Chronic Dizziness: What is Persistent Postural-Perceptual Dizziness?

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Persistent Postural-Perceptual Dizziness. It’s a great name - it says it all (for short, call it 3PD). It’s not great to have, though - it’s a chronic sense of dizziness, unsteadiness, rocking, or swaying. 

It’s considered a chronic functional vestibular disorder - chronic because it may last for months or years, and functional because it is associated with dysfunction in how the vestibular and balance mechanisms operate. It’s not a psychiatric syndrome or a structural condition, and a patient with 3PD is not malingering or “faking it.” Just like we’re starting to understand that chronic pain is real, so is chronic dizziness. 

Other names that have been used in the past to describe what we now call 3PD include phobic postural vertigo, space-motion discomfort, visual vertigo, and chronic subjective dizziness. These terms are slowly falling out of favour because, for the most part, they describe the symptoms but don’t capture the full scope of the disorder. 

Symptoms and Timing of Symptoms

Patients with 3PD report dizziness, unsteadiness, and/or non-spinning vertigo. These symptoms are present on most days, and in most patients, they occur every day or nearly every day. Patients usually report that symptoms increase as the day goes on. 

If a patient doesn’t have symptoms daily, a diagnosis of 3PD is still made if symptoms are present for more than 15 out of 30 days. 

Symptom Exacerbation

It’s in the name - 3PD occurs with persistent symptoms, meaning that they’re always or nearly always present, and don’t have specific triggers. But in patients with 3PD, symptoms get worse with:

  • Upright posture - standing or walking. In some patients, this may also include sitting unsupported

  • Active or passive movement regardless of the direction or position. Examples include walking, riding in a car, or being jostled in a group of people.

  • Moving visual stimuli or complex visual patterns. These can be things like a passing car, a busy carpet or wallpaper, or large screens. In some cases, a small object held up close, like a computer or phone screen, can have the same effect.

Onset and Clinical Presentation

Most often, 3PD develops as a patient recovers from another condition that disrupts balance or causes vertigo or dizziness. These can include peripheral or central vestibular disorders, vestibular migraine attacks, panic or anxiety attacks that include dizziness, concussion, whiplash, or other medical illnesses. 

Most conditions that precede 3PD are acute or episodic, and 3PD usually develops as the acute symptoms of the initial condition resolve. Patients usually don’t have a symptom-free period between the acute and chronic conditions, but as the acute vertigo symptoms fade, they develop the characteristic chronic symptoms of 3PD. This can vary, and less often some patients develop 3PD very gradually.

3PD may be present alone, or it may co-exist with other diseases or disorders. 


Pathophysiology

Prevalence: About 15-20% of patient presenting for evaluation of vestibular symptoms are estimated to have 3PD. This makes it one the most common vestibular diagnoses in adults. 

The reasons why some people develop 3PD are poorly understood. Hypotheses include changes in strategies used for postural control strategies, changes in multi sensory integration, and inefficiencies in the brain networks responsible for spatial orientation. As we often hear, more research is required. 

Risk Factors

There are certain factors that can be correlated with developing 3PD. As always, correlation is not causation - these things go together, but we can’t say what causes what. However, there is a higher risk of developing 3PD in people with:

  • Anxiety-related personality traits (neuroticism and introversion)

  • Family or personal histories of anxiety disorders

On the other hand, people with traits like resilience and optimism were less likely to develop persistent dizziness after an acute vestibular disorder. 

Management

I say this all the time, but rehab is not a DIY project. This is not a condition that a patient should try to self-manage, for a variety of reasons. 3PD should be managed by an experienced vestibular rehab therapist.


If you’re interested, here are the diagnostic criteria for 3PD (from Staab JP et al., 2017)

A) Primary symptom: Dizziness, unsteadiness, non-spinning vertigo

  • Present on most days for ≥ 3 months

  • Persistent but can wax and wane in severity (spontaneously or provoked)

    • Do not need to be present continuously for entire day

    • Tend to increase as day progresses

B) Exacerbating factors

  1. Upright posture

  2. Active or passive motion

  3. Moving visual stimuli or complex visual patterns

C) Onset: Precipitated by an acute vestibular event or other even that disrupts postural control

  • Vestibular disorders (25-30%)

  • Vestibular migraine (15-20%)

  • Panic/anxiety (15% each)

  • Concussion/whiplash (10-15%)

  • Autonomic disorders (7%) or other events which may produce dizziness (ex. cardiac dysrhythmia, adverse drug reactions)

D) Symptoms cause significant distress or functional impairment

E) Symptoms are not better accounted for by another disease or disorder

  • Although 3PD may co-exist with other diseases or disorders


Reference