Persistent Postural-Perceptual Dizziness (PPPD)

What is PPPD?

Persistent Postural-Perceptual Dizziness (PPPD) is a chronic balance disorder that causes ongoing dizziness, unsteadiness, or a “rocking” or “floating” sensation. Unlike vertigo conditions such as BPPV, PPPD does not usually cause true spinning.

It is a functional vestibular condition, meaning the problem lies in how the brain processes balance signals rather than structural damage to the inner ear.

What does PPPD feel like?

People with Persistent Postural-Perceptual Dizziness often describe symptoms such as:

• Constant or near-constant dizziness

• Feeling unsteady when standing or walking

• A “drunk” or swaying sensation

• Light-headedness (not fainting)

• Sensitivity to movement

• Discomfort in visually busy environments

• Symptoms that fluctuate throughout the day

Symptoms are typically present on most days for three months or more.

What causes PPPD?

PPPD usually develops after an initial trigger that disrupts the balance system. Even after the original issue resolves, the brain can remain in a heightened state of alert.

Common triggers include:

• Benign Paroxysmal Positional Vertigo (BPPV)

• Vestibular neuritis

• Labyrinthitis

• Vestibular Migraine

• Panic attacks, anxiety, or stress-related dizziness

• Concussion or head injury

• Prolonged illness or hospitalisation

Why does PPPD happen?

After an initial dizziness event, the brain may:

• Over-rely on visual information for balance

• Become hypersensitive to movement

• Increase postural “guarding” (tensing up for stability)

• Develop anxiety about dizziness returning

This creates a feedback loop where dizziness leads to anxiety, and anxiety increases dizziness.

How is PPPD diagnosed?

There is no single scan or blood test for PPPD. Diagnosis is based on clinical history.

A healthcare professional will typically look for:

• Dizziness on most days for at least 3 months

• Symptoms worsened by standing, movement, or visual complexity

• A clear initial trigger (e.g. vestibular illness or stress event)

• Normal or non-explanatory vestibular test results

• Exclusion of other causes such as stroke or active inner ear disease

PPPD vs other dizziness conditions

PPPD is often confused with other vestibular disorders:

• BPPV: brief spinning triggered by head position

• Ménière’s disease: episodic vertigo with hearing loss and tinnitus

• Vestibular neuritis/labyrinthitis: sudden severe vertigo lasting days

• PPPD: chronic, non-spinning dizziness with visual sensitivity

Treatment for PPPD

1. Vestibular rehabilitation therapy

• Retrains balance processing

• Reduces visual dependence

• Gradual exposure to movement and triggers

2. Psychological therapy (CBT)

• Helps break the dizziness–anxiety cycle

• Reduces symptom-related fear and avoidance

• Improves confidence in movement

3. Medication (in some cases)

• SSRIs or SNRIs may help regulate sensory processing and anxiety

• Often most effective alongside VRT

4. Lifestyle changes

• Regular sleep routine

• Stress management techniques

• Gradual return to normal activity (avoid over-avoidance)

• Reducing prolonged screen or visual strain where appropriate

Can PPPD go away?

Persistent Postural-Perceptual Dizziness is a long-term but reversible condition. Many people improve significantly with treatment.

Recovery often involves:

• Gradual desensitisation to movement

• Reduced anxiety response to dizziness

• Rebuilding confidence in balance

Improvement can take weeks to months, but prognosis is generally good with the right support.

Living with PPPD

PPPD can be frustrating because routine tests often appear normal, yet symptoms are very real.

Common daily challenges include:

• Difficulty in supermarkets or crowded spaces

• Discomfort when scrolling on phones or screens

• Feeling worse when tired or stressed

• Avoiding activities due to fear of dizziness

Understanding the condition is an important first step toward recovery.

When to seek help

You should seek assessment if you experience:

• Persistent dizziness lasting longer than 3 months

• Ongoing imbalance affecting daily life

• Visual or motion-triggered dizziness

• Anxiety linked to balance symptoms

Final thoughts

Persistent Postural-Perceptual Dizziness is one of the most common causes of chronic dizziness, yet often misunderstood. It develops after an initial vestibular or stressful event and persists due to changes in how the brain processes balance signals.

With vestibular rehabilitation, psychological support, and gradual exposure, most people experience significant improvement and can return to normal daily activities.