sie anwendet.
Therapy option
Vestibular rehabilitation is an exercise-based therapy for dizziness. Its goal is to help your brain relearn how to balance and respond to signals from the visual and vestibular systems. A certified IVRT® Dizziness and Vestibular Therapist with experience in PPPD can help you set treatment goals and develop an individualized program for your needs.
It is very important to start gradually with the exercises and to increase them slowly and steadily.
Doing too much too soon can worsen the symptoms of PPPD. The certified IVRT® Dizziness and Vestibular Therapist will monitor your progress. The frequency, duration and complexity of the exercises will be gradually increased depending on your response. Treatment may extend over several months.
Therapy option
Your doctor may decide to treat your PPPD with medication. Note that medication alone usually does not completely relieve PPPD symptoms. Two types of antidepressants can be used:
- SSRIs (selective serotonin reuptake inhibitors), including fluvoxamine, paroxetine and sertraline
- SNRIs (serotonin-norepinephrine reuptake inhibitors), which are usually tried when two SSRIs have not worked
These medications are used to treat depression and anxiety, but they can also help with PPPD. They all work in slightly different ways. If the first medication doesn't work or has too many side effects, your doctor may suggest trying a different one.
It is important to start with a low dose and gradually increase the dose. Inform your doctor if you have any side effects. It usually takes 8 to 12 weeks for the medication to start working. If you find a medication that helps with your symptoms, you may need to take it for several months. Don't stop your medication or change your dose without talking to your doctor.
Some medications used to treat other forms of dizziness, such as dimenhydrinate, betahistine, tranquilizers and other antidepressants, have not been shown to be effective in treating PPPD. Some of them may even slow down your recovery. Be sure to discuss all medications with your doctor, including over-the-counter and herbal products
Therapy option
Cognitive behavioral therapy (CBT) is a form of psychotherapy. It usually lasts a relatively short time and is geared towards a specific goal.
CBT focuses on the relationship between your thoughts (cognition) and your behavior. Cognition includes your conscious thoughts (which you can control), your automatic thoughts (which you may not be able to control) and your core beliefs (called schemas). In CBT you learn how to:
- recognize and identify your thoughts and beliefs
- look at your thoughts and beliefs from different angles
- change your behavior patterns
KVT should help you with PPPD:
- Overcoming fears
- Manage symptoms when they occur
- no longer avoid situations that could trigger symptoms
- Gaining self-confidence
Some studies have shown that just 3 sessions of CBT lead to an improvement in symptoms in 3 out of 4 PPPD patients.
Other forms of anxiety management such as mindfulness-based stress reduction can also be helpful in PPPD treatment.
What happens next?
What you can expect in the future.
So far, there is not much research on recovery from PPPD. Vestibular rehabilitation seems to help many people with PPPD, especially when combined with patient education and/or anxiety management.
PPPD symptoms may never go away completely, but the skills you learn in vestibular rehabilitation and CBT should alleviate symptoms and help you return to your normal activities
