“I’ve been feeling dizzy and unsteady for months.
Why is this and will it ever end?”

Dizziness is a really common condition - most people experience dizziness in their lifetime. Sometimes it can drag on for weeks or months and in these cases Persistent Postural Perceptual Dizziness (PPPD) is one of the most common causes.

PPPD has a long definition. We’re going to break it down for you here:

1. Persistent non-vertiginous dizziness, unsteadiness, or both lasting three months or more.

This refers to a sense of feeling off balance and having dizziness that isn’t spinning (people often feel light-headed, woozy, intoxicated or like they’re swaying).

2. Symptoms are present most days, often increasing throughout the day, but may wax and wane. Momentary flares may occur spontaneously or with sudden movement.

Some people also notice that particular movements or situations bring on their dizziness or unsteadiness. These symptoms are frequent but also fluctuating.

3. Affected individuals feel worse when upright, exposed to moving or complex visual stimuli, and during active or passive head motion. These situations may not be equally provocative.

This describes the fact that most people feel much better when sitting or lying, but have their symptoms come on when they stand up. It mentions visual stimuli: this means that patterned or really vibrant scenes can bring on the dizziness or imbalance, as well as movement in front of someone - like cars crossing at the traffic light or an action movie. Similarly, being in a busy place like a supermarket with its bright lights, customers moving around unpredictably, myriad displays and rows of shelving can be very challenging for people.

4. Typically, the disorder follows occurrences of acute or episodic vestibular or balance-related problems. Symptoms may begin intermittently, and then consolidate.

Symptoms usually come on after a dizziness event of some sort. It might be another vestibular/inner ear condition like BPPV or vestibular neuritis, or due to blood pressure changes, a panic attack or vestibular migraine. Sometimes it just starts gradually and over time a person will notice that it has become part of their life.

OK, so why didn’t I just recover from the original problem?

After the first episode of dizziness, which can be quite traumatic (especially if you’re vomiting or unable to walk by yourself!) your brain learns that dizziness and unsteadiness are bad things and to avoid them at all costs. This can persist even after the initial condition has gone away, particularly if you are under stress for another reason. Once the dizziness starts it is then perpetuated by a group of changes your brain makes to try and keep you safe (and are totally normal!):

1) It prioritises your vision over your other balance systems to try to have a single point of truth, and it doesn’t trust your inner ear to be giving accurate information.

But if your head is moving quickly, you’re not looking at the ground or you’re sensitive to light this won’t work for you: any disagreement between your balance systems and your vision will make you feel dizzy. The brain should be constantly integrating and weighing up the input from all your balance systems to keep you steady:

In PPPD your brain listens to your vision too much. It means you can feel like you’re moving even when you’re standing still.

2) You are very sensitive to any sway. Force plate data shows that people with PPPD feel like they’re on the edge of their balance earlier than they should, and feel more unsteady for a given amount of sway than someone without PPPD.

Often we see people who look quite still when balancing but they feel like they’re about to lose their balance. People often walk like they’re on slippery tiles or with wider steps than normal

*Image source:* *Balance and Strength Laboratory,* *The University of Nebraska*

Your brain will also ask you to be on the lookout for stable supports to grab onto to help with balance and make you really vigilant of the environment you’re in - constantly assessing for threats to your balance.

It’s a vicious cycle…

This vigilance means that any sensation similar to dizziness (like the light-headed feeling you get when standing up too fast, or by spinning round too quickly) that you’d normally ignore now becomes something your brain alerts you to and focuses on.

Of course, it is very difficult to be always in a state of vigilance. Fatigue is really common in PPPD - there is only so much that your brain can concentrate on! Neck stiffness is also common - people tend to hold their head still to avoid dizziness. People tend to leave the house less because busy and unpredictable environments make their symptoms worse, and sometimes travelling in a car can too.

Is there a link between PPPD and anxiety?

The symptoms of PPPD are definitely real. Around half of the people that develop PPPD also have anxiety, and there are other things that make your risk of developing it more likely.

Being someone that is really in tune with their body is often a good thing, but it does mean you’ll notice any subtle disagreements from your balance systems about where your head is in space, causing the sensation of dizziness. When you are under stress your brain puts you on high alert - it wants to know ASAP if things are out of the ordinary. This means it makes your brain notice any perceptual anomalies more than it usually would, which can lead to dizziness. It is for these reasons that people that suffer from anxiety are more likely to develop PPPD.

But it’s not all bad news – a full recovery is possible with the right support

PPPD is a common cause for dizziness and there are a range of ways that vestibular physiotherapy can help. We can diagnose PPPD, address many of the symptoms and associated conditions, and we collaborate with other experts in this area to ensure that each person receives the treatment that’s right for them. Get in touch if this sounds like something you or someone you know is going through.