Persistent Postural-Perceptual Dizziness (PPPD)

Definition and epidemiology

Persistent Postural-Perceptual Dizziness (PPPD) is a chronic functional vestibular disorder for which the Bárány Society published diagnostic criteria in 2017. According to the criteria, PPPD is neither a structural nor a psychiatric disorder; it can occur on its own or alongside other vestibular, medical or psychological conditions (Staab et al., 2017). It sits within the spectrum of functional neurological disorders (Popkirov et al., 2018).

PPPD brings together the shared features of conditions previously described as phobic postural vertigo, chronic subjective dizziness and visual vertigo (Popkirov et al., 2018). This consolidation has moved the diagnosis away from exclusion towards positive clinical criteria. A recent review describes PPPD as the most common functional neuro-otological disorder (Staab, 2023).

The exact population prevalence is unknown. In tertiary dizziness centres, the diagnoses regarded as forerunners of PPPD account for about 15-20% of presentations and are the second most common diagnosis, and dizziness persists in about one in four people after vestibular neuritis or BPPV (Popkirov et al., 2018). Data on PPPD in Türkiye are limited to small studies (Binay Bolat and Tokgöz Yılmaz, 2026).

Symptoms and signs

The main complaint is non-spinning dizziness, swaying, rocking or a sense of fogginess in the head. Patients often describe it as “like being on a boat”, “the ground moving under my feet” or “my head feels light and woolly”. Symptoms are present on most days, last for hours and may wax and wane through the day (Popkirov et al., 2018).

Symptoms occur without specific provocation but are clearly worse in three situations: upright posture (standing, walking), motion (active movement or passive movement such as travelling in a car, regardless of direction) and moving or complex visual stimuli (supermarket aisles, crowds, scrolling screens, patterned floors). Because upright posture makes them worse, symptoms usually ease when lying down (Staab et al., 2017).

Over time many patients develop secondary problems: avoiding situations that provoke symptoms, walking with short steps and a stiffened body (secondary functional gait disorder), anxiety, fatigue and marked restriction of daily life (Popkirov et al., 2018). Onset may be sudden or gradual, depending on the triggering event.

Causes and risk factors

PPPD begins with a triggering event. Reported triggers are peripheral or central vestibular disorders in about 25% (for example BPPV and vestibular neuritis), vestibular migraine in about 20%, panic attacks in 15%, generalised anxiety disorder in 15%, mild head injury or whiplash in up to 15%, autonomic disorders in 7%, and dysrhythmias or adverse drug reactions in 3% (Popkirov et al., 2018).

According to the proposed mechanism, during an acute balance problem the brain shifts to “high-risk” postural strategies to avoid falling: it stiffens the body, shortens the stride and relies more on visual information for balance. In PPPD these strategies persist after the triggering event has passed. Persistently high visual dependence predicts failure to recover. Imaging studies show greater activity and connectivity in visual relative to vestibular cortex, and reduced connectivity between the posterior insula, hippocampus and anterior cingulate cortex (Popkirov et al., 2018; Staab, 2023).

Pre-existing anxiety and anxious personality traits predispose to PPPD; high anxiety and excessive attention to bodily sensations after the acute event are among the predictors of persistence (Popkirov et al., 2018). This does not mean that PPPD is “psychological”: the symptoms are linked to measurable changes in how the brain processes balance information.

Audiological and clinical assessment

PPPD is diagnosed on positive criteria; all five of the following must be met (Staab et al., 2017; Popkirov et al., 2018):

• A. One or more symptoms of dizziness, unsteadiness or non-spinning vertigo on most days for at least three months; symptoms last for hours and may vary in severity.
• B. Symptoms are present without specific provocation but are worsened by upright posture, active or passive motion, and moving or complex visual stimuli.
• C. The disorder was precipitated by an event causing vertigo, unsteadiness, dizziness or balance problems (vestibular, neurological, medical or psychological).
• D. Symptoms cause significant distress or functional impairment.
• E. Symptoms are not better accounted for by another disease or disorder.

Vestibular tests and routine imaging are usually normal in PPPD (Popkirov et al., 2018). Normal results are not the basis of the diagnosis, but testing is needed to detect coexisting or triggering conditions and to assess criterion E. The audiological and vestibular test battery covers pure tone and speech audiometry, Dix-Hallpike and supine roll tests, the video head impulse test (vHIT), caloric testing and, where indicated, vestibular evoked myogenic potentials (VEMP). These tests may reveal a compensated deficit from earlier vestibular neuritis or a BPPV that needs treatment; such a finding does not exclude PPPD but changes the treatment plan.

The differential diagnosis includes persisting BPPV, uncompensated unilateral or bilateral vestibulopathy, vestibular migraine, Ménière’s disease, mal de débarquement syndrome, orthostatic hypotension, drug side effects and central nervous system disease. PPPD often coexists with one of these, so both diagnoses may need to be made. For a general approach, see the introduction to vertigo and balance disorders.

Treatment and audiological rehabilitation

The first step is explanatory counselling. Patients should be told clearly that their symptoms are real, not imagined or exaggerated, that they arise from a change in how the brain processes balance and that this change can be reversed with treatment. Naming the diagnosis and explaining the mechanism in plain terms reduces the search for further tests and avoidance behaviour (Popkirov et al., 2018).

Vestibular rehabilitation in PPPD is based on habituation exercises: the patient is exposed to provoking movements and visual environments, starting gently and increasing slowly. Supervision by a physiotherapist or audiologist experienced in PPPD is advised, because progressing too quickly can worsen symptoms and lead to drop-out (Popkirov et al., 2018). A feasibility trial in 40 patients comparing psychologically informed vestibular rehabilitation with standard physiotherapy produced promising but preliminary results (Herdman et al., 2022).

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs) helped most patients with chronic subjective dizziness, the forerunner of PPPD, in open-label studies; response is usually seen at 8-12 weeks, and about one in five patients stopped because of side effects (Popkirov et al., 2018). In PPPD these medicines are also used in patients who are not depressed; the choice of drug and duration rest with the physician. Cognitive behavioural therapy (CBT) targets the cycle of avoidance and anxiety; in a waiting-list controlled study of 41 patients, three sessions of CBT led to significant improvement in 75% (Popkirov et al., 2018).

High-quality evidence, however, is limited. Cochrane reviews found no eligible randomised trials comparing SSRIs or SNRIs with placebo (Webster et al., 2023a) and only one small trial of non-drug treatment (Webster et al., 2023b). In practice these approaches are combined to suit the patient, and coexisting BPPV, migraine or anxiety disorder is treated separately.

Impact on quality of life and advice

PPPD can have a marked impact on daily life. A small study of eight patients from Türkiye reported clinically relevant depressive symptoms, reduced confidence about falling and limitations on the Vestibular Disorders Activities of Daily Living Scale, particularly in instrumental activities (Binay Bolat and Tokgöz Yılmaz, 2026). Supermarkets, public transport, screen work and crowded places are the situations people find hardest; avoiding them brings short-term relief but reinforces symptoms in the long run.

Practical advice: rather than staying away from difficult situations altogether, enter them briefly and gradually, as in your rehabilitation programme. Keep up daily walks and regular physical activity, and consciously try to keep your stride at a natural length. Reducing fast scrolling, enlarging text and taking frequent breaks lighten the visual load of screens. Sleep routine and stress management influence how severe symptoms are.

Self-report questionnaires such as the Dizziness Handicap Inventory, the Vestibular Disorders Activities of Daily Living Scale and the Visually Induced Motion Sickness Susceptibility Questionnaire can be used to track the impact of symptoms on daily life and the response to treatment.