Persistent Postural-Perceptual Dizziness

Original Editor - Alyssa Brooks-Wells
Top Contributors - Alyssa Brooks-Wells and Kim Jackson

Description

Persistent Postural-Perceptual Dizziness (PPPD or 3PD) is a chronic disorder presenting with continual subjective dizziness or unsteadiness. Upright positions and environments with complex visual stimuli worsen symptoms and are perceived as a threat. These predominant symptoms may lead to incidental complications such as fear avoidance and functional gait abnormalities.

Incidence and Prevalence

The World Health Organization (WHO) included PPPD in the 11th edition of the International Classification of Diseases as a new diagnosis to unify varied and overlapping predecessors such as phobic postural vertigo, space-motion discomfort, visual vertigo, chronic subjective dizziness, psychogenic gait disorders, etc.

As this disorder has recently been redefined, valid data is difficult to obtain. Prospective studies have found that 25% of individuals developed PPPD 3-12 months after acute or episodic vestibular disorders (e.g. vestibular neuritis, benign paroxysmal positional vertigo (BPPV)). In 20% of cases, a vestibular migraine was a triggering event. Panic attacks or generalized anxiety preceded 15% of cases, and 7% were precipitated by an autonomic disorder.

Diagnosis

All Barany Society Criteria must be met for a diagnosis of PPPD and thus is reliant on subjective history. PPPD symptom intensity can vary from distraction and energy levels but are overall chronic and persistent. This variability should not be mistaken for inauthenticity, as it is possible of the presentation.

Barany Society Criteria for PPPD:

1+ symptoms of dizziness, unsteadiness or non spinning vertigo on most days for at least three months Symptoms last for prolonged (hours long) periods of time, but severity may wax and wane Symptoms need not be present continuously throughout the entire day Persistent symptoms occur without specific provocation, but are exacerbated by three factors: upright posture active or passive motion without regard to direction or position exposure to moving visual stimuli or complex visual patterns The disorder is triggered by events that cause vertigo, unsteadiness, dizziness, or problems with balance, including acute, episodic, or chronic vestibular syndromes, other neurological or medical illnesses, and psychological distress When the precipitant is an acute or episodic condition, symptoms settle into the pattern of criterion A as the precipitant resolves, but they may occur intermittently at first, and then consolidate into a persistent course When the precipitant is a chronic syndrome, symptoms may develop slowly at first and worsen gradually. Symptoms cause significant distress or functional impairment Symptoms are not better accounted for by another disease or disorder

A patient might also present with secondary psychiatric symptoms including fear of falling and avoidance behaviors, as well as functional gait abnormalities due to compensations such as body sway or hesitancy. Distracting motor tasks may be effective for the gait pattern to return to normal. This can demonstrate to the patient that it is possible to improve and return to normal gait patterns.

Pathophysiology

PPPD is theorized to develop by three main mechanisms:

1. Stiffened postural control
2. Favoring visual inputs rather than vestibular inputs to process spatial orientation information
3. Failure to modulate the first two processes from higher cortical mechanisms

Outcome Measures

• Dizziness Handicap Inventory: measures a patient's perception of their disability related to their dizziness

Management / Interventions

• Patient Education
  • Acknowledge the patient's symptoms are genuine and common
  • Educate the patient that their symptoms can improve, and the nervous system is malfunctioning rather than permanently damaged
  • Informing the patient on how various factors can trigger their symptoms including physical and emotional health
  • Vestibular rehabilitation can be introduced as a tool to retrain the brain to improve movement and stability
• Individualized Vestibular Rehabilitation
  • The physical therapist should focus the goals of rehab on improving function and movement rather than the impairment
  • Habituation exercises are most appropriate to address the patients subjective dizziness. It is recommended to start slow and progress gently, as exercises that are too aggressive may aggravate their symptoms.
  • Patients have shown to benefit from interventions to desensitize the patient to busy visual input
• Medications
  • Two classes of antidepressants may be effective in decreasing symptoms of dizziness: selective serotonin reuptake inhibitors (SSRI) and serotonin norepinephrine reuptake inhibitors (SNRI)
• Psychological Therapy
  • Cognitive Behavioral Therapy (CBT) may be an effective intervention for PPPD to reframe beliefs, decrease fear and worries and improve overall psychological health as this can be effected by chronic subjective dizziness

Differential Diagnosis

• Benign Paroxysmal Positional Vertigo (BPPV)
• Vestibular Neuritis and Labyrinthitis
• Neurologic Disorders (such as multiple sclerosis)
• Cerebral Vascular Accident
• Traumatic Brain Injury or Concussion
• Meniere's Disease
• Migraine (vestibular migraine)
  

Resources

A patient education resource can be found here for further information.