PPPD Treatment Success And The 3 Keys to Feeling Better

Persistent postural-perceptual dizziness (PPPD or 3PD) is a chronic vestibular disorder characterized by long-standing non-spinning vertigo, often a rocking or swaying sensation, for over three months. Unlike other vestibular disorders, people with PPPD often present with normal imaging and vestibular function testing (VEMPs, Calorics, VNGs, etc.). Instead, it is a clinical diagnosis based on five criteria established by the Barany Society.

Despite the complexity, there is absolutely a path forward for people living with PPPD. The truth is that our current medical system simply isn’t properly equipped to handle complex vestibular disorders. The average vestibular patient sees about four to five different providers before ending up at the right place. This leaves many people living with PPPD feeling confused and hopeless. But with the right resources, as detailed in this article, people with PPPD truly can make substantial improvements.

PPPD is a Real Disorder

People living with PPPD are often dismissed by their healthcare practitioners. It’s not uncommon for patients to be told that “It’s all in your head” or “It’s just anxiety,” largely due to a lack of awareness and “normal” test results.

But we actually have very high levels of evidence that people living with PPPD do present differently than those without dizziness in regards to their balance and overall function. We have multiple studies that show people living with PPPD often exhibit increased postural stiffness, decreased standing stability, and poor tolerance to visually busy environments. These findings are objectively measured for the most part through force plate studies, where researchers can track a test subject’s center of mass under various conditions.

“Normal” Test Results aren’t the Whole Picture

So how can someone exhibit these deficits even though everything looks “normal”?

It’s because PPPD is now largely understood to be a “software” problem and not a “hardware” issue. MRIs are largely used to rule out a “hardware” issue, such as a brain bleed, tumor, or stroke. But since “faulty neuronal networks” (ie a software problem) happen on a cellular level, we aren’t able to detect the issue with current technology. For the most part, the clinical utility of an MRI is more so to rule out more serious pathology as opposed to ruling something in for those living with PPPD.

The Five Diagnostic Criteria for PPPD

Now that we understand the pathophysiology behind PPPD, let’s go over the five clinical criteria for diagnosis. It’s worth noting that when it comes to complex dizziness however, people don’t always fit nicely into diagnostic boxes. The five requirements are as follows:

1. Dizziness, unsteadiness, or non-spinning vertigo that is present on most days for at least three months. Typically described as a swaying, rocking, or bobbing for long periods. Symptoms can wax and wane and do not necessarily need to be continuous.
   
2. Symptoms are made notably worse with upright posture, active or passive motion, and exposure to visually busy environments.
   
3. Symptoms are precipitated by a triggering event, including acute vestibular insults, other medical illnesses, or severe psychological distress.
   
4. Symptoms cause significant distress or functional impairment in daily life.
   
5. Symptoms cannot be accounted for by another medical condition or vestibular disorder.

People have to meet all five criteria in order to be formally diagnosed with PPPD. If you can relate to all of these conditions, there is a good chance you are dealing with PPPD.

The Three Pillars to PPPD Treatment Success

Make no mistake, PPPD is a complex disorder. But with the right team, PPPD treatment success is absolutely possible. It’s important to manage expectations and understand that there currently is no cure for PPPD. Success is therefore defined as having a drastic improvement in quality of life rather than total elimination of symptoms.

1. Vestibular Rehabilitation

Arguably the most important component, vestibular rehabilitation is the gold standard for PPPD treatment success. It is a specialized form of physical therapy specifically for those suffering from dizziness or vertigo. It often includes a mixture of functional testing, maneuvers, manual therapy, therapeutic exercise, balance training, and more.

Not all vestibular rehabilitation is the same. Most physical therapists only get one or two lab sessions on the subject when in school. For the most part, qualified vestibular therapists with extensive post-graduate training are simply hard to find. It isn’t uncommon for the standard vestibular patient to see four to five different providers before ending up at the right place.

For PPPD specifically, therapy is aimed at recalibrating vestibular deficits, improving balance, and reducing visual dependency through gradual exposure.

2. Cognitive Behavioral Therapy and Anxiety Management

PPPD is a very distressing disorder so naturally it can also lead to anxiety. This creates a feedback loop where dizziness leads to anxiety, which then feeds back into the dizziness, a process known as the dizzy anxious cycle. Therefore, the right mental health support is absolutely necessary for PPPD treatment success to help break the cycle.

We have to stress that this does not mean that the symptoms are “in your head.” There is simply a lot of overlap between the neural networks responsible for dizziness and anxiety. This is why PPPD is usually linked with anxiety and not seen so much with other psychiatric disorders such as depression or mania.

The most evidenced mental health approach we currently have is cognitive behavioral therapy (CBT). It’s a structured form of psychotherapy that teaches you how to identify and change negative thought patterns. We know that people with PPPD have hyper-vigilant nervous systems, often times doing too much to maintain balance. By bringing a sense of calm, we can effectively bring back a sense of normalcy to our overall balance.

While the most evidence is behind CBT, we shouldn’t dismiss other forms of mental health support and stress management. Other helpful interventions can include mindfulness, breathing techniques, or even journaling.

3. Consider Medication

Vestibular rehabilitation and cognitive behavioral therapy together already create a strong foundation for improvement. Sometimes, they can even be enough on their own. For some however, it is still worth considering medication.

This is ultimately a conversation to have with your physician, but the most common medications used for PPPD are SSRIs and SNRIs such as Zoloft or Lexapro. While these drugs are classified as antidepressants, they can have a meaningful impact on PPPD as well by calming a “hyper-reactive brain”. In simple terms, some people with PPPD simply have dysregulated serotonin level and are hence responsive to medical management.

If the aforementioned class of drugs don’t work, then your physician may consider alternative medications. Regardless of whether or not you choose to include pharmaceuticals to your treatment plan, it is important to have medical workup with your doctor to rule out any more serious pathology such as a stroke or brain tumor. You’ll also want to make sure you’re being followed by the appropriate specialist such as a neurologist or neuro-otologist.

PPPD Treatment Success is Possible

Navigating the health care system with PPPD is not easy. Unfortunately, there are still those who don’t think it is a real disorder. But what’s even more common is health care providers never having heard of the condition ever before. In short, patients are often left advocating for themselves.

The research is very clear however that PPPD does respond to the treatment approaches previously described. Every case is unique and requires an individualized treatment plan. Ideally, you’d want to find someone who sees PPPD regularly.

It isn’t fair that there are so many roadblocks to PPPD treatment success but there is certainly hope. Focus on taking one small step at a time. With the right support, people living with PPPD are often surprised at just how simple recovery can be.

If you’re having difficulty getting a handle on your dizziness, you’re not alone.

Dizziness often requires a more individualized approach. A personalized plan can help clarify what’s contributing to your symptoms and outline next steps. Get your FREE treatment plan from Pang PT here.