The disorder
Clinical features
The complaint is constant and wearing: “I’m never quite steady — and supermarkets, screens and traffic make it worse.” The examination, reassuringly and tellingly, is normal.
The cardinal features
People describe a constant off-balance, swaying or “foggy” feeling — not spinning — on most days. It eases when lying down or resting and when distracted, and builds up when standing, walking, moving around, or being in busy places. Tap each feature below.
The pattern is persistent non-spinning dizziness or unsteadiness, present on most days for months, worsened by the three exacerbating factors — upright posture, self-motion, and complex/moving visual stimuli (visual vertigo, space-and-motion discomfort).1 Symptoms fluctuate, often build through the day, and ease with rest and distraction.
The neuro-otological examination is normal — no spontaneous nystagmus, a normal head impulse, normal gait — and that normality, with such disabling symptoms, is itself a clue.2 Anxiety and depression are common and amplify symptoms but are neither necessary nor sufficient; PPPD is a disorder of postural-perceptual function in its own right.3
At the bedside
The purpose of the examination is twofold: to confirm it is normal, and to exclude an active alternative. Check for spontaneous and positional nystagmus, a normal head impulse, normal stance and gait, and a normal orthostatic blood pressure. Patients are often steadier than they fear, and frequently steadier when distracted (e.g. during dual-tasking) — a characteristic, supportive observation. The full battery is in Bedside clinical tests.
Key points
- Persistent non-spinning dizziness/unsteadiness on most days, fluctuating and building through the day.
- Worse upright, with self-motion, and in busy/moving visual environments; eased by rest and distraction.
- The neuro-otological examination is normal — a key, supportive feature.
- Anxiety/depression are common amplifiers but are not the diagnosis.