PPPD: A Brain Reset Glitch after Vestibular Challenges

Note: Unrelenting Dizziness and Balance issues are symptoms with numerous and diverse causes. They are not normal and must be checked out, the sooner the better.

Persistent Postural-Perceptual Dizziness (PPPD) is classified as a “chronic functional vestibular disorder.” Symptoms are due to a maladaptation of the brain after acute “vestibular trigger events” that cause dizziness, imbalance or unsteadiness and disrupt the function of the balance system.

Normally, the brain adjusts for the challenges and after the offending event is over, it switches back into “normal” mode. However, in the case of PPPD, the brain does not recalibrate itself. Instead, the brain’s processing of balance signals remains out of sync – and people end up with PPPD symptoms.

Triggers can be sudden, recurring or ongoing. The lengthy list includes inner ear infections (labyrinthitis), vestibular neuritis (nerve inflammation), vestibular migraines, BPPV (ear rock dislocation), Ménière’s Disease as well as head injuries, strokes, panic or anxiety attacks and more.

Frustration over lack of diagnostic consensus

Such confusion! In our vestibular support group, we had heated discussions about unpredictable, life-changing balance issues. People felt “off” in unpleasant ways. Some had been told that it was “all in their heads.” Looking back, many of us could pinpoint a trigger event after which problems began.

Though stories and symptoms overlapped, there was little agreement on diagnostic names. I called it the Big Hall Effect. My doctor called it Chronic Subjective Dizziness (CSD). Others spoke about Visual Vertigo (VV), Space-Motion-Discomfort (SMD) or the Supermarket Syndrome – and more. With variations, these are functional vestibular conditions. The physical balance system works but the brain remains stuck in adjustment mode.

Since 2017 – A long overdue unifying diagnostic name

It turns out that scientists also wanted clarity on these often-debilitating balance & dizziness issues. They reviewed past study results and patient cases. They identified and classified shared functional vestibular markers and symptoms and included them into the unifying diagnosis of PPPD – which was also found not to be a psychiatric condition.

Ultimately, researchers settled on five diagnostic criteria to assist physicians and vestibular specialists as they sort out vestibular (balance) complaints. And so, as of 2017, the relatively new PPPD diagnosis is officially listed with the World Health Organization.  

PPPD: What’s in the name?

Those affected suffer from Persistent unpredictable dizziness sensations that may vary in duration and severity. The notion of Dizziness includes swaying, unsteadiness, rocking or floating but not spinning. Symptoms must be present on most days for three months or more for a PPPD diagnosis.

PPPD is Postural as it is aggravated by upright postures and movement – standing, walking, sitting or riding in a car. It is Perceptual because of the brain’s continued altered perception and misinterpretation of balance signals.

 Also, the brain’s already stressed processing capabilities are further challenged by complicated patterns and busy visual stimuli. These can be very disturbing. We had quite a list: Rapidly changing TV pictures, reading, scrolling through emails/texts, fast traffic, milling-about shopping mall crowds, dizzying carpet and tile patterns etc. I would step into a store and before long I would start “floating.” And the world turned into a foggy, scary and fatiguing slo-mo sway.

Effects on quality of life

PPPD can have very negative effects on people’s self-confidence and outlook on life. They feel vulnerable. They become afraid of falling. They worry about their jobs. The unpredictable balance and unsteadiness attacks are often accompanied by fatigue and brain fog. As the brain becomes overwhelmed, many say that they feel – and probably act – as if they were drunk. Trying to avoid looming dangers and embarrassment, people may stay home. Of course, this results in anxiety, depression and isolation, which make things worse.

Difficult Diagnosis

To the frustration of patients, Vestibular Disorders are tricky to diagnose. Nowadays, whole specialty teams may be involved. Multiple disorders can coexist. There are no specific tests for PPPD. Doctors often start with scans and blood tests to check for other physical dizziness causes, such as cardiovascular, blood sugar or thyroid issues. They order ear and stability evaluations and study eye movements. Yet, they find their best clues in the patient’s history and description of symptoms, trigger events and timing.

Managing PPPD to regain stability and confidence

Once PPPD has been diagnosed, a treatment plan specific to the patient is devised. Such a management program may include:

Vestibular Balance Rehabilitation Therapy (VBRT). This is an essential exercise and gaze retraining program led by vestibular physical therapists. The therapy is said to help “retrain the brain.” VBRT is credited by many, including myself, for getting some normalcy back into life.

Cognitive Behavioral Therapy (CBT) supports patients as they learn more about the condition. Better understanding eases anxiety. People’s thinking changes, which helps them develop coping skills for independent daily living.  Learning about it is empowering and helped me the most.  

Antidepressant medications such as SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin norepinephrine reuptake inhibitors) can also be used, depending on the case. They help relieve anxiety and depression, but are also said to have balance stabilizing effects.  

Be a good historian

In the end, PPPD still holds plenty of mysteries. For instance, why do some people come out of trigger events just fine while others are hit by PPPD? This is an area of current research – and yes, there are differences and predisposing factors. Until we learn more, be a good historian. The secret to improved stability and quality of life may lie in the details that we provide.

For further reading: https://vestibular.org/article/diagnosis-treatment/types-of-vestibular-disorders/persistent-postural-perceptual-dizziness/