- PPPD is characterised by a persistent rocking or swaying sensation, especially in upright positions such as standing, walking, or working at a desk.
- The severity of dizziness fluctuates over time, with changes occurring over timescales ranging from hours to weeks and even months.
- Unlike dizziness related to neck problems, PPPD is associated with more psychological symptoms and fewer measurable physical findings.
What is PPPD?
PPPD, also known as 3PD (persistent postural-perceptual dizziness), is a relatively new diagnosis, first defined in 2017.
Brain imaging studies have shown that PPPD is associated with changes in brain regions that regulate balance and emotional processing. These findings suggest that PPPD results from an imbalance in brain functional circuits, with some regions being overactive while others are underactive, leading to the typical sensations of dizziness and instability.
Diagnostic Criteria
A PPPD diagnosis requires all five criteria to be met:
- Duration of symptoms: Rocking dizziness or imbalance lasting at least three months. Symptoms may fluctuate or even disappear temporarily, but usually worsen in the evening.
- Aggravating factors: Symptoms are exacerbated by upright posture, physical movement, and heightened visual stimuli—for example, in crowded environments such as railway stations or shopping malls.
- Onset: Often triggered by vestibular disorders or psychological factors such as anxiety, stress, fear, or depression.
- Functional impairment: The dizziness causes significant limitations in daily activities.
- Exclusion: Symptoms cannot be better explained by another medical condition.
Associated Symptoms
PPPD differs from cervical vertigo. While cervical vertigo mainly causes rocking dizziness, PPPD is more often associated with:
- Psychological distress
- Brain fog, poor concentration, and memory difficulties
- Sensitivity to visual stimuli (e.g., complex patterns, crowded environments, or fast-moving objects)
Common triggers include scrolling on a smartphone while standing or shopping in a crowded mall.
Contributing Factors
Several factors increase the likelihood of developing PPPD:
- More common in women
- Variable dizziness and vertigo episodes
- Head or neck injuries (e.g., concussion, whiplash)
- Psychological trauma
- History of cerebrovascular events, Ménière’s disease, vestibular migraine, or vestibular neuritis (inner ear inflammation)
- Mental health conditions (present in about half of patients)
- History of panic attacks or high stress reactivity
Treatment and Rehabilitation
PPPD differs from cervical vertigo in that vestibular tests typically reveal fewer findings in the balance system. For instance, patients may not experience vertigo when standing with eyes closed, which is very common in cervicogenic dizziness.
- Vestibular rehabilitation: Individualised, gradual programmes can improve symptoms, though recovery may be slower than in cervicogenic vertigo.
- Lifestyle strategies: Gentle mind-body exercises (such as yoga, Tai Chi, and Pilates), breathing exercises, and better sleep habits.
- Psychological support: Cognitive behavioural therapy (CBT) and other psychotherapies.
- Medication: In selected cases, medication can be used to manage psychological symptoms.
Read more
What causes vertigo, dizziness and imbalance?
Read more about common causes of dizziness and imbalance
Concussion (Post-Concussion Syndrome)
Read more about common causes of vertigo and imbalance
Benign Paroxysmal Positional Vertigo (BPPV)
