Vestibular disease
Persistent postural-perceptual dizziness (English: Persistent Postural-Perceptual Dizziness [PPPD])
This information is intended as a general introduction to this topic. As everyone is affected differently by balance and dizziness problems, you should speak to your doctor for individual advice.
For reasons of better readability, the generic masculine is used and the simultaneous use of the language forms male, female and diverse (m/f/d) is dispensed with. Unless otherwise indicated, the personal designations used in this patient information refer to all genders.

What is persistent postural-perceptual vertigo?
Persistent postural-perceptive dizziness (PPPD) is the most common cause of chronic (long-lasting) dizziness. It is usually treatable, especially if diagnosed early.
PPPD is usually triggered by an attack of vertigo. After this initial attack, the person continues to have feelings of movement, dizziness, unsteadiness or lightheadedness that can last for hours or days. These symptoms almost always occur, but can be better or worse at times. Sitting and standing upright and complex patterns and movements often exacerbate the symptoms. This is why people with PPPD are often afraid of losing their balance or falling. They may avoid situations that exacerbate their symptoms to the point where they begin to severely impact their lives.
PPPD can be very frustrating for sufferers. Many healthcare professionals are not well versed in dizziness and the symptoms of PPPD can be vague and difficult to describe. As a result, the condition often goes undiagnosed for a long time and many sufferers are also given incorrect diagnoses (such as cervical vertigo), leading to even more confusion. PPPD can severely affect work, school, leisure and family life.
PPPD was defined as a disorder in 2015. Prior to this, various names were used for disorders with similar symptoms, including phobic vertigo, functional vertigo, visual vertigo and chronic subjective vertigo.
Researchers are not sure exactly how many people suffer from PPPD. However, some studies suggest that up to 25% of people who have a vestibular disorder such as neuritis vestibularis, Meniere's disease or benign paroxysmal positional vertigo (BPLS) go on to develop PPPD.
PPPD can occur at the same time as another vestibular disorder. For example, someone may have both Meniere's disease and PPPD. And some people with Meniere's disease may never develop PPPD.
PPPD appears to be more common in women and often develops between the ages of 20 and 50.
Summary
- The most common cause of chronic dizziness.
- Can last three months or longer (even decades).
- In some people, it begins after an event that triggers vertigo, e.g. an inner ear disorder.
- Instead of fully recovering and calming down, the brain remains on high alert and hypersensitive.
- The anxiety often begins with movements, situations and stimuli that trigger the symptoms.
- Daily life is usually considerably impaired.
- The disease leads to a vicious circle: as the anxiety increases, so do the symptoms.
- The symptoms are real - NOT imaginary.
- Treatment usually involves "retraining" the brain through a mixture of vestibular rehabilitation, medication and counseling.
- There is no quick fix, but with time, understanding and the right treatment, a cure is possible.
What causes persistent postural-perceptual vertigo?
The brain's balance system combines information from many sources, including:
- the vestibular system (the semicircular canals and macula organs in the inner ear), which perceives head movements and head movement speeds
- the visual system that perceives the movement of your surroundings
- the proprioceptive system, which perceives signals about position, pressure, movement and vibration from the legs and feet and the rest of the body
Normally, you are not consciously aware of all these different sources of information. The balance system combines them for you in the background and you can stand, walk or turn your head without having to think about how to keep your balance. But with PPPD, perception is no longer seamless. You start to notice the different signals, especially if they don't all match up. This can make you feel like you're moving or about to fall even though you're standing still.
When the brain thinks you are in danger of falling, it automatically reacts to protect you. Think about how you feel when you walk on ice or stand on a ladder: your body stiffens, you take shorter steps and concentrate on staying upright. At the same time, the vestibular system uses less information from the vestibular system and more from the visual system. Normally, the vestibular system returns to normal when the danger of falling has passed. But with PPPD, the brain remains in "high-risk mode" instead. This creates a vicious circle:
- You worry that you might fall and pay more attention to keeping your balance.
- The brain remains on alert and relies more on visual stimuli.
- Visual signals such as rapid patterns and movements indicate that you are in danger of falling.
This description may make it seem like PPPD is "all in your head", but the symptoms are real. PPPD has some similarities to anxiety disorders, but it is not a mental disorder. Some studies have found differences in brain activity in people with PPPD compared to people without PPPD. These differences can make it difficult for the brain to integrate different sources of information and correctly assess danger.
PPPD is usually triggered by a first episode of dizziness or balance disturbance. This first episode can be triggered by many different causes that disrupt the balance system, such as
- a vestibular disorder such as:
- Meniere's disease
- Vestibular neuritis
- Benign paroxysmal positional vertigo (BPLS)
- Isolated otolith dysfunction
- Vestibular migraine
- mild traumatic brain injury (TBI)
The first episode of dizziness or gait instability can also be caused by a psychological event, e.g. anxiety or a panic attack. Panic attacks and anxiety can cause physical symptoms such as dizziness, light-headedness, rapid heartbeat, shortness of breath, sweating, trembling, muscle tension, tiredness or nausea.
PPPD can cause various symptoms, including:
- Swaying dizziness (as if you are swaying or rocking, even when you are sitting or standing still)
- Vague, diffuse feelings of drowsiness (as if slightly intoxicated)
- Stance and gait instability
- Mild dissociative disorder (e.g. the feeling of being "beside oneself" or floating)
These symptoms occur on most days for at least three months. They can last for hours. However, they do not have to occur every day.
Many people with PPPD find it difficult to describe their symptoms. They often feel "not clear-headed", "foggy" or not like themselves.
People with PPPD often feel worse when:
- they stand or sit upright
- they see movement, e.g. when scrolling on their cell phone, watching TV, observing traffic or when many people are walking around them
- they see complex patterns, such as a patterned carpet, wallpaper or a supermarket aisle
- they are traveling on foot or by car
The symptoms sometimes get worse when the person is tired or pays more attention to the symptoms, and better when the person is distracted. The symptoms are usually persistent and last for a long time.
The pattern of symptoms may vary slightly depending on what originally caused the PPPD:
- If it was caused by an acute problem or an episodic problem, PPPD symptoms may begin when the original problem improves. Symptoms may come and go at first and become chronic in the long term.
- If the cause is a chronic problem, PPPD symptoms can develop slowly and gradually get worse.
People with PPPD may also develop other problems, such as:
- Neck tension
- Exhaustion and tiredness
- Fear of falling
- Fear or avoidance of situations that trigger dizziness, such as crowded places or leaving the house
Diagnosis of persistent postural-perceptual vertigo
PPPD can be diagnosed by a specialist in dizziness such as a neurologist, an ENT specialist or a psychologist.
There is no test that is specific for PPPD. However, PPPD is not a diagnosis of exclusion: the diagnosis is not made because no other cause for the symptoms could be found. The diagnosis is made on the basis of clinical criteria.
These specialized doctors will take a thorough medical history, perform a neurological examination and various tests to assess the function of your vestibular system.
You may undergo some of the following diagnostic tests:
- General physical examination
- Vestibular functional examination
- Balance tests
- Blood tests
- Imaging (CT or MRI scans)
PPPD can occur with other vestibular disorders such as Meniere's disease or vestibular migraine. Therefore, your doctor should also look for signs of triggering diseases.
To be diagnosed with PPPD, a person must have all of the following symptoms:
- One or more symptoms of dizziness (not rotary vertigo but rather vertigo or dizziness) and unsteadiness of gait on most days for at least three months. Symptoms last for hours but may increase and decrease in severity. The symptoms do not have to be present continuously throughout the day.
- Persistent symptoms occur without specific provocation but are exacerbated by three factors: (A) upright posture, (B) active or passive movement regardless of direction or position, and (C) moving visual stimuli or complex visual patterns.
- The disorder is triggered by events that cause dizziness, lightheadedness, unsteady gait or balance problems. These include acute, episodic or chronic vestibular disorders, other neurological or medical conditions and psychological stress.
- The symptoms cause considerable suffering or functional limitations.
The symptoms cannot be better explained by another disease or disorder.
Treatment of persistent postural-perceptual vertigo
Once diagnosed, the first step in treatment is to understand what is causing PPPD and why the brain is overreacting to normal signals as if you are in danger. Understanding what is causing your symptoms will help you feel in control and able to participate in treatment.
Treatment for PPPD usually involves 'retraining' your brain through a combination of vestibular rehabilitation, anti-anxiety strategies such as medication and cognitive behavioral therapy (CBT). You may also benefit from relaxation exercises for your neck and shoulders. Ideally, you will have a treatment team of health professionals working together to help you. Remember that both vestibular rehabilitation and CBT require a lot of practice and dedication. Your therapists will teach you the necessary techniques, but you are the one who applies them.
Therapy option

Vestibular rehabilitation is an exercise-based therapy for dizziness. Its goal is to help your brain relearn how to balance and respond to signals from the visual and vestibular systems. A certified IVRT® dizziness and vestibular therapist with experience in PPPD can help you set treatment goals and develop an individualized program for your needs.
It is very important to start gradually with the exercises and to increase them slowly and steadily.
Doing too much too soon can worsen the symptoms of PPPD. The certified IVRT® Dizziness and Vestibular Therapist will monitor your progress. The frequency, duration and complexity of the exercises will be gradually increased depending on your response. Treatment may extend over several months
Therapy option

Your doctor may decide to treat your PPPD with medication. Note that medication alone usually does not completely relieve PPPD symptoms. Two types of antidepressants can be used:
- SSRIs (selective serotonin reuptake inhibitors), including fluvoxamine, paroxetine and sertraline
- SNRIs (serotonin-norepinephrine reuptake inhibitors), which are usually tried when two SSRIs have not worked
These medications are used to treat depression and anxiety, but they can also help with PPPD. They all work in slightly different ways. If the first medication doesn't work or has too many side effects, your doctor may suggest trying a different one.
It is important to start with a low dose and gradually increase the dose. Inform your doctor if you have any side effects. It usually takes 8 to 12 weeks for the medication to start working. If you find a medication that helps with your symptoms, you may need to take it for several months. Don't stop your medication or change your dose without talking to your doctor.
Some medications used to treat other forms of dizziness, such as dimenhydrinate, betahistine, tranquilizers and other antidepressants, have not been shown to be effective in treating PPPD. Some of them may even slow down your recovery. Be sure to discuss all medications with your doctor, including over-the-counter and herbal products
Therapy option

Cognitive behavioral therapy (CBT) is a form of psychotherapy. It usually lasts a relatively short time and is geared towards a specific goal.
CBT focuses on the relationship between your thoughts (cognition) and your behavior. Cognition includes your conscious thoughts (which you can control), your automatic thoughts (which you may not be able to control) and your core beliefs (called schemas). In CBT you learn how to:
- recognize and identify your thoughts and beliefs
- look at your thoughts and beliefs from different angles
- change your behavior patterns
KVT should help you with PPPD:
- Overcoming fears
- Manage symptoms when they occur
- no longer avoid situations that could trigger symptoms
- Gaining self-confidence
Some studies have shown that just 3 sessions of CBT lead to an improvement in symptoms in 3 out of 4 PPPD patients.
Other forms of anxiety management such as mindfulness-based stress reduction can also be helpful in PPPD treatment.
What happens next?
What you can expect in the future.
So far, there is not much research on recovery from PPPD. Vestibular rehabilitation seems to help many people with PPPD, especially when combined with patient education and/or anxiety management.
PPPD symptoms may never go away completely, but the skills you learn in vestibular rehabilitation and CBT should alleviate symptoms and help you return to your normal activities