Persistent Postural-Preceptual Dizziness (PPPD)

Persistent postural-perceptual dizziness (PPPD) also known as Chronic subjective dizziness (CSD) is a condition in which patients experience a constant sensation of dizziness i.e. dizziness all day, every day. Usually patients are sensitive to head movements or movement of their surroundings. If patients become dizzy when there is movement of their surroundings or when the visual environment is busy e.g. in a supermarket, the label “visual vertigo” is also used. Usually patients feel better when they are not moving.

If no other cause is found for the dizziness and the patient has a feeling of unsteadiness which is worse with head movement, movement of their surroundings or busy visual environment, then PPPD is a possible label which could be applied to their condition. The exact cause of this problem is unclear but in some patients there is a clear precipitating event such as BPPVvestibular neuronitis (viral labyrinthitis)migraine, head or neck trauma or an episode of depression/psychological stress. These events seem to trigger/precipitate a state of hypersensitivity to stimuli such as motion.

Other causes of chronic dizziness

Patient with Multi-factorial dizziness can also have persistent dizziness. Patient with multifactorial dizziness usually have multiple other medical conditions (diabetes, joint problems, nerve/neurological problems, visual problems or are on a number of various medications) which together cause dizziness (see Multi-factorial dizziness). Patient with bilateral vestibular hypofunction can also feel dizzy when mobilising but they tend not have sensitivity to a visual environment. They often describe unsteadiness. While sat in a chair they can shake their head from side to side rapid without it having a lasting dizziness.

In PPPD it is particularly important that patients are assessed by their GP for conditions other than ear disease which may be causing dizziness. This includes low blood pressure, irregular heart beat (arrhythmia), anaemia (low blood count), abnormal levels of salts or sugar in the blood, abnormal hormones ( e.g. low Thyroid hormone), low Vitamin levels (e.g. Vitamin D or B12), inflammation in or around the brain, abnormal function of nerves (e.g. neuropathy due to diabetes or trapped nerves due to disc problems in the back or neck), side effects from medications and brain tumours (the last is very rare).

Management

There is not a single universally agreed treatment. Broadly the treatments include desensitisation/compensation and drug treatment (or both).

Visual / vestibular desensitisation/compensation. This involves gradually increasing exposure to the situations that can cause dizziness in an attempt to build up your tolerance. For example, some patients feel dizzy particularly when going to the supermarket, driving or even walking outside e.g. in crowds. The activity/ exercise should last at least a few minutes and be sufficiently rapid to cause some dizziness/unpleasantness for a few minutes after you stop. This allows the brain to either habituate and/or compensate. Unfortunately, many patients with CSD are sensitive to any stimuli (whether exercises or drug treatment) and habituate/compensate very slowly. After an exercise you should aim to keep this period of “unpleasantness” to below half an hour if possible. This would allow you to repeat the exercise 2 to 3 times a day. If the period unpleasantness lasts longer than half an hour it is likely to aggravate the overall problem. If required you would need to reduce the complexity, speed and duration of activity. Of course, you do have to carry out the activity for a few minutes otherwise no benefit/progress will be made. You may opt to carry out the activity for a shorter duration but more frequently for example 1 minute 5 times a day rather than 5 minutes 3 times a day. You will need to decide yourself if the activity is manageable. If moving your head from side to side causes dizziness then I would recommend initially carrying out the VOR exercises and Cooksey Cawthorne exercises explained in the section on vestibular neuronitis (click here). If movements of your surrounding precipitates the dizziness even when your head is still, then the “disco ball” exercise (optokinetic stimulation) may be of some benefit. This involves sitting in a completely dark room with a shelf behind you at the same level as the top of your head. On the shelf place a children’s disco ball (this can be purchased from the children’s section of shops such as Argos or Amazon) which emits moving pattern of multicoloured lights onto the walls. As mentioned above, increase your exposure gradually so that the exercise causes some unpleasantness which lasts for less than half an hour. This would need to be done 3 times a day over a few weeks. If you find you cannot tolerate any significant period of time with the disco ball exercise you may opt to allow some light into the room initially.

Once you are confident in your own house you can progress to exercises outside. If you are unable to tolerate walking well then start with a short walk to the end of your own path. Gradually increase the period of walking or driving. You may wish to walk in crowded areas initially in the direction of the crowd and later in the opposite direction. With respect to supermarkets which are often a cause of problems for patients I would recommend a short visit initially with the aim of not actually doing any shopping i.e. just walking through the aisles. The concentration required to maintain your balance and looking for specific items for your shopping may initially be too challenging. Gradually as you are able to walk around for longer periods you can then begin to actually look for items. Initially you may aim to purchase items whose position/place is known to you.

Some patients seem intolerant to the lights in supermarkets or are have difficulty viewing items on a computer or even reading a book. I would recommend using sunglasses or tinted overlays which can be placed over a computer screen or book. Tinted overlays can be purchased from shops selling material for children with dyslexia. Search google with the term “dyslexia overlays” for suppliers.

Medications

Antidepressant class medication including Venlafaxine or Amitriptyline. Antidepressant medications have been shown to be of some benefit in some patients PPPD. Some patients can be sensitive to medication side effects and may need to start on the smallest dose (or even half or a third of the smallest tablet). Sustained release formulations are better tolerated. Sometime the medication is better tolerated if take n in a split dose (i.e. twice or three time a day instead of taking it in one go). More details can be found here.

Benzodiazepines e.g. Diazepam (Valium), Lorazepam or Clonazepam. These medications can be effective, but they are addictive if taken long term. To maintain their effect the does may have to be escalated which will eventually be counterproductive. Despite this I have effectively treated a number of patients with this class of medication. They have stayed on the lowest dose with long term benefit. The patient will have to accept that the patient will be addicted but if the dose is not increased this may be an acceptable compromise.

 

Psychological Treatment

If patient is particular anxious psychological treatment as appropriate can be considered.