Persistent, Postural-Perceptual Dizziness
This page looks at a condition that causes dizziness, unsteadiness or non-spinning vertigo and affects patients on most days over three months or more. Such patients may be a challenge to diagnose, particularly because the pattern of their symptoms may not be familiar and because, in common with many patients, they find it hard to describe their symptoms.
The recently evolved diagnostic criteria will be presented first and then its natural history, triggers, and management.
A more in depth treatment of the subject can be found in: Persistent postural-perceptual dizziness (PPPD): a common, characteristic and treatable cause of chronic dizziness by Popkirov S et al in Journal of Practical Neurology 2018;18:5-13. This page draws from that and other sources.
PPPD is a relatively recently codified condition but patients with its symptoms have been with us always. The diagnostic criteria for the condition are published in 'Diagnostic Criteria for Persistent Postural-Perceptive Dizziness (PPPD): Consensus document of the Committee for the Classification of Vestibular Disorders of the Bárány Society'. It is an excellent read and gives a wealth of background and historical context for the new condition.
Patients with PPPD complain of persistent dizziness, non-spinning vertigo and / or unsteadiness. These symptoms have arisen due to some past vestibular, neurological, medical or psychological event. Patients often have associated anxiety, show avoidance behaviour, and, sometimes, severe disability.
The diagnostic criteria proposed by the Bárány Society are as follows:
1. One or more symptoms of dizziness, unsteadiness or non-spinning vertigo on most days for at least three months.
a. Symptoms last for prolonged periods (hours or more) but may wax and wane in severity
b. Symptoms need not be continuously present through the day
2. Persistent symptoms occur without specific provocation, but are exacerbated by 3 factors: upright posture, active or passive motion (without regards to direction or position, e.g. walking, standing and being in a vehicle), and exposure to moving visual stimuli or complex visual patterns (e.g. supermarkets, traffic, boldly patterned carpets etc).
3. The disorder is triggered by events that cause vertigo, unsteadiness, dizziness, or problems with balance including acute, episodic or chronic vestibular syndromes, other medical or neurologic diseases, and psychological distress.
a. When triggered by and acute or episodic precipitant, symptoms settle into the pattern of criterion 1 above as the precipitant resolves, but may occur intermittently at first and then consolidate into a persistent course
b. When triggered by a chronic precipitant, symptoms may develop slowly at first and worsen gradually
4. Symptoms cause significant distress or functional impairment.
5. Symptoms are not better accounted for by another disease or disorder.
The diagnosis is from the history, and examination and investigations are used to diagnoses co-morbid conditions. In PPPD these are often normal.
Taking histories from patients with balance disorders is complex anyway. We concentrate on triggers, duration of attack and associated symptoms to help us decide on a diagnosis. Imagine how complicated it might be for a patient with Ménière's Disease and PPPD between attacks to describe their problem.
It is estimated that 1 in 4 of patients with an acute balance disturbance caused by a vestibular syndrome will develop PPPD - so we are going to see a lot of patients with it in our specialist clinics.
Visual vertigo, the sensation of imbalance when confronted with supermarkets, moving traffic, bold patterns, stripes, trees moving in the wind etc, can exist by itself. So, even though it is a diagnostic criterion of PPPD, its presence does not automatically mean the patient has PPPD.
Symptoms come and go with levels of fatigue and activity. A patient may be distracted from their problem at times but dwell on it at others.
Patients may appear relatively well when examined despite their description of the problem and its apparent impact on their life. This is a common finding in other functional neurological disorders, too. It does not always mean that the patient is trying to mislead you for their own gain.
25% are triggered by an acute inner ear type balance disorder
20% are associated with vestibular migraine
15% triggered by panic attack
15% triggered by a generalised anxiety disorder
15% triggered by head injury or whiplash
10% caused by drug side effects, heart problems, and other medical disorders.
The symptoms of PPPD start to appear as the symptoms of the trigger start to fade. If the symptoms arise without an obvious precipitating event caution should be used in making the diagnosis. This is very unusual and another underlying cause should be carefully sought.
These are important in PPPD and contribute in three main ways:
a. patients with introverted personality or pre-existing anxiety disorders may be predisposed to PPPD after a precipitating event
b. Patients with high levels of anxiety while experiencing vestibular symptoms are more likely to develop PPPD
c. Patients with high levels of caution and anxiety, who also have negative expectations also a predictor
Anxiety about symptoms will prevent patients making the intermediate and long term adaptations that are required for full vestibular compensation.
According to one source:
60% of PPPD sufferers have clinically significant anxiety
45% had clinically significant depression
25% had neither
There are some good screening tools for anxiety and depression (GAD and PHQ-9 respectively) and if PPPD is a possibility these should be given to the patient. Management of underlying mental disorders is important in rehabilitating the patient.
Treatment of PPPD
1. Explain the diagnosis and let the patient know that it is well-known, common and potentially treatable condition.
2. Explain the mechanism by which it has arisen so that they understand the reason for your treatment plan
3. Physiotherapy to desensitise the balance system
4. Medications - usually for underlying mental health disorder e.g. SSRI and SNRI antidepressants
5. Psychological therapies (CBT) to reprogram heightened balance vigilance, decrease behavioural maladaption, and lessen worry and demoralisation
6. Provide written information on the functional neurological conditions to engage and educate the patient further e.g.
7. Individualised treatment program according to the specific needs of the patient, starting gradually and increasing in intensity at a rate that does not demoralise the patient
Knowledge of PPPD will help you understand patients with chronic persisting symptoms that otherwise do not fit into an established vestibular diagnostic pattern. We are all familiar with symptoms of Ménière's, BPPV and Vestibular neuritis but understanding PPPD will help diagnoses the harder to pin down diagnoses.
The condition is common in our practice and treatable as long as a multidisciplinary approach is taken.