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Central· Onset: Subacute; usually after a precipitating vestibular event · Duration: ≥3 months
Persistent postural-perceptual dizziness (PPPD)
Overview
Summary
Functional vestibular disorder (Bárány criteria 2017): chronic dizziness/unsteadiness/non-spinning vertigo ≥3 months, present most days, exacerbated by upright posture, motion, and complex visual stimuli.
Diagnostic criteria
See the Bárány Society / clinical practice guideline papers[12] listed on the references page for the consensus diagnostic framework used in this profile.
Epidemiology
Most common cause of chronic dizziness in 30–50s. Frequently follows BPPV, neuritis, or vestibular migraine.
Pathophysiology
Maladaptive reweighting of postural control with over-reliance on visual and somatosensory cues plus heightened threat-monitoring of vestibular signals.
Prognosis
Often improves substantially with combination therapy but recurrence with new vestibular triggers is common.
Key examination findings
- ◆Examination typically normal between exacerbations.
- ◆Provoked by visually complex environments (grocery stores, scrolling screens).
- ◆Romberg often normal; subjective rather than objective imbalance.
Investigations
- ▸Diagnosis is clinical (Bárány criteria).
- ▸Vestibular tests usually normal or show only mild residual abnormalities from the precipitating event.
Management
- ●Patient education and reassurance is foundational.
- ●Vestibular rehabilitation with habituation and gaze-stabilization exercises.
- ●SSRIs/SNRIs (sertraline, venlafaxine) — moderate evidence for symptomatic benefit.
- ●Cognitive-behavioral therapy targeting threat-monitoring of motion cues.
Clinical pearls
- ★Coexists with anxiety disorders in >50% of patients — both must be treated.
- ★Don't pursue more vestibular testing once PPPD is established — reinforces illness behavior.