PERSISTENT POSTURAL PERCEPTUAL DIZZINESS OR PPPD

 

If you have already read the article on balance problems then this has I hope given insight as to how the body reacts to a damaged balance mechanism. There is however a recently recognised disorder known as Persistent Postural Perceptual Dizziness or PPPD. In simple terms, this is long-lasting dizziness when individuals have a feeling of floating, swaying, rocking, or unpleasant dizzy feelings that can affect individuals for long periods of time and will usually be present on a daily basis. There is no doubt that in the past this condition was always out down as a psychological disorder. People were thought to have the chronic hyperventilation syndrome, anxiety or even panic attacks. I am not saying that those conditions do not exist, because that would be ridiculous as they do. It is just so important to identify that if there are primary balance symptoms then anxiety almost naturally follows or accompanies. It is this superadded anxiety that can make the diagnosis so difficult.
 
One of the problems with this particular diagnosis is that the balance tests however sophisticated are usually normal. I have seen many reports over the years of balance tests whereby it has been thought that normal tests mean that the balance or dizzy symptoms must be psychologically mediated and nothing we now know is further from the truth.
 
Many of you will have also read about Functional Neurological Disorders and how I explain that people with migraine be it with or without the neurological aura, when fully investigated have no abnormalities found on standard sophisticated testing. This does not mean that an individual does not have a problem and the same comment applies with regard to PPPD. It is quite simply the brain getting it wrong.
 
Not everyone with PPD has anxiety but the two often go hand in hand or the anxiety follows the PPPD. It does seem that PPPD is more common in women but so is BPPV and migraine. It frequently occurs between the ages of 30 and 50, but no age is spared and in one study, the median age of patients was actually 75 with a range of 33 to 87. In that study 75.8% of the patients were female.
 
When trying to understand the disorder, I note that it is regarded as a “software” disorder meaning that routine examinations and tests are normal. Those tests always focus on “hardware” problems in the nervous system such as Multiple Sclerosis, Stroke or Parkinson’s Disease. None of those conditions apply with regard to PPPD.
 
If you want a full review of this condition then if you are able to get hold of the practical neurology article published on 2024, then this does give a full medical oversight. Dr Barry Seemungal and Dr Luca Passamonti have commented on this article which is by the Drs Popkirov, Staab and Stone.

It is thought that perhaps the disorder is caused by a mismatch between the balance mechanism input to the central nervous system and the vision. This so-called mismatch leads to a challenge with regard to the processing of the information. The individual then experiences the symptoms generated by movement. Intriguingly just like the work of Professor Arnold Wilkins from the University of Essex, geometric patterns or lighting in the environment may precipitate symptoms. The main difference between BPPV and PPPD is that fact that the dizziness may not be associated with environmental mechanisms. The current thinking is that the condition is often preceded by a definite problem with the peripheral balance mechanism be it is BPPV or even Meniere’s Disease or an inflammatory process of the balance mechanism called Vestibular Neuritis or Labyrinthitis.
 
It is remarkable that the thought about this condition started more than 100 years ago. At one time it was even called Phobic Postural Vertigo and an old mentor of mine Professor Adolpho Bronstein was the major the major encouragement of the establishment of our own balance investigation and treatment facility in 1995, called this Visual Variant Vertigo.
 
The key perhaps to the disorder is the fact that the vertigo symptom persists even after vestibular function seems to have made a full recovery as proved by objective testing.
 
The diagnostic criteria for this disorder were first included in the International Classification of Disease (ICD) in 2017 showing firstly how recent this phenomenon has been fully recognised and second why so many doctors are not aware of it and will still perceive that it is predominantly psychiatric. This opinion is often compounded by the fact that anxiety, depression and migraine are conditions that are often associated or concurrent with PPPD.

The diagnosis is made by five clinical criteria which should all be met for this diagnosis to be secure as described in the International Classification of Vestibular Disorders. It goes without saying that a condition requires and MRI brain scan with specific views of the internal auditory meatii, vestibular function tests and some blood tests to be normal. The five criteria are as follows:

Not that I have personally used such an instrument, but there is an assessing questionnaire known as the Niigata PPPD questionnaire that can be used in the absence of any, as they put it, biomarkers or neuroimaging results.
 
A number of other diagnoses have emerged  over the years including what is known as Phobic Postural Vertigo when the symptoms last for seconds rather than hours. It is said that this condition is associated with obsessive-compulsive personality traits, which again perhaps over-emphasises the link with emotion and psychology.
 
The condition Visual Variant Vertigo provoked by moving or complex visual stimuli is only different in that people do not experience postural instability and unsteadiness. For some reason that is poorly understood, there is a drug called acetazolamide that does provide relief of those symptoms in people with this Visual Variant Vertigo.
 
Finally, the condition known as Chronic Subjective Dizziness is persistent dizziness and over sensitivity to movement of self or the environment in patients without an active vestibular disorder. I find that this then makes it very difficult to distinguish from PPPD.

The absolute key is reassurance. The literature confirms the relatively common nature of this disorder and how it will get better with appropriate balance that is vestibular rehabilitation and also dealing with any psychological or emotional comorbidities. People do seem to respond as well to selective serotonin re-uptake inhibitors or serotonin norepinephrine re-uptake inhibitors when taken for about a year. These medications work even in people who do not have anxiety or depression and so there is more to this treatment than just how it reacts on the psychological state. The vestibular rehabilitation programme as offered at the Body Factory by consultant level rehabilitation physiotherapy specialist is the primary treatment of choice. The exercise programme in my opinion is much best served by face to face contact. It is regrettable that during COVID there was so much attempt to treat people online which looking back on it, was truly absurd. The key to the exercise programme is the gradual increase in the exercise programme focusing on each individual and their resilience and tolerance. Individuals often have a fear of falling and by virtue of avoiding behaviours that might generate more symptoms actually make the situation worse.