Understanding Persistent Postural Perceptual Dizziness (PPPD)
PPPD (also referred to as 3PD) stands for Persistent Postural Perceptual Dizziness. It’s historically been referred to as other names such as Chronic Subjective Dizziness (CSD) or Phobic Postural Vertigo (PPV), but new research and a better understanding of the pathophysiology has led to the most recent diagnostic name and criteria.
Persistent Postural Perceptual Dizziness is a type of chronic dizziness. Symptoms must be present for at least 3 months to be considered PPPD (per diagnostic criteria). However, the earlier that symptoms are picked up on and addressed- the better!
Those with PPPD usually describe a chronic sense of dizziness, often constant (if not constant, then present on most days), and may wax and wane in intensity throughout the day and over time. Symptoms are generally better when laying or sitting down, and worse when standing up, walking, or moving.
Symptoms are usually provoked by:
Busy visual environments (like going to the grocery store or using screens)
Passive or active movement (like riding in a car or moving about your house)
An upright position (like standing or walking as opposed to laying down)
The dizziness is usually described as a sense of swaying, rocking, bobbing, disequilibrium, an unsteadiness or off-balance sensation, poor spatial orientation, or like a swimming sensation (it's often difficult to describe). This is not an all-encompassing list by any means. However, per definition, PPPD does not cause episodes of room-spinning vertigo (it's possible to have both PPPD and another condition that does cause vertigo though).
It's also important to note that PPPD is usually precipitated by some other vestibular diagnosis, such as BPPV or vestibular neuritis. However, it may also be precipitated by other diagnoses not related to the vestibular system, such as cardiac events, COVID, or a panic attack, among others. In some cases, you may not know what the precipitating factor is.
It’s possible, and arguably very common, for PPPD to exist with similar comorbidities, such as vestibular migraine or vestibular dysfunction, which can lead to difficulty with obtaining a proper diagnosis.
What’s Actually Happening?
Here’s how I like to explain PPPD to my clients:
PPPD is often triggered by some precipitating event (as discussed above). The precipitating event usually causes some form of vertigo, dizziness, or imbalance. As a natural adaptation to such an event, your body will likely adopt a safer gait pattern, for example, walking slower with a wider base of support and/or using hand support. You will also likely utilize your vision more for balance and mobility, as opposed to your inner ear/ vestibular system. Your body also tends to shift to a high alert mode. These are common and natural adaptations, that allow you to continue to move safely within your environment and continue to function while you’re recovering...
Over time, as you recover from the initial precipitating factor, your body should shift back to your baseline gait and balance function. However, sometimes these adaptive responses “get stuck.” For example, those with PPPD tend to continue to over-rely on visual input for balance and mobility, and the high alert system is often left on for a prolonged period. The adaptive responses can become maladaptive over time.
You can think of PPPD as more of a software issue of the nervous system and brain, versus a hardware issue. There aren’t any structural changes to your anatomy, but the circuitry and programming have gone awry.
I’ve met many clients who've become discouraged and frustrated that all of their testing came back “normal.” For example, clients will often undergo imaging such as MRIs or CT scans, and even vestibular/ inner ear testing. It’s common for these imaging studies to come back normal if you have PPPD. This is because PPPD does not cause any structural changes to your body or nervous system. However, as discussed above, it’s the “software,” that’s affected.
The software of the brain and nervous system is responsible for receiving loads of sensory input from your body and environment, making sense of and integrating all that information, then creating a plan and output. If something goes awry in this process, it can lead to symptoms of dizziness, imbalance, and your body being in high alert mode.
Recent studies have shown that although there aren’t normally changes on imaging like a standard MRI, there are changes on functional MRI (fMRI) in people with PPPD. Unfortunately, fMRI is used mostly for research purposes at this time. Functional MRIs measure brain activity by detecting changes in blood flow. fMRI studies have shown a shift in sensory integration in people with PPPD, with increased activity in the visual cortex.
The main take away from this is: It. Is. Not. All. In. Your. Head! Your symptoms are real, even if standard testing and imaging is normal. PPPD is also NOT a psychiatric diagnosis. However, it is possible to have a psychiatric comorbidity, which may exacerbate symptoms.
Is it treatable?
This may all seem very complicated, but there’s some good news. Since PPPD is more of a “software” issue, this means that it is treatable!
Research has shown that a combination of specific vestibular rehabilitation strategies, certain medications, and CBT (cognitive behavioral therapy) or ACT (acceptance commitment therapy) are effective in reducing symptoms and improving function in those with PPPD. It’s important to work with therapists who are familiar with the diagnosis of PPPD, as standard vestibular rehabilitation approaches may not always be appropriate or beneficial for PPPD.
If you live in the Rochester, NY area (or anywhere in New York State via telehealth), let's talk! It's time to take back control of your life.
Reference:
Holmberg, Janene. (2020). Pathophysiology, Differential Diagnosis, and Management of Persistent Postural-Perceptual Dizziness: A Review. Perspectives of the ASHA Special Interest Groups. 5. 1-11. 10.1044/2019_PERSP-19-00105.
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