Persistent postural-perceptual dizziness is defined by the Barany Society as dizziness, unsteadiness or non-spinning vertigo present on most days for three months or more, exacerbated by upright posture, by active or passive motion, and by exposure to moving or complex visual stimuli, and typically precipitated by an event that caused acute vestibular symptoms. Every one of these elements is present here, including the classic trigger of vestibular neuritis and the visual exacerbation in a supermarket or with a scrolling screen.
The syndrome unifies the older concepts of phobic postural vertigo, chronic subjective dizziness, space-motion discomfort and visual vertigo. The mechanism is a maladaptive persistence of the high-risk postural control strategy and visual dependence that are normal, adaptive responses during an acute vestibular insult; when they fail to switch off after recovery, the patient continues to walk stiffly, to over-rely on vision and to monitor balance consciously, all of which perpetuate the symptom. Diagnosis is positive and does not require normal vestibular testing, although testing is usually normal or shows only compensated deficits.
This is solid PGY-3 and PGY-4 neuro-otology and increasingly examined, placing the item at the Intermediate level of RITE content. Effective treatments are vestibular rehabilitation adapted for visual desensitization, serotonergic antidepressants and cognitive behavioural therapy.
Incorrect Answers
- A. Incomplete vestibular compensation produces motion-provoked oscillopsia with an abnormal head impulse test and a persisting caloric asymmetry, which have resolved here.
- B. Vestibular migraine causes discrete attacks of vertigo lasting minutes to days with migrainous features, rather than continuous daily unsteadiness.
- C. Benign paroxysmal positional vertigo produces brief spinning triggered by specific head position changes with characteristic positional nystagmus on Dix-Hallpike testing.
- E. Bilateral vestibulopathy causes oscillopsia on head movement and severe imbalance in the dark with bilaterally absent caloric responses.
Testing Pearls
- Persistent postural-perceptual dizziness requires symptoms on most days for at least three months.
- Upright posture, motion and complex visual stimuli are the three defining exacerbating factors.
- It is usually precipitated by an acute vestibular, medical or psychological event.
- It unifies phobic postural vertigo, chronic subjective dizziness and visual vertigo.
- Diagnosis is positive; vestibular testing is typically normal or shows compensated deficits.
References
- Jankovic J, Mazziotta JC, Newman NJ, Pomeroy SL, editors. Bradley and Daroff's Neurology in Clinical Practice. 8th ed. Philadelphia, PA: Elsevier; 2022. p. 2084.
- Staab JP, Eckhardt-Henn A, Horii A, Jacob R, Strupp M, Brandt T, et al. Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): consensus document of the Committee for the Classification of Vestibular Disorders of the Barany Society. J Vestib Res. 2017;27(4):191-208.
- Popkirov S, Staab JP, Stone J. Persistent postural-perceptual dizziness (PPPD): a common, characteristic and treatable cause of chronic dizziness. Pract Neurol. 2018;18(1):5-13.
