One of the many rhyming acronyms in vestibular disorders is PPPD, or Persistent Postural Perceptual Dizziness. Because the diagnosis is based on symptoms only, with no objective signs, it has become overused, and the diagnosis can be given to almost anyone who has anxiety combined with dizziness. Dizziness causes anxiety, so it’s extremely easy to shoehorn people into this category. There is also no simple treatment, and it tends to be long-lasting, so it has become a favorite way to group (and forget about) difficult or non-responding patients.
PPPD’s definition includes that it is set off and preceded by a vestibular condition. In other words, it follows things like BPPV, Meniere’s disease, viral infections of the ear, and other problems. This raises the possibility that there is residual damage or malfunctioning in the balance system in these people for which we don’t yet have adequate testing or for whom little testing was performed.
Another key criterion is that the symptoms include feeling unsteady or off balance, and that there is no spinning of the room or strong internal spinning feelings. Instead it is often characterized as a floating or rocking feeling. The problem with this criterion is that true vertigo with strong spinning is easy to describe, but as spinning slows down with recovery, it is more difficult for people to describe. Often following viral infections of the ear or other damage, there is a prolonged period of less severe vertigo and imbalance that is not a new disease, just a continuation of the prior damage.
To be PPPD, the problem must impair the sufferer for at least 3 months and be present on most days. Of course, it can take a year after a balance system injury to recover fully (and some never return to normal), so the PPPD definition unfortunately includes these people.
Changes in posture and visually confusing environments (stripes, checkerboards, panning motion in films, etc.) can make the symptom more noticeable. Of course, this is true of most vestibular disorders. PPPD also includes the usual disclaimer, that it cannot be better explained by another disorder. This disclaimer means that providers with a limited knowledge of other disorders are much, much more likely to diagnose it.
These definitions are far too vague to define a syndrome, and it has become a waste bucket term to justify giving up on difficult patients. It is far more useful to concentrate on the vestibular diseases that led to the condition and try to figure out why it persists. For example, if BPPV was followed by this low grade feeling of imbalance, perhaps there is entrapment of particles or continued mild BPPV. If the initial trigger was a viral infection, consideration should be given to persistent damage in parts of the balance system that are harder to test, including problems like reduced sensation in the legs and feet, poor sight or visual tracking problems. There are likely to be several different disorders that will later be found to fall under the now very wide umbrella of PPPD. Once these are better defined, PPPD will shrink in importance.
As for the often-discussed symptom of anxiety and obsession with symptoms in PPPD, these do not require a new vestibular diagnosis. Anxious people will report more anxiety if they develop a vestibular problem, and people who tend to be OCD will obsess more about their symptoms. If you take away the underlying vestibular disorder, the obsessions and anxiety will decline back to baseline. For example, for people with damage to the vestibular system, it is normal to have certain feelings of very mild dizziness brought on by head movements. Explaining this can go a long way to relieving their anxiety and need to obsess.
Ending Vertigo Today 