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Persistent Postural-Perceptual Dizziness (PPPD)

7 May, 2024

Persistent Postural-Perceptual Dizziness (PPPD)

Approximate reading time: 4 minutes

Persistent Postural-Perceptual Dizziness (PPPD or 3PD) is a common cause of dizziness in the middle aged. It significantly impacts day to day tasks - making everyday life very challenging.

PPPD Symptoms

  • More than three months of rocking, swaying unsteadiness and dizziness
  • Symptoms occur almost daily
  • Aggravated by movement, standing / sitting or complex visual environments
  • Relief with lying down
  • Frequently starts after an acute attack of:
    • Vestibular disorder such as BPPV or Ménière’s
    • Vestibular migraine
    • Vestibular neuronitis
    • Panic attack with dizziness
    • Concussion or whiplash
    • Dysautonomia
    • Anxiety
    • Drug induced vertigo
Persistant postural perception dizziness
Persistent Postural-Perceptual Dizziness unsteadiness feet

PPPD Diagnosis

Diagnosis is made after excluding other causes - it's not a migraine, inner ear disease or anything else.

It's not a structural condition. MRIs and other tests come back "normal" but you can feel far from normal.

It's not a psychiatric condition. It's not all in your head.

PPPD Probable Diagnostic Questionnaire

The following questions forms the Niigata Persistent Postural-Perceptual Dizziness Questionnaire which your doctor might give to you to help diagnosis and understand your daily difficulties due to your dizziness. Please not that this is included here not to self-diagnose (yes we are all guilty of that after a quick Google search). This is here so that you can share with your doctor as some doctors are still not aware of PPPD.

During the past week, how have the following been impacted by your dizziness. If there's no impact, rate it 0 and if you've avoided the action due to your dizziness, rate it 6.

  • Quick movements such as standing up or turning your head
  • Looking at large store displays
  • Walking at your natural pace
  • Watching TV or movies with intense movement
  • Riding a car, bus, or train
  • Sitting upright in a seat without back and arm support
  • Standing without touching fixed objects
  • Watching a scroll screen on PC or smartphone
  • Performing activities such as housework or light exercise
  • Reading small letters in a book or newspaper
  • Striding at a rapid pace
  • Riding an elevator or escalator

Sourced from Yagi et al. (2019).

What did you score?

Mechanisms of PPPD

PPPD Dizziness holding head

It’s not known exactly what’s happening - yet. It’s believed to involve a number of functional factors:

  • Psychological components - with anxiety or depression affecting up to 75%
  • Altered sensory perception
    • Postural control
    • Visual processing
    • Vestibular processing
    • Pain perception

Functional disorders, such as PPPD, means that the structure of the brain, vestibular system and other balance areas are all intact. They just are a bit wonky in the way they work.

This is like a software glitch on a computer. The computer hardware (aka the keyboard, screen and processing unit) are all working. It’s just the software that needs an update or reboot.

Vestibular rehabilitation aims to update and reboot the vestibular system.

PPPD Treatment Options

Medication for PPPD

Serotonin based drugs are frequently effective in reducing dizziness. They also help with the anxiety & depression experienced by up to 75% of PPPD patients.

It's not known how these medications might help but potentially through altering the brain's hyper-excitability, impacting the balance network of the brain or by improving psychological state (ie: anxiety).

Medication is generally required for at least a year and, like all therapies, has potential side effects such as headaches, gut complaints, sleep problems, psychological disturbances, lightheadedness, heart palpitations or sexual dysfunction (Webster et al. 2023). You should discuss with your GP or neurologist if you think this might be an option for you to know.

Vestibular Rehabilitation for PPPD

The vestibular system is the inner ears and is responsible for balance and stability.

Training the vestibular system can reduce dizziness symptoms as well as associated anxiety & depression. Not only does it help with balance, but also allows more easy for moving about and reduces falls risk.

Vestibular Rehabilitation should be continued for 3 - 6 months.

Psychotherapies for PPPD

Counselling, psychologist or hypnotherapy may be helpful to reduce the likelihood of developing ongoing issues when a balance disorder first starts. 

If you’ve had PPPD for a while, it’s helpful for any anxiety and depression associated with it but not as much the dizziness.

Appointments available in Moonee Ponds or online.


  • Persistent Postural-Perceptual Dizziness (PPPD) is a mismatch of sensory information
  • PPPD occurs almost daily for more than 3 months
  • Vestibular rehabilitation, medication and, in the early phases, counselling may help with the dizziness & associated anxiety / depression

About the Author

Dr Cassie Atkinson-Quinton - Chiropractor, Brain Health Coach & Biofeedback Practitioner

Dr Cassie is a Chiropractor and Brain Health Coach. Having a special interest in treating nerves and brain-based conditions like nerve pain, chronic pain, dizziness, whiplash, migraines and fibromyalgia. She's one of a handful of practitioners to be trained in Neuro-Rehabilitation, Neurofeedback, QEEG Functional Brain Scans and Brain Health Coaching.

She’s had concussions and atypical migraines as well as a vestibular disorder called Labyrinthitis. During this time, she would hold on to tables to avoid falling over. She understands the journey coming from a family of chronic pain and migraine sufferers.

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  • Holle D et al. (2015). Persistent Postural-Perceptual Dizziness: A Matter of Higher, Central Dysfunction? PLoS One. 2015; 10(11): e0142468. Published online 2015 Nov 16. doi: 10.1371/journal.pone.0142468
  • Staab JP. (2012). Chronic Subjective Dizziness. Continuum (Mineapp.Minn.). 2012 Oct; 18(5 Neuro-otology):1118-41.
  • Staab JP et al. (2017). Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the committee for the Classification of Vestibular Disorders of the Bárány Society. Journal of Vestibular Research, vol. 27, no. 4, pp. 191-208, 2017. DOI: 10.3233/VES-170622
  • Persistent Postural-Perceptual Dizziness. World Health Organization, International Classification of Diseases (ICD-11). Accessed via
  • Webster KE, Kamo T, Smith L, Harrington-Benton NA, Judd O, Kaski D, Maarsingh OR, MacKeith S, Ray J, Van Vugt VA, Burton MJ. Non‐pharmacological interventions for persistent postural‐perceptual dizziness (PPPD). Cochrane Database of Systematic Reviews. 2023(3).