Might that Persistent Dizziness be PPPD?

Dizzy and unsteady? Check it out!

Dizziness is a symptom with numerous and diverse causes. It is not normal and must be checked out, the sooner the better. Untangling the complexities of “dizziness” is a serious diagnostic challenge for doctors. 

Persistent Postural-Perceptual Dizziness (PPPD) is only one of the reasons why people may suffer from chronic, on-and-off symptoms of dizziness and unsteadiness. The Bárány Society ─ International Society for Neuro-otolgy ─ set forth strict criteria that must be met before a PPPD diagnosis to be made.   

A new name for an old problem. 

PPPD is an ongoing or chronic condition that results from a malfunction between the inner-ear vestibular (balance) system and the brain. It is classified as “a chronic functional vestibular disorder.” 

PPPD typically follows an event that sets off balance disturbances, dizziness, vertigo, unsteadiness etc. Such trigger events can be sudden, recurring or ongoing. It is estimated that 1 in 4 patients with vestibular ailments, such as vestibular neuritis, BPPV – a dislocation of “ear rocks”, or Meniere’s Disease end up with PPPD. 

However, vestibular migraines, panic reactions, head injuries like concussions or a stroke can also set off dizziness attacks that may result in PPPD. 

Brief balance review

Information signals are sent to the brain from the eyes, the inner ear balance or vestibular system and from sensors located throughout the body in muscles, joints and limbs. Various areas of the brain sort and coordinate these signals, which enables movement in different directions and environments while maintaining balance.

Disagreements between the inputs from these three areas lead to confused information for the brain. This results in dizziness and balance disruptions to which the brain adapts. Once the offending event that caused the input disagreements is over, the brain switches back into normal mode.

No balance reset button in PPPD

For those with PPPD, feelings of unsteadiness, lightheadedness and dizziness continue. Some people report rocking or swaying motions. Some feel like floating on air. However, “spinning” episodes are not characteristic of PPPD. Symptoms may vary in severity throughout the day, but they do not stop – for at least 30 days according to the diagnostic criteria.  

PPPD is aggravated by standing or sitting upright, active movement such as walking, passive movement such as riding in cars or in elevators. Watching crowds milling about at the mall or traffic in the streets can make the brain believe that the person is in motion when that is not so. Complicated visual cues, such as eyeball-bending carpet or floor patterns are often cited as being particularly distressing.  

Fear of falling

If left unchecked, PPPD symptoms can become incapacitating. Fear of falling puts people on almost continuous alert. The world is full of threats for unpleasant and painful experiences. Patients lose self-confidence and isolate themselves, which may result in anxiety and depression. Changes in behavior, such as avoidance of perceived dangers, hypervigilance and gait changes punctuated by hesitancy when walking or tapping along as if walking on ice are common.   

Managing PPPD 

There are no specific tests for PPPD. Doctors find their clues mostly in the patient’s history. So, when going for an evaluation be prepared with details, especially on symptoms, trigger events, timing and emotional impact. 

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

Vestibular Rehabilitation Therapy(VRT). This is an exercise program led by specially trained physical therapists. Although results may vary, symptoms can be reduced by 60 to 80%. As people desensitize and habituate to motion stimuli, their self-confidence improves and anxiety is reduced. This translates into increased activity and quality of life.  

Cognitive Behavioral Therapy (CBT). For many it is helpful to learn more about the condition and to understand it better. Through information and support CBT aims to change the patient’s thinking and behavioral patterns related to PPPD. In the process, people gain confidence and skills for coping and self-help that allow them to move forward. 

Antidepressant medications such as SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin norepinephrine reuptake inhibitors) can also be used to relieve symptoms.

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For more reading:

Summary of PPPD Diagnostic criteria: https://pubmed.ncbi.nlm.nih.gov/29036855/

https://vestibular.org/article/diagnosis-treatment/treatments/vestibular-rehabilitation-therapy-vrt/

https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral

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