Persistent postural-perceptual dizziness

Lore & Background

The term persistent postural-perceptual dizziness (PPPD) unifies key features of a variety of Chronic Subjective Dizziness (CSD). Perhaps the first account of CSD was the German neurologist Karl Westphal's portrayal in the late 1800s of people who suffered dizziness, anxiety and spatial disorientation when shopping in town squares, a phenomenon then called 'agoraphobia.' Unlike people who feel anxious in crowds because they feel something bad will happen, people with CSD may dislike crowds because all the movement leads to a sensation of dizziness.

Diagnostic terms for this disorder have included 'space motion discomfort,' 'phobic postural vertigo,' 'psychogenic dizziness,' 'chronic subjective dizziness,' and 'psycho-physiological dizziness.' As of January, 2025, the condition is recognized as 'Persistent Postural-Perceptual Dizziness' by the International Classification of Diseases 11th Revision as code AB32.0. Clinical studies are ongoing into PPPD at the Mayo Clinic and other institutions.

Reader's Guide

PPPD represents a significant shift in understanding chronic dizziness, moving from purely psychological explanations to a model of a chronic functional vestibular disorder where the central nervous system integrates sensory information differently. Its codification in ICD-11 provides a standardized diagnosis, which is crucial for research and treatment. The condition frequently follows an initial vestibular injury, but symptoms persist after healing, often worsened by stress, anxiety, or complex visual environments. Diagnosis typically occurs after other conditions are ruled out, with key features including persistent nonvertiginous dizziness or unsteadiness for at least 3 months, exacerbated by motion or visual stimuli. Effective treatment combines vestibular rehabilitation therapy, medications such as SSRIs or buspirone, and psychotherapy including cognitive behavioral therapy and acceptance and commitment therapy. Recent exploratory studies suggest potential benefits from transcranial direct-current stimulation and non-invasive vagus nerve stimulation, though further research is needed. The condition's history, from Westphal's agoraphobia to modern PPPD, illustrates the evolving understanding of the interplay between sensory processing and psychological factors.

Did You Know?

• PPPD is estimated to be one of the more common causes of chronic dizziness, with an incidence of 15%–20%.
• One study showed 60% of PPPD patients had clinically significant anxiety and 45% had clinically associated depression, but 25% had no psychiatric condition.
• Perhaps the first account of Chronic Subjective Dizziness was the German neurologist Karl Westphal's portrayal in the late 1800s of people who suffered dizziness, anxiety and spatial disorientation when shopping in town
• Recent experiments with transcranial direct-current stimulation combined with vestibular rehabilitation showed significant improvement in symptoms over a sham group in an exploratory study.