Six months of dizziness — but the exam is normal
A 38-year-old IT consultant had a single episode of acute spinning vertigo 8 months ago, diagnosed as right vestibular neuritis at the time and treated with prednisone. The acute spinning resolved within 2 weeks. Since then, however, he has felt persistently unsteady and 'foggy', particularly when standing or walking through visually complex environments — supermarkets, scrolling phone screens, crowded streets. Symptoms are present most days. He has stopped driving on the highway. Anxiety about the symptoms is escalating.
A 38-year-old IT consultant had a single episode of acute spinning vertigo 8 months ago, diagnosed as right vestibular neuritis at the time and treated with prednisone. The acute spinning resolved within 2 weeks. Since then, however, he has felt persistently unsteady and 'foggy', particularly when standing or walking through visually complex environments — supermarkets, scrolling phone screens, crowded streets. Symptoms are present most days. He has stopped driving on the highway. Anxiety about the symptoms is escalating.
Standard bedside neuro and vestibular exams are unremarkable. No spontaneous or gaze-evoked nystagmus. Head impulse normal. Dix-Hallpike negative. Romberg negative. He walks normally in the office. vHIT today shows residual mild gain reduction on the right (gain 0.78). Caloric testing shows mild residual right unilateral weakness (28%).
Which diagnosis best fits this presentation?
Best initial treatment plan?
Persistent postural-perceptual dizziness (PPPD)
- 1.PPPD is the most common cause of chronic dizziness in the 30-50 age group. It typically follows a precipitating vestibular event (neuritis, BPPV, migraine, panic).
- 2.Mechanism: maladaptive reweighting of postural control with over-reliance on visual and somatosensory cues plus heightened threat monitoring of motion signals.
- 3.Treatment is multimodal: vestibular rehabilitation (habituation > gaze stabilization) + SSRI/SNRI + CBT. Patient education is foundational — naming the disorder validates the experience.
- 4.Pitfall: continued vestibular testing reinforces illness behavior. Once PPPD is diagnosed, stop chasing peripheral signs.