Persistent Postural Perceptual Dizziness
Persistent Postural Perceptual Dizziness (PPPD, or 3PD) was formerly called Chronic Subjective Dizziness and even earlier known as Phobic Postural Vertigo. While the word dizziness is in the name of the condition, some people may not experience dizziness as a symptom. Symptom classification includes persistent sensations of rocking or swaying unsteadiness and/or dizziness without vertigo lasting greater than 3 months, and present at least 15 out of every 30 days, but can often occur daily. Symptoms are noted to be worse with upright postures, such as when walking, standing, or sitting, with head or body motion, and exposure to complex or motion-rich environments. 3PD typically starts shortly after an event that causes acute vertigo, unsteadiness, dizziness or instability.
3PD can develop spontaneously in people that may have a history of motion sensitivity, anxiety or depression, however, more commonly there is a triggering event that initially causes disequilibrium, vertigo, or dizziness. For example, following the resolution of Benign Paroxysmal Positional Vertigo (BPPV), the most common reason for peripheral vertigo, 3PD may result as a sequela.
Common for many vestibular disorders, there may be an underlying or associated anxiety disorder concomitant to 3PD. 3PD is not a psychiatric disorder, however, patients may begin to avoid socialization, become recluse, or go to extreme measures to avoid exacerbating symptoms, fearing the worst, resulting in abnormal psychological behaviors. The pathways from the inner ear to the brain have been shown to overlap with those that deal with anxiety, depression, and migraine. Because of this overlap, one system can “drive” the other, for example, if a person feels unsteady, they may become easily anxious which subsequently makes the unsteadiness worse and results in a perpetual cycle of escalating symptoms. It can be very common to have overlapping conditions and symptoms.
Those with 3PD become hypersensitivity to excessive visual feedback, visual motion or a visual mismatch such as what might occur in busy environments, or looking at complex patterns. Symptoms may be referred to as ‘space and motion discomfort’ and relate to an uneasiness or dizziness associated with heights, large rooms, small room, being in motion (whether body movements, head movements or both), viewing motion, viewing repeating patterns or fluorescent lights, watching television, reading, going to the movies or grocery store or eating out in a restaurant, to name a few. The grocery store is such a prevalent problem, it has been dubbed ‘Supermarket Syndrome’ or ‘Grocery Store Syndrome’ depending on what part of the country you call home.
Computerized testing and scans are often normal, unless an underlying or concomitant condition is discovered. The diagnosis is made based on presentation and ruling out other possible causes. When present, anxiety needs to be addressed, whether through counseling, relaxation exercises, meditation, yoga, acupuncture or, when necessary, medication. Patients with 3PD can be desensitized to the hypersensitivity of visual and body motion through vestibular rehabilitation. Recovery times vary from one month to several months, however, a consistent and gradually progressive program can result in a full recovery. Selective Serotonin Reuptake Inhibitors (SSRI) and Serotonin Norepinephrine Reuptake Inhibitors (SNRI) have been trialed with moderate success when medication is tolerated. Vestibular suppressants, such as Benzodiazepines, have not shown to be an effective primary treatment for 3PD and can result in negative consequences long-term.
3PD, often resulting from a prior vertiginous event or disturbance in balance, can be successfully treated with vestibular rehabilitation when done properly. To optimize successful outcomes when anxiety, migraine, or depression coexists, all sources of symptoms must be addressed. AVORA providers have specialized training and the right, sophisticated equipment to ensure a proper diagnosis and proper treatment for successful outcomes!
3PD can develop spontaneously in people that may have a history of motion sensitivity, anxiety or depression, however, more commonly there is a triggering event that initially causes disequilibrium, vertigo, or dizziness. For example, following the resolution of Benign Paroxysmal Positional Vertigo (BPPV), the most common reason for peripheral vertigo, 3PD may result as a sequela.
Common for many vestibular disorders, there may be an underlying or associated anxiety disorder concomitant to 3PD. 3PD is not a psychiatric disorder, however, patients may begin to avoid socialization, become recluse, or go to extreme measures to avoid exacerbating symptoms, fearing the worst, resulting in abnormal psychological behaviors. The pathways from the inner ear to the brain have been shown to overlap with those that deal with anxiety, depression, and migraine. Because of this overlap, one system can “drive” the other, for example, if a person feels unsteady, they may become easily anxious which subsequently makes the unsteadiness worse and results in a perpetual cycle of escalating symptoms. It can be very common to have overlapping conditions and symptoms.
Those with 3PD become hypersensitivity to excessive visual feedback, visual motion or a visual mismatch such as what might occur in busy environments, or looking at complex patterns. Symptoms may be referred to as ‘space and motion discomfort’ and relate to an uneasiness or dizziness associated with heights, large rooms, small room, being in motion (whether body movements, head movements or both), viewing motion, viewing repeating patterns or fluorescent lights, watching television, reading, going to the movies or grocery store or eating out in a restaurant, to name a few. The grocery store is such a prevalent problem, it has been dubbed ‘Supermarket Syndrome’ or ‘Grocery Store Syndrome’ depending on what part of the country you call home.
Computerized testing and scans are often normal, unless an underlying or concomitant condition is discovered. The diagnosis is made based on presentation and ruling out other possible causes. When present, anxiety needs to be addressed, whether through counseling, relaxation exercises, meditation, yoga, acupuncture or, when necessary, medication. Patients with 3PD can be desensitized to the hypersensitivity of visual and body motion through vestibular rehabilitation. Recovery times vary from one month to several months, however, a consistent and gradually progressive program can result in a full recovery. Selective Serotonin Reuptake Inhibitors (SSRI) and Serotonin Norepinephrine Reuptake Inhibitors (SNRI) have been trialed with moderate success when medication is tolerated. Vestibular suppressants, such as Benzodiazepines, have not shown to be an effective primary treatment for 3PD and can result in negative consequences long-term.
3PD, often resulting from a prior vertiginous event or disturbance in balance, can be successfully treated with vestibular rehabilitation when done properly. To optimize successful outcomes when anxiety, migraine, or depression coexists, all sources of symptoms must be addressed. AVORA providers have specialized training and the right, sophisticated equipment to ensure a proper diagnosis and proper treatment for successful outcomes!