What is PPPD?
Persistent Postural-Perceptual Dizziness (PPPD) is a type of long-term, frequent dizziness that you feel for much of the day. People suffering from PPPD often complain of feeling dizzy, unsteady, lightheaded, or like they are floating, rocking, or swaying.
Breaking down the name for Persistent Postural-Perceptual Dizziness (PPPD) can help make it easier to understand:
- Persistent – The dizziness isn’t momentary – it lasts. This means dizziness that is present for much of the day, most days, for at least 3 months. It’s not only in response to certain situations or triggers.
- Postural – How you move your body can influence the dizziness you feel. Dizziness in PPPD is there even when you’re not moving. But it also often worsens with changes in body position, like going from sitting to standing. Moving (e.g., walking or riding in a car) can also make it worse.
- Perceptual – The dizziness comes from your perception – the information you get from your five senses and from feelings within your body. You feel off-balance within your body or in regard to your surroundings. Looking at something visually disorienting (e.g., a busy picture or pattern) often worsens PPPD.
- Dizziness – The main complaint from people with PPPD is dizziness (but there can also be unsteadiness, lightheadedness, floating, rocking, and swaying sensations as mentioned above).
Of course, dizziness can come from many things other than PPPD. Perhaps some of the most common are feeling dizzy after spinning around or turning quickly, or from the effects of substances (e.g., alcohol, marijuana). Dizziness can also be a sign of various medical conditions. So, if your dizziness is recurrent or long-lasting, it’s important to get a consultation with a physician to determine if your dizziness requires medical treatment.
PPPD’s dizziness is impactful and lasting
Occasional, momentary dizziness is something that most people experience at various times. As such, it may not disrupt life much when it happens. However, for people suffering from PPPD, it can have a significant impact on day-to-day living. It can limit your ability to drive a car, operate machinery, or do other activities that require a sense of balance – even walking. If you have PPPD, it’s important to get treatment so that it doesn’t diminish your quality of life.
PPPD vs Vertigo
Vertigo is often confused with PPPD, but they are not the same. Vertigo is uniquely a spinning sensation, as if you or your surroundings are moving. Unlike PPPD, vertigo is also more often accompanied with feeling nauseous or ill.
Causes of PPPD
PPPD usually first starts after some sort of event that affects your balance, your emotional state, or both. These events can include:
- Physical injuries or accidents (e.g., falling and hitting your head)
- Certain medical conditions (e.g., vestibular migraines or inner ear disorders)
- Acute psychological distress (e.g., a panic attack, receiving extremely upsetting news)
One noteworthy thing about events that often lead to PPPD is that they are also particularly startling, surprising, or disorienting. Any experience that makes you feel this way activates your fight-or-flight response. The fight-or-flight response is a survival mechanism, and ultimately a good thing for your body and mind to have.
However, the fight-or-flight response also changes how you perceive yourself in regard to your surroundings, as well as how your body is moving. This is also helpful for escaping to safety and survival, but can leave you feeling even more disoriented, and lead to each of the sensations that characterize PPPD.
Typically, after you calm down and your fight-or-flight response is no longer activated, your sense of your body, how it moves, and your surroundings goes back to normal. However, in PPPD your mind has a hard time doing this, and “remembers” feeling off-balance even after the event is over and anxiety has passed. This can lead to the ongoing symptoms of dizziness and disorientation.
Why does this happen? One important factor to consider is the two-way relationship between dizziness and anxiety.
The Connection between PPPD and Anxiety
As described above, events that leave you dizzy or disoriented often also leave you feeling anxious, startled, or shocked. When you feel anxious, your fight-or-flight response is activated, which puts your brain into “high alert” mode to help you escape from threats. Being on “high alert” naturally makes you pay more attention to the source of threat – which in the case of PPPD, is actually the sensations of dizziness, swaying, rocking, etc. Over time, being acutely aware of your balance and sense of movement makes you more sensitive to any changes in it, which then makes PPPD symptoms worse.
Avoidance of situations that worsen dizziness (e.g., giving up walking), or adopting safety behaviors (e.g., specific ways of turning your head to limit dizziness) are common reactions to the discomfort caused by PPPD. Unfortunately, avoidance and safety behaviors only help in the moment – in the long term, they can worsen anxiety. This is one reason why both dizziness and anxiety tend to persist in PPPD, even if the original cause of dizziness has passed.
Anxiety and dizziness
It’s important to mention that anxiety itself also can lead to dizziness. The fight-or-flight response naturally leads to a number of uncomfortable sensations in your body. These sensations can be present any time you experience anxiety, whether mild (e.g. feeling slightly nervous before speaking in a meeting), or more intense (e.g., having a panic attack). One of these sensations is dizziness.
As you can see, this feedback loop between dizziness and anxiety often plays a key role in why PPPD symptoms persist. It’s also why PPPD can look similar to panic disorder and other anxiety disorders, although these conditions are distinct. If you have previously suffered from an anxiety disorder, you may be more likely to develop PPPD following an event like the ones described above.
Fortunately, cognitive behavioral therapy (CBT), which is proven effective in treating anxiety, can also help treat PPPD symptoms.
SEE ALSO: Can Anxiety Cause Dizziness?
Treatment for PPPD
Cognitive behavioral therapy (CBT) is the most effective psychological treatment for PPPD. The symptoms of PPPD tend to make people anxious over time. Focusing on and being acutely aware of your balance and sense of movement can make you more anxious about dizziness. Anxiety also worsens PPPD symptoms. This is why treating anxiety is often an important part of treating PPPD. CBT is proven effective and uses a variety of proven techniques to help alleviate anxiety and improve quality of life. Some components of CBT for PPPD include:
- Attentional retraining
- This helps you pay less attention to your body and its sensations, and more on your surroundings
- Relaxation training
- This helps reduce tension and the dizziness that can come from hyperventilation
- Behavioral experiments
- These help you test out whether the consequences of PPPD are as scary or unmanageable as you may fear
- Interoceptive exposure
- This helps reduce your reactivity to the uncomfortable sensations that come from the fight-or-flight system
- Reduce avoidance and safety behaviors
- This helps break the feedback loop between anxiety and PPPD symptoms
CBT isn’t the only treatment helpful for PPPD. Vestibular rehabilitation therapy is another. It is usually provided by vestibular physical therapists and includes exercises that help you properly integrate your sensory input (e.g., visual information, sense of balance) with movement to help reduce symptoms of disorientation. Some medications like SSRIs and SNRIs can also help manage the symptoms of PPPD. They can lessen anxiety symptoms, and thus make you less hyperaware of your balance and body movement, which can further lessen dizziness and disorientation.
Unfortunately, PPPD doesn’t ever go away completely, and there is no cure. But effective treatments, including CBT, can significantly reduce your symptoms and improve your quality of life by helping you learn to manage your dizziness.
Summary
All in all, while PPPD symptoms can be persistent, improvement and relief are possible! Understanding PPPD and how it relates to anxiety is key to effective treatment. Cognitive Behavioral Therapy (CBT) is one treatment option that focuses on the connection between dizziness and anxiety to bring you relief. With CBT and other treatments, PPPD doesn’t have to hold you back in your daily life. If you’re experiencing long-term dizziness, swaying, or rocking sensations and suspect it’s PPPD, it’s important to seek treatment. Contact us if you need help managing dizziness from PPPD.
Sources
Whalley, M.G. & Cane, D.A. (2017) A Cognitive-Behavioral Model of Persistent Postural-Perceptual Dizziness. Cognitive and Behavioral Practice, 24, 72-89.
https://my.clevelandclinic.org/health/diseases/persistent-postural-perceptual-dizziness
