PERSISTENT POSTURAL-PERCEPTUAL DIZZINESS (PPPD)

CHRONIC FUNCTIONAL DIZZINESS

 

In Brief

PPPD is a chronic, functional balance disorder (a disturbance in how the brain processes balance information, without structural damage to the balance system) causing dizziness, unsteadiness and non-spinning vertigo on most days for at least three months. It usually begins after an episode of dizziness – such as displaced ear crystals, vestibular neuritis, vestibular migraine or a panic attack – when symptoms persist even though the original problem has resolved. It is one of the most common causes of chronic dizziness. It is treatable: with a clear understanding of the condition, balance exercises and, when needed, medication, most patients improve considerably.

 

EMERGENCY: Even if you have already been diagnosed with PPPD, if a new and different sudden dizziness comes with slurred speech (dysarthria), double vision (diplopia), numbness or weakness in the face, arm or leg, inability to walk, or a severe headache, call 112.

 

How Does It Develop? (Pathophysiology)

During an acute bout of dizziness, the brain switches to a protective mode to avoid falling: it stiffens posture (rigid postural control), relies more on vision to stay balanced (visual dependence) and starts to treat movement as a threat (heightened threat perception). Normally these adaptive responses fade once the original problem settles. In PPPD they do not, and they become persistent. Advanced imaging studies have shown changes in the connections between brain areas involved in balance, vision and anxiety. The condition is not “imaginary” or “psychological”; it is a real, non-structural dysfunction of the brain’s balance networks.

 

Symptoms (Clinical Findings)

• Dizziness, unsteadiness or non-spinning vertigo on most days for three months or longer

• Symptoms that fluctuate during the day, often worse towards evening

• Worse when standing or walking, better when lying down (postural triggering)

• Worse with your own movement or when moving in a vehicle

• Marked discomfort with complex or moving visual scenes (visual triggering): busy shopping centres, supermarket aisles, scrolling screens, patterned floors

• Often accompanied by anxiety, fear of falling and avoidance of triggering situations

 

Precipitating Conditions

• Displaced ear crystals (BPPV)

• Vestibular neuritis

• Vestibular migraine

• Ménière’s disease

• Panic attacks or generalised anxiety disorder

• Mild head injury (concussion)

• Fainting (syncope) or episodes of low blood pressure

 

How Common Is It? (Epidemiology)

It is seen in about one in five patients attending specialised dizziness centres and is among the most common causes of chronic dizziness. It is most common in middle age and more frequent in women.

 

Diagnosis

The diagnosis is made using the clinical criteria defined by the Bárány Society; no single test confirms it. Balance tests (VNG, vHIT, VEMP), a hearing test and, when needed, MRI (Magnetic Resonance Imaging) are used to check whether the precipitating condition is still active and to rule out other diseases with similar symptoms. In PPPD, test results are often normal or show only traces of the earlier illness; this does not mean the symptoms are not real.

 

Treatment

• Understanding the condition (education): A clear understanding of what causes the symptoms, and that recovery is possible, is the first and most important step of treatment.

• Balance exercises (vestibular rehabilitation): Habituation exercises based on gradual, controlled exposure to triggering movements and visual environments help the brain recalibrate its exaggerated responses. Exercises should start at low intensity and be increased slowly.

• Medication: Selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs) are used – even without depression – because of their effects on the brain’s balance and threat-perception networks. The effect usually becomes clear within 8–12 weeks, and treatment is continued for several months.

• Cognitive behavioural therapy (CBT): Makes an important contribution when anxiety and avoidance are prominent.

• What to avoid: Long-term use of anti-dizziness medicines (vestibular suppressants) and avoiding movement both slow recovery.

 

Course

With treatment, symptoms decrease considerably over months in most patients. They may increase again during stressful periods or after a new episode of dizziness; the techniques learned during treatment make these periods shorter and milder.

 

Frequently Asked Questions

Is this a psychological illness? No. PPPD is a real disorder of how the brain processes balance information. Anxiety often accompanies it and can make it worse, but it is not the cause.

My tests were normal – why does my dizziness not go away? In PPPD the problem lies not in the structure of the balance organs but in how the brain uses the information they send; that is why tests are often normal.

I am not depressed – why am I given an antidepressant? In PPPD these medicines are not used to treat depression but because they regulate the brain networks involved in balance and threat perception.

Will it go away completely? Most patients improve considerably and return to daily life without restrictions; in some, mild symptoms may come and go.

 

Detailed information and diagnostic criteria for physicians: the Vestibology link at the top of the page (vestibology.com).

Last updated: November 2026 · Editor: Assoc. Prof. Mehmet Sürmeli · Source: Bárány Society diagnostic criteria for persistent postural-perceptual dizziness (PPPD) (2017). This page is for general information and does not replace examination and diagnosis.