What is Persistent Postural-Perceptual Dizziness?
In 2017, the International Classification of Vestibular Disorders (ICVD) identified a condition called persistent postural-perceptual dizziness or PPPD. The symptoms of PPPD include a constant feeling of being unsteady or dizzy, which may not always be associated with a feeling of spinning (non-vertiginous dizziness). These symptoms are present on most days for three months or longer and can get worse when the person is sitting up straight, standing, walking, or in visually complex environments.
PPPD is usually due to disruptions in how our eyes process what we see (visual processing) and how our bodies maintain balance (postural control). Although it’s categorized as a chronic balance disorder, it can also be linked with issues like migraines, anxiety, and depression. It should also be noted that this condition is more frequently found in women than in men.
Usually, imaging tests and other examinations may not reveal anything extraordinary about this condition. The usual way to manage PPPD involves a combination of strategies. This may include cognitive-behavioral therapy (a type of psychology-based therapy), physical therapy, and medications that affect serotonin (a chemical in the body related to mood).
What Causes Persistent Postural-Perceptual Dizziness?
The exact cause of this health condition isn’t known, but doctors believe it might be due to issues within or between the mechanisms that control our vision and bodily posture. The trigger might be disorders of the ear and brain (neuro-otologic), metabolic conditions such as diabetes, or stress and other emotional strains.
Commonly, the symptoms appear after an episode affecting the inner ear balance, such as vestibular neuritis (inflammation of the inner ear), BPPV (a common cause of dizziness), Meniere’s disease (a disorder of the inner ear), or other pre-existing medical conditions. This condition could be the result of not fully recovering after an inner ear event or lingering issues between different episodes of such events.
Psychological factors also play a role in this condition. It’s often spotted in patients who have high levels of anxiety, overly self-awareness, depression, or keen body self-monitoring.
Risk Factors and Frequency for Persistent Postural-Perceptual Dizziness
Persistent postural-perceptual dizziness is the most frequently occurring long-term balance disorder in people aged between 30 and 50 years. This condition can also affect children. It’s more common in females than in males, with up to four times as many women being affected. However, as this condition has only recently been defined, we need more research to get a clearer picture of who is most likely to experience it.
Signs and Symptoms of Persistent Postural-Perceptual Dizziness
Patients with persistent postural-perceptual dizziness (PPPD) need to be assessed thoroughly, as the determination of their condition mostly relies on their reported symptoms. It’s helpful to inquire about feelings of anxiety or depression due to their potential connection with PPPD. It’s crucial to understand that PPPD isn’t a fall-back diagnosis but has explicit diagnostic standards. Diagnosis shouldn’t be based on vague or unclear complaints, and it’s possible for PPPD to occur along with other health issues. For instance, in PPPD patients, there are experiences of feeling off-balance or swaying, but they don’t usually report actual or near-fall incidents. Tests are applied not necessarily to confirm PPPD but to exclude other possible conditions.
Physical exams generally show normal results in PPPD patients, and this includes normal neurological tests. A specific examination known as the Head Impulse test, Nystagmus, and Test of Skew (HINTS), has less utility in chronic scenarios of dizziness and is more suitable for acute cases, hence, the results of this test usually turn out normal in PPPD patients.
Patients may show signs of swaying during a walking examination, indicating a balance disorder or a disruption in the mechanisms that compensate for this imbalance. However, they typically don’t fall down. It’s still crucial to rule out other potential conditions or look for the presence of concurrent health problems.
Testing for Persistent Postural-Perceptual Dizziness
Persistent postural-perceptual dizziness (PPPD) is a long-lasting condition that affects a person’s sense of balance. It has a very specific set of criteria that must be met for a doctor to diagnose it. Five key criteria have been outlined in the International Classification of Vestibular Disorders:
1. The individual must have symptoms related to balance, such as feeling unsteady, dizziness, or a sensation of non-spinning vertigo, for more than half of the days in a 90 day period. These symptoms should last for hours, distinguishing it from conditions like BPPV (benign paroxysmal positional vertigo). The severity of these symptoms can vary from person to person.
2. The symptoms cannot be triggered by specific events, unlike conditions such as BPPV or orthostatic hypotension (a sudden drop in blood pressure when standing up). However, being upright, seeing moving objects, or trying to move can make the symptoms worse, regardless of which direction the individual is facing or their position.
3. The condition must have been triggered by an event or condition that caused balance problems. This could be another balance-related condition like BPPV, vestibular neuritis (inflammation of the inner ear), or a traumatic brain injury. Other conditions that might play a part include neurological and psychiatric disorders such as anxiety and depression.
4. The condition must be having a negative impact on the person’s life. For instance, patients often report that they feel as though they are swaying from side to side even when they are actually still, or that they are having problems doing things like walking or driving.
5. The final condition is that the symptoms cannot be fully explained by any other medical condition.
Once the above criteria are met, a doctor would diagnose PPPD based on the person’s medical history. Physical and neurological exams are usually normal. Additional tests may be carried out to rule out other conditions, such as the HINTS test, cervical and ocular vestibular evoked myogenic potentials (tests related to inner ear and eye function), brain imaging with an MRI or CT scan, and hearing tests.
Current research suggests that there are differences in the brains of patients with PPPD compared to healthy individuals. They have lower “fluctuation amplitude” and regional uniformity in certain parts of the brain, supporting the idea that PPPD isn’t related to physical structure or psychiatric conditions, but to balance perception.
Treatment Options for Persistent Postural-Perceptual Dizziness
There isn’t a one-size-fits-all way to treat Persistent Postural-Perceptual Dizziness (PPPD), a condition that can make people feel dizzy or unsteady. It’s important to remember that dizziness can come from a variety of sources, including issues in the brain, the inner ear, and the blood vessels.
Some types of medications known as SSRIs (Selective Serotonin Reuptake Inhibitors) and SNRIs (Serotonin and Norepinephrine Reuptake Inhibitors) have been found to help alleviate the dizzy and unsteady feelings associated with PPPD.
Physical therapy, specifically a kind known as vestibular balance rehabilitation therapy, can also help manage PPPD. This therapy aims to train and harmonize the movements of the eyes, head, and body to better respond to motion stimuli — that’s when things around you are moving and your brain needs to adjust to it. The goal of this type of therapy is to increase both balance and self-confidence in patients struggling with balance disorders.
Moreover, a type of psychological therapy known as cognitive-behavioral therapy has proven effective in enhancing the effects of vestibular therapy. It does this by breaking a vicious cycle where anxiety and problems with balance control feed into each other. By addressing the mental health aspect of the struggle with balance, it can make the physical therapy more effective.
What else can Persistent Postural-Perceptual Dizziness be?
If a person is diagnosed with PPPD, they must satisfy five specific criteria. If all five parts of the criteria are not fulfilled, doctors should think about other health issues that might be causing the symptoms. When a patient is feeling dizzy, a variety of conditions could be the cause:
- Post-concussive syndrome
- Stroke
- Lack of physical conditioning
- BPPV (a type of vertigo)
- Vestibular migraine (a type of migraine)
- Panic attacks
- Meniere’s disease (a disorder of the inner ear)
- Heart rhythm problems
- Autonomic disorders (affecting the nervous system)
- Generalized anxiety
- Peripheral neuropathy (nerve dysfunction)
- Semicircular canal dehiscence (a hole in the inner ear)
- Neurodegenerative disorders (progressive loss of nerve cells)
- Functional gait disorder (problem with walking)
- Low blood pressure
What to expect with Persistent Postural-Perceptual Dizziness
There isn’t much research to firmly say if persistent postural-perceptual dizziness, a condition where a person has a feeling of persistent dizziness, imbalance, and/or unsteadiness, lasts for a lifetime. However, it is observed that patients who engage in vestibular balance rehabilitation therapy and cognitive behavioral therapy, coupled with the use of prescribed medication, tend to have a better quality of life. They can also return to their normal daily activities faster than those who don’t do any treatment.
Research also suggests that those who get treatment immediately after the start of the condition tend to do better than those who don’t seek any intervention after the onset. In simpler terms, prompt treatment can make a significant difference in managing this type of dizziness.
Possible Complications When Diagnosed with Persistent Postural-Perceptual Dizziness
People with persistent postural-perceptual dizziness (PPPD) may experience increased levels of anxiety and depression, and become more aware of their bodily sensations. They may also develop additional issues, like stiffness in the neck, difficulty walking, fear of falling, extreme fatigue, and a sense of disconnection from their surroundings. It’s crucial to remember that PPPD is not a mental health illness, but it can lead to mental health concerns because it makes life more challenging for these individuals.
Furthermore, individuals with PPPD might become fearful of leaving their homes because they want to avoid situations that could make their symptoms worse.
Here are the common complications associated with PPPD:
- Anxiety
- Depression
- Increased bodily awareness
- Stiffness in the neck
- Difficulty walking
- Fear of falling
- Agoraphobia (fear of leaving home)
- Fatigue
- Dissociation (feeling disconnected)
Recovery from Persistent Postural-Perceptual Dizziness
For those struggling to return to their everyday routines, two kinds of therapy – vestibular and cognitive behavioral therapy – are highly beneficial. The sooner a patient starts these therapies, the more they’re likely to benefit.
Vestibular therapy is effective for handling issues related to unsteadiness and balance. This type of therapy can also aid individuals in dealing with situations that make their symptoms worse. Cognitive-behavioral therapy, on the other hand, can help patients learn how to handle anxiety caused by their symptoms.
Consequently, individuals with PPPD, or constant dizziness and discomfort in any sort of movement, greatly benefit from receiving care from a variety of medical experts. This ‘multidisciplinary and interprofessional’ care can help them manage and cope with their condition much more effectively.
Preventing Persistent Postural-Perceptual Dizziness
Persistent postural-perceptual dizziness, which is a condition that affects balance and perception, is a challenging diagnosis. It can significantly impact an individual’s quality of life and unfortunately does not have a quick-fix solution. It is crucial for patients to understand that their recovery will take time and involve various treatments. These treatments may include vestibular therapy – which can help improve balance and spatial orientation; cognitive behavioral therapy – a type of talking therapy that can help manage problems by changing the way one thinks and behaves; and certain types of medications like SNRIs (serotonin and noradrenaline reuptake inhibitors) or SSRIs (selective serotonin reuptake inhibitors), which are generally used for managing mental health conditions.
It’s also important for patients not just to take their medications as directed by their doctors, but also to regularly attend follow-up appointments. These measures can go a long way in aiding their recovery and ensuring they get back their normal lives.
