What could be causing my dizziness?

May 28, 2020

Persistent postural-perceptual dizziness is a common cause of chronic dizziness

Do you find yourself feeling dizzy or have trouble maintaining balance? Do you feel like objects are moving when they aren’t or feel like you’re falling when you aren’t?

These are just some of the signs of persistent postural-perceptual dizziness (PPPD). PPPD is a common cause of persistent or chronic dizziness. It’s usually treatable, especially if it is diagnosed early.

Kathy Dement

Studies suggest that PPPD may occur in as many as one in four patients with a vestibular problem such as Meniere’s disease or vestibular neuritis. In addition, it tends to occur more in women and between the ages of 30 and 50 years.  

Related Article: What is Meniere’s disease?

Our bodies maintain balance by signals sent from the ears, eyes and muscles and joints in the legs and feet to the brain, says Kathy Dement, AuD., clinical audiologist with the St. Joseph’s/Candler Center for Oto-Neurology. The brain uses these signals to maintain balance when walking in different environments or with head or body movements.

When there is confusion in the signals sent from the three systems to the brain, a person may experience vertigo, imbalance or sensation of movement, Dement says. When the brain detects risk for falling, input from the balance center in the ears is typically reduced while input from the eyes is increased until the fall risk resolves.

“With PPPD, the brain is on constant alert for fall risk and uses more information from the visual system than the vestibular system,” Dement says. “Visual input like busy patterns or movement suggests to the brain that there is risk for fall causing the person to have to concentrate on maintaining balance when walking and having anxiety about falling.”

How is PPPD diagnosed?

There are five major criteria that must be present for the diagnosis of PPPD.

1. Symptoms include complaints of dizziness, unsteadiness, non-spinning vertigo (swaying/rocking sensation when sitting or standing still), lightheadedness or floating feeling present for extended periods of time on most days for at least three months. Symptoms may vary in intensity through the day and typically increase as the day progresses.

2. Symptoms are persistent, occur without obvious reason and increase in the following situations:

  • Standing or sitting upright, especially sitting unsupported
  • With active or passive head/body movements like walking (active movement) or riding in the car or elevator (passive movement)
  • Exposure to moving visual stimuli like passing traffic, scrolling on a computer or phone, watching television or seeing the movement of others in the environment
  • Exposure to complex visual stimuli like busy wallpaper or floor patterns, items in the grocery aisles and seeing flickering light patterns like sunlight and shade.

3. These symptoms begin after an event that causes acute vertigo, imbalance or dizziness such as:

  • Vestibular disorder, for example, Meniere’s disease, benign paroxysmal positional vertigo or vestibular neuritis
  • Stroke
  • Vestibular migraine
  • Concussion
  • Panic attacks/anxiety with dizziness

4. Symptoms cause significant distress or impairment in daily life like difficulty with walking, neck stiffness, fatigue, fear of falling and avoidance of things/situations that exacerbate symptoms like going to crowded places like the mall, movies and even going outside the house.

5. Symptoms cannot be attributed to another disease or disorder but can coexist with other disorders.

How do you test for PPPD?

There is no specific test for PPPD; therefore, diagnosis of the condition requires that patients meet the clinical criteria stated above. Some patients with dizziness and complaints of imbalance are referred for vestibular testing.

The Center for Oto-Neurology, located at St. Joseph’s Hospital, has doctoral-level audiologists who are familiar with PPPD, Dement states, and can perform a number of tests including VNG (Videonystagmography), VEMP (vestibular evoked myogenic potential) and Equitest.

“These tests assess the function of the central and peripheral vestibular system, as well as the function of the vestibular, visual and somatosensory systems in maintaining balance,” Dement says.

Learn more on our website.

How do you treat PPPD?

Treatment for PPPD can involve a three-prong approach:

1. Vestibular rehabilitation is exercise-based therapy performed by a physical therapist with the goal of retraining the brain’s responses to signals from the vestibular and visual systems in order to desensitize the brain’s response to stimuli that trigger symptoms. Vestibular rehab has been found to reduce vestibular symptoms by 60 to 80 percent, increase mobility and enhance daily functioning as well as to reduce anxiety and depression in PPPD patients.

Related Article: Have trouble with your balance? Physical therapy can help.

2. Medication is the second method of treatment which can include use of antidepressants, in particular SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin norepinephrine reuptake inhibitors).

3. The third type of treatment is cognitive-behavioral therapy which focuses on the relationship of thoughts (cognition) to behaviors to help patients manage anxiety, cope with situations that occur, stop avoidance behaviors and gain confidence.

If you are concerned about dizziness or imbalance, talk to your physician today. You may be a candidate for a referral to the Center for Oto-Neurology for furthering testing. 

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