Persistent postural perceptual dizziness
In the early 2000’s, a diagnosis was given to a group of symptoms which included dizziness and unsteadiness, brought on by movement, visually demanding tasks and/or complex visual environments. The name given to this condition was chronic subjective dizziness, or CSD.
It seemed that the definition of CSD, however, did not define precisely the disease, which led to the agreement of a new diagnostic criteria and name, validated by the World Health Organization, called persistent postural perceptual dizziness (PPPD). The key distinguishing feature of PPPD is that sufferers feels worse when exposed to visual stimulus.
It is estimated that 25% of all dizzy patients referred to tertiary care are PPPD sufferers. This condition causes significant distress and functional impairment to the subject and it is likely to accompany the existence of low levels of fear and anxiety (60%) or depression (40%), although these are not symptoms of the disease. It should be noted here that PPPD is NOT a psychiatric syndrome, although it is affected by behaviour and emotions.
PPPD is defined as a chronic, persistent sense of dizziness, unsteadiness, rocking or swaying present on most days (>50%), for over 3 months. It should be noted that the “dizziness” with respect to PPPD is a form of non-spinning vertigo. The term “vertigo” does not necessarily refer to “spinning”, as it is more precisely defined as an “illusion of movement”. Symptoms of PPPD include a vague sensation of motion, aggravated by stress and exacerbated whilst standing or walking (and improved when sitting/lying), whilst in motion, or in view of a complex visual environment. It is triggered by an acute event that causes disruption of balance, such as:
- Vestibular syndromes e.g vestibular neuronitis, BPPV (25-30%)
- Migraine (15-20%)
- Panic/anxiety (15% each)
- Concussion/whiplash (10-15%)
- Autonomic disorders e.g cardia dysrhythmia, drug reactions (7%)
Usually, PPPD starts quite suddenly, due to one of the above events. It rarely begins slowly.
Most often, people with PPPD suffer symptoms every day, with symptoms worsening as the day goes on. Many PPPD sufferers have had “spinning-vertigo” in the past, due to a past incident, however, the likely day to day symptoms are not so acute.
Visual vertigo, visual-induced dizziness and visual motion sensitivity have all become synonymous terms which explain the symptoms of PPPD. They refer to a dizziness/vertigo which is brought on by unusual motion, not matched by vestibular information. For example, heights, repetitive visual patterns, shopping isles, neck extension, unfamiliar body accelerations, misleading cues. One theory is that people suffering these symptoms over-rely on their visual function due to compensation for a dysfunctional vestibular system, making them prone to over-response to visual stimuli.
If you think you have visual vertigo you can fill out these questionnaires which may help measure your symptoms:
Try watching these videos for an example of visually “busy” environments. Warning : cease watching these videos if symptoms increase.
NB: Motion sickness is distinctively different – it has a tendency to produce nausea, persist longer and be more disturbing.
Treatment for PPPD could involves:
- Cognitive behavioural therapy with a psychologist
- Medications (SSRI)
- Habituation exercises
“Habituation” involves exposure to a provocative stimulus, usually involving a visually complex environment, gradually increasing from short durations to longer durations over a period of weeks or even months.
It may also be beneficial to address the autonomic nervous system, with some conservative measures such as:
- Aerobic exercise
- Good sleep hygiene
- Mindfulness/meditation
- Balance/movement challenges
In summary, PPPD is not a simple presentation. It presents as “normal” on many of the standard vestibular tests, and it is likely to be accompanied and complicated by emotional factors. Treatment may involve multiple strategies from a team of health professionals, each working together to create a sense of “safety” towards engaging comprehensive treatment for the disease.
