PPPD Demystified: Understanding Persistent Postural Perceptual Dizziness

Persistent Postural Perceptual Dizziness (PPPD or 3PD) is a chronic functional vestibular condition that can be a challenge to manage. While it isn’t caused by structural damage or psychiatric disorders, it’s one of the most common reasons people experience long-term dizziness. This condition is especially prevalent in specialized dizziness centers, where understanding PPPD can make a big difference in patient care. Let’s take a closer look at its symptoms, history, and what healthcare providers need to know. We hope that in sharing what we have found, this helps you better understand this challenging condition and improve patient outcomes.

What Does PPPD Look Like?

Patients with PPPD often describe their dizziness as a non-spinning sensation, paired with a feeling of imbalance. Their symptoms tend to flare up in certain situations, such as standing or walking, and they find visually complex environments—like busy streets or supermarkets—particularly challenging. You might notice these patients moving cautiously, trying to avoid anything that could make their symptoms worse.

Even though physical exams and diagnostic imaging often come back normal, there might still be lingering signs from the event that initially triggered the condition, like vestibular neuritis or BPPV.

What Leads to PPPD?

PPPD usually starts after a specific event. For about 70% of patients, it’s a vestibular condition like vestibular neuritis, BPPV, or vestibular migraine. For another 30%, the trigger could be a mental health issue such as anxiety or depression. Staab 2017  This isn’t to say these conditions cause PPPD outright, but they often set the stage for it to develop.

Who Is Most at Risk?

PPPD typically affects people in their mid-40s to 50s, though cases range from adolescence to late adulthood. It’s more common in women and tends to occur in those with a personal or family history of anxiety disorders. (Staab 2017; Yagi 2024)

How Is PPPD Diagnosed?

The diagnostic criteria for PPPD, published by the Bárány Society in 2017, require three key features:

1. Symptoms lasting more than three months. These include non-spinning dizziness or unsteadiness that’s triggered by upright posture, motion, or visually complex environments.

2. A functional cause. The symptoms can’t be explained by structural or psychiatric conditions.

3. A triggering event. This is often, but not always, a vestibular or mental health condition.

For a detailed review of the diagnostic criteria click HERE.

What Causes PPPD?

The exact mechanisms behind PPPD aren’t fully understood, but it’s thought to involve a hypersensitive vestibular system and possibly neurotransmitter dysfunction. What’s clear is that symptoms persist even after the original triggering event resolves, pointing to maladaptive processing in the brain’s handling of vestibular and sensory inputs.

A Glimpse Into History

Although PPPD was officially named in 2017, its symptoms have been recognized for over a century. German physicians in the 1800s described it as “Platzschwindel” (vertigo in open squares), “Platzangst” (fear of open squares), and “Die Agorophobie” (fear of marketplaces). These early terms reflect the interplay between dizziness, environmental triggers, and anxiety—a hallmark of PPPD.

More recent terms you might recognize include phobic postural vertigo, space-motion discomfort, visual vertigo, and chronic subjective dizziness. All of these describe aspects of what we now call PPPD.

How Common Is PPPD?

PPPD is more widespread than you might think. Studies show it accounts for 14% of vestibular complaints in primary care, 20% in neurology clinics, and over 50% in specialized dizziness centres. (Staab 2023) These numbers highlight its significant impact on clinical practice.

How Do We Treat PPPD?

Managing PPPD takes a team effort and a lot of patience. Changes often take months to see a difference and treatment often includes:

• Education and reassurance: Patients often feel better when they understand that PPPD is a functional condition and that improvement is possible with the right strategies.

• Addressing activity and fear avoidance: Patients need support to overcome deconditioning and gradually reintroduce motion and visually complex environments.

• Vestibular Rehabilitation Therapy (VRT): Tailored exercises help recalibrate the brain’s sensory integration and reduce motion sensitivity. This is done through 3 main strategies that include providing grounding and relaxation techniques in conjunction with exposure therapy and balance retraining (especially with the eyes closed to reduce any visual dependance). 

• Mental health support: Cognitive Behavioral Therapy (CBT) can address anxiety and maladaptive thought patterns.

• Medications: Serotonergic antidepressants like SSRIs may help manage symptoms for some patients.

• Comorbidities: It’s crucial to treat any underlying vestibular or other health conditions.

 For further details about the assessment and treatment of PPPD, feel free to watch our 1.2-hour course on PPPD available on Embodia.

Click HERE to access the PPPD summary cheatsheet that we share with our patients.

Why Understanding PPPD Matters

PPPD is a leading cause of chronic dizziness and sits at the crossroads of vestibular and psychological health. As healthcare providers, recognizing its features and offering evidence-based treatment can make a huge difference in patients’ lives. Early identification and targeted interventions can help patients regain control and confidence, empowering them to return to their daily activities. We hope this information helps you approach this challenging condition with greater clarity and equips you to achieve better outcomes for your patients.