Why Do I Feel Dizzy in Supermarkets? 4 Critical Reasons Beyond Visual Dependence

“Why do I feel dizzy in supermarkets?” “What is visual vertigo?” “Is this my new normal, and can I actually get better?” These are questions I hear from patients dealing with chronic dizziness all the time. And the short answer is yes — you can get better.

First thing we have to establish is that vertigo is not a diagnosis. Vertigo is a symptom. This is where a lot of patients get led astray from the very beginning. Vertigo gets framed as always being BPPV, or “the inner ear crystal issue,” and when it turns out to be more complex than that, people are left confused with nowhere to go.

So how do we actually define vertigo? A lot of people equate it to a room-spinning sensation, but that’s not quite right. Vertigo is an illusory sense of movement of yourself or your surroundings when in fact there is none. This includes sensations of feeling like you’re on a boat, rocking or swaying, an internal sense of motion, or even feeling disembodied. These symptoms can feel bizarre but aren’t exactly unexpected when you’re dealing with vestibular pathology.

There are actually 25 to 30 different disorders that can cause vertigo. And vestibular disorders can be classified into two distinct categories: central versus peripheral. A peripheral disorder means that there is dysfunction at the inner ear while a central disorder originates from the brain. Any of these vestibular disorders could cause dizziness in visually busy environments. But when dizziness in supermarkets is particularly pronounced, we are generally thinking of central disorders especially a condition called PPPD.

Why Do I Feel Dizzy in Supermarkets Specifically? (PPPD and “Supermarket Syndrome”)

PPPD or 3PD is short for persistent postural perceptual dizziness. It’s a chronic dizziness disorder with a hallmark sign of dizziness and discomfort in visually busy environments, commonly Costco or the grocery store.

This is baked right into the diagnostic criteria for PPPD. PPPD is especially unique in that it usually looks completely normal on imaging and other routine examinations. They can even present with normal results on vestibular function testing which is the most precise test battery we have for vestibular disorders, often involving state of the art medical equipment. This leaves many confused, but we now understand PPPD to be a software problem. That the pathology occurs at the cellular level currently undetectable with modern medical equipment. PPPD is ultimately the result of faulty neuronal networks in the brain.

That leaves a lot of PPPD patients frustrated, because nothing shows up on testing. Instead, the diagnosis is based on clinical criteria and patient history. Even within the medical field, there is controversy surrounding PPPD, but suffice it to say PPPD is categorically a real disorder with established diagnostic criteria. This becomes even more obvious once you start looking past routine imaging and examinations and instead look at tests of physical function.

We have loads of evidence from force plate studies. A force plate is something you stand on that tracks your center of mass — how much your weight shifts around while standing. Nobody ever stands perfectly still and there is always some normal sway. But when you put a PPPD patient on the force plate, that variance is smaller and more concentrated. Their vestibular and neurological systems are hyper-vigilant, doing way too much work to keep them upright — and oddly enough, that can make you feel dizzy or ill at ease in visually busy places.

The correlation between PPPD and poor tolerance to the grocery store isn’t exactly new. When this condition was first getting documented back in 1957, it was actually named “supermarket syndrome,” because that’s exactly where these patients kept reporting problems.

So What Is Visual Dependence?

To really answer “why do I feel dizzy in supermarkets,” you need to understand how your sense of balance gets built in the first place. Your brain produces your sense of balance by integrating signals from multiple peripheral sensory systems of the body listed below.

• Vision — this makes intuitive sense. Try balancing on one foot with your eyes open, then closed. It is obviously much more difficult with your eyes closed because your vision plays a critical role in keeping you oriented in space.
  
• Proprioception or Joint position Sense — this refers to how well your body knows where it is in space. There is actually a lot that goes into proprioception but a great example is lower extremity neuropathy. Feeling the floor underneath your feet keeps you balanced. But if you have neuropathy, it can feel like you’re standing on clouds effectively reducing your balance.
  
• Vestibular system — most people know that the inner ears have a role to play in balance even if they don’t truly understand the mechanism. Your inner ears are essentially like two little gyroscopes telling your brain how your head is oriented and moving relative to gravity. Since we walk upright, knowing how your head is oriented in space is critical for day-to-day functioning.
  
• Cognition — This occurs more at the level of the brain. When there is heavy cognitive load, the brain has to divert “power” to executive functioning more thereby impacting its ability to maintain balance. Stand on one foot and start doing math problems out loud and you’ll see how much more difficult it is.

Your brain is constantly deciding how much to trust each of these systems and adjusting in real time — a process known as sensory re-weighting. Walk into a dark room and your brain can’t rely on vision anymore, so it leans harder on your feet and your inner ears instead. If one system goes offline or gets noisy, the brain compensates by leaning harder on the others.

Visual dependence is what happens when the brain leans too hard on vision for too long. Usually there’s a triggering event first — something like vestibular neuritis or BPPV or even severe psychological distress — and for whatever reason, the brain holds onto that sense of dizziness even after it should have resolved. It keeps re-weighting more and more toward vision, becoming over-dependent on it. That might work fine in a calm space with minimal visual information. But walk into a supermarket, or a crowd, or any busy environment, and it’s a real overload — your brain is putting way too much neural drive into that one system.

Why We Don’t Jump Straight to Visual Habituation Exercises

PPPD is largely a maladaptation of the brain but that also means it can be retrained. Our brains have a real capacity to adapt with the right stimulus in a process known as neuroplasticity. Vestibular therapy for PPPD is often really just a form of exposure therapy, gradually and incrementally increasing the challenge until someone gets better.

But here’s the mistake people make: someone gets identified as visually dependent, dizzy in supermarkets, and we jump straight to visual environment exercises — checkerboards, optokinetic strips, throwing them straight into busy visual environments. It’s tempting, because clinicians hear “visual dependence” and think they already know exactly where the problem is. But there is so much more to the clinical picture.

Vestibular disorders don’t exist as a monolith. With chronic, complex cases, it’s almost always “yes, and” — yes, you have visual dependence, and you may be dealing with something else at the same time. Jump straight to advanced habituation without a good comprehensive evaluation, and you overload a foundation that hasn’t been built yet.

The Four Systems We Actually Have to Look At

Vestibular. A lot of PPPD starts with an initial vestibular insult, so if we catch it early enough, we can still identify what actually happened at the start — something like vestibular neuritis. We’re also looking closely at how well the inner ears and eyes are working together, known as gaze stability. And more recent research shows a lot of PPPD patients have some form of otolith dysfunction — the otoliths being the organs that pick up linear movement, like going up an elevator or sitting in a moving car. Problems there create a different flavor of vertigo than the classic room-spinning kind — more of a “boaty, floaty” rocking or swaying.

Vision. Visual dependence obviously involves your eyes. But vision is much deeper than people realize. You could have 20/20 vision and still present with visual impairments. Vestibular therapists are mostly looking at ocular motor impairments, that is how smoothly the eyes move and are coordinated. And PPPD can often coexist with other disorders like vestibular migraine. If the eyes aren’t coordinated, visually busy environments become that much more stressful, adding insult to injury.

Cervical (neck). Your ears tell your brain where your head is oriented in space and your head obviously sits on top of your neck. Therefore, your brain also needs an accurate representation of where your neck is in space. We can even go so far as to label the neck as a “balance organ.” Any impairments there can result in cervicaogenic dizziness. Whiplash is a great example such as after a motor accident, where the ligaments of the neck get strained. This damages the proprioceptive receptors that live there resulting in dizziness. There’s also the cervico-ocular reflex, where neck movement informs the brain how the eyes should move to keep images stable.

Autonomic. With everything we see in force plate studies, we’re dealing with a nervous system that’s hyper-vigilant, and a lot of those neural pathways overlap closely with the pathways implicated in anxiety. That creates a dizzy-anxious cycle. This does not mean your dizziness is “all in your head” as we understand, there are real neurological processes behind these symptoms. But dizziness and anxiety absolutely feed into each other, and if that piece goes unaddressed, it can be hard to break the cycle. For severe cases, we can even see symptoms such as palpitations, excessive sweating, or fluctuating blood pressure. This happens when the nervous system is so dysregulated the automatic processes of the body we don’t think about become impaired.

How You Actually Get Better

Habituation exercises make much more sense once these four systems are better calibrated. Patients should also have real nervous system regulation or grounding skills on hand for when that anxiousness spikes. That’s obviously not something that happens overnight but can be achieved through consistent practice.

Clinic tools like checkerboards or a TV playing grocery store footage are a great starting point. But at some point, we have to start including real-life exposure. This doesn’t mean you should march yourself back into Costco on free sample day and grit your teeth through it for hours. Rather use small deliberate missions. You can start by going to the grocery store and only buying one item before leaving. Week after that you can buy two items. Then maybe do that same trip 2-3 times a week. That’s really where we want to get our patients. And have them equipped to understand when they’re pushing too hard and have strategies to calm their nervous system appropriately.

Hopefully you now understand “why do I feel dizzy in supermarkets” more clearly. Good results start with the right approach and a strong understanding of all the physiological systems involved. Even among licensed healthcare providers, many aren’t aware of PPPD. There are many roadblocks involved but recovery is definitely possible.

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.