Dizziness is a very common complaint in society, often described as “loss of balance,” “swaying while walking,” or “ground slipping from under my feet.” While this complaint is short-term and temporary in some people, it can become chronic lasting for months or even years in others. Persistent imbalance can be a symptom of many different diseases; however, Persistent Postural-Perceptual Dizziness (PPPD), defined in recent years, has become one of the most common causes of chronic imbalance sensation. Persistent postural-perceptual dizziness (PPPD) is a complex condition that can seriously affect the patient’s daily quality of life and requires a multidisciplinary approach.

In this disease, the person generally complains of:

• Continuous feeling of imbalance (especially when standing or walking),
• Hypersensitivity to visual movements (for example, crowded environments, shopping malls, watching television or phone screen),
• Dizziness increasing when moving or standing upright,
• Feeling of falling even in safe environments.

This condition is quite exhausting both physically and psychologically. Living with these symptoms can cause significant limitation in the person’s work, social, and private life. Over time, secondary effects such as anxiety, fatigue, and loss of self-confidence can also develop in patients.

Medical Definition and By Whom Was It Determined?

Bárány Society is a society consisting of doctors and scientists working on ear-nose-throat, neurology, and balance system. This community works to classify dizziness and balance disorder diseases, determine diagnostic criteria, and create a common language worldwide.

Persistent postural-perceptual dizziness (PPPD) was defined in 2017 by an international scientific committee called Bárány Society. That is, the PPPD term is a scientifically accepted diagnosis with international validity. Persistent postural-perceptual dizziness was included in the “chronic vestibular syndromes” group by Bárány Society in 2017.

What Does “Chronic Vestibular Imbalance” Mean?

The word “vestibular” refers to the balance organ in the inner ear.
This system ensures body balance by working together with eyes and muscles.

In some patients, this system’s function is not disrupted but the brain starts to misinterpret balance signals.
In this case, the person constantly feels imbalanced — but no physical balance disorder is found in examinations and tests.

This condition is called “chronic vestibular imbalance.” That is, in PPPD, the problem is not in the inner ear, but in the brain’s processing of balance information and control of movement perception.

In Whom Is PPPD Seen?

Persistent postural-perceptual dizziness (PPPD) is generally seen more frequently in women between ages 30 and 50.
However, this disease is not specific to women only — it can also appear in men and even young adults.

There are some conditions that increase the risk of PPPD:

• Stressful lifestyle or anxiety disorder
• Migraine or history of other dizziness attacks
• Balance system diseases such as vestibular neuritis (inner ear inflammation) or benign paroxysmal positional vertigo (BPPV)
• Long-lasting fatigue, sleep disorder, or depression
• After experiencing a severe dizziness attack, balance not completely recovering

This disease often develops as a result of “even though the body has completely healed, the brain’s balance perception cannot return to its former state.”
That is, PPPD is more like an error in the brain’s way of interpreting movement and balance signals than a physical disorder.

When diagnosed early and appropriate treatment is started, significant improvement can be achieved in the majority of patients.

What Is Persistent Postural-Perceptual Dizziness (PPPD)?

Persistent postural-perceptual dizziness (PPPD) is a type of dizziness defined in medicine in recent years, progressing with continuous feeling of imbalance, swaying, or perception of ground slipping.
In this disorder, the person generally experiences a feeling like “not that the world is spinning but I am imbalanced.”
That is, it is different from classic spinning-type vertigo — here, not dizziness but continuous feeling of imbalance and lightheadedness is prominent.

What Happens in This Disease?

PPPD occurs as a result of confusion in the brain’s balance perception without a structural disorder in the balance system in the inner ear.
That is, the body is actually balanced but the brain misinterprets incoming balance signals.

Distinctive Features:

Symptoms seen in PPPD disease are generally grouped in three main categories:

1. Continuous feeling of imbalance:
   The person feels “swaying,” “floating,” or “like drunk” when standing or walking.
2. Complaints increasing with movement:
   Walking, sitting up and standing, even turning the head to look in a direction can increase the feeling of imbalance.
3. Visual sensitivity:
   Symptoms become pronounced in crowded environments, shopping malls, or when looking at moving images (for example, in metro, on television or screen).

These symptoms are generally felt almost every day for at least 3 months.
Balance tests and brain MRI mostly come out normal; this makes PPPD a “functional balance disorder” — that is, the system works, but perception is disrupted.

What’s Happening in the Brain?

The system ensuring balance combines in the brain information coming from the inner ear, eyes, and muscle-joint receptors. In PPPD, information coming from these three sources cannot be processed correctly. The brain comes to a “false alarm” state that keeps the imbalance perception constantly on.

At the foundation of persistent postural-perceptual dizziness (PPPD) is an incompatibility (multisensory integration disorder) occurring in the brain’s ability to combine information from multiple senses.
Normally, the brain perceives body position by combining information sent by the balance organ (vestibular system), visual system (eyes), and muscle-joint sense (proprioception).

In PPPD, signals coming from these systems cannot be processed in a coordinated manner within the brain.
As a result, the brain develops abnormal postural (posture-related) control strategies to maintain body balance.

Scientific studies show that there are activity changes especially in posterior parietal cortex, temporo-parietal junction, and prefrontal cortex regions. Since these regions are responsible for healthy coordination of balance and movement perception, these changes play an important role in PPPD development. That is, the problem is not in the inner ear, it originates from faulty adjustment in the brain’s balance perception.

What Causes Persistent Postural-Perceptual Dizziness (PPPD)?

Persistent postural-perceptual dizziness (PPPD) generally occurs with the combination of more than one factor. This disease often develops following an event such as a dizziness attack experienced beforehand, a stressful period, migraine, or inner ear disease.
That is, PPPD is a feeling of imbalance that becomes permanent as a result of the brain’s balance control system making a “wrong adjustment” after this event.

We can explain disease development under three main headings:

1. Personal Predisposition (Factors Preparing the Ground)

The risk of developing PPPD is higher in some people.
These include:

• Anxious or perfectionist personality structure,
• Previously experiencing migraine, vertigo, or balance problem,
• Predisposition to motion sickness (for example, car sickness),
• History of anxiety or panic attack.

In these people, there is a hypersensitive control mechanism against the brain’s balance system. This situation causes even a small deviation in the balance system to be perceived exaggeratedly.

2. Triggering Events

PPPD generally appears after an “initiating event.” This event can be physical, psychological, or neurological.

Most frequently seen triggers:

• Acute inner ear diseases (for example, BPPV, vestibular neuritis, Meniere’s attack),
• Migraine attacks,
• Head trauma or concussion,
• Surgical operations or post-anesthesia period,
• Panic attacks,
• Serious stress or emotional trauma.

After this event, the normal adaptation process is disrupted while the brain tries to regain its balance and develops a wrong “balance strategy.”

3. Incompatibility in the Brain (Continuing Mechanisms)

Normally, the balance system combines information coming from the inner ear, eyes, and muscle-joint sense.
In PPPD, the brain processes these signals incompatibly. As a result, the person feels imbalanced even though actually balanced.

• The brain becomes overly dependent on visual stimuli.
  Dizziness increases in crowded, moving, or bright environments.
• Muscle control changes.
  The person unknowingly uses more muscles to maintain balance, which makes the body even more tense and painful.
• Excessive attention and anxiety come into play.
  The fear of “I will feel imbalanced again” keeps the brain’s balance system constantly active.
  This situation creates a vicious cycle — the more attention the person pays, the more balance sensation deteriorates.

To summarize briefly;

• PPPD generally develops after a dizziness attack, migraine, or stress.
• The brain develops a wrong balance strategy while relearning balance.
• The person constantly feels imbalanced but no physical disorder is seen in tests.
• Stress, anxiety, and excessive attention maintain this condition.
• Treatment aims to re-educate the brain’s balance system.

Bárány Society (2017) Persistent Postural-Perceptual Dizziness Diagnostic Criteria- Persistent postural-perceptual dizziness (PPPD)

Bárány Society defines PPPD as a “chronic functional vestibular disorder” and states that all of the following 5 main diagnostic criteria must be met.

A. Symptoms

• Imbalance, swaying sensation, or dizziness (non-spinning type vertigo) lasting almost every day for at least three months
• Complaints generally continue for hours, not within minutes (may fluctuate during the day).

B. Aggravating Situations

Symptoms significantly increase in the following conditions:

1. Standing upright (worse than sitting),
2. Walking or moving,
3. Complex visual stimuli (crowded environments, shopping malls, metro, moving images, etc.),
4. Rapid head or body movements.

C. Onset Condition

• Symptoms generally start after a triggering event:
  • Acute or recurrent vestibular disease (for example, BPPV, vestibular neuritis, Meniere’s disease),
  • Vestibular migraine,
  • Panic attack,
  • Head trauma or medical illness,
  • Severe stress period.
• Symptoms become permanent within days or weeks after triggering event.

D. Functional Impairment

• Symptoms significantly restrict the patient’s daily life (impairment in work, social, or personal activities).

E. Not Better Explained by Another Disease

• Symptoms cannot be fully explained by another neurological, vestibular, psychiatric, or medical disease.

How Is Persistent Postural-Perceptual Dizziness (PPPD) Diagnosed?

The diagnostic process generally includes carefully listening to the patient’s history and some balance tests.

Disease History (Anamnesis)

The doctor wants to learn the following information from the patient:

• How dizziness started,
• How long it lasted,
• In which situations it increased (for example, crowds, lit environments, walking),
• Whether there was a disease, infection, migraine, or stress beforehand.

Patients often describe their feelings as follows:
“I feel like I’m not on the ground.”
“As if there’s a slight spinning in my head, but the world isn’t spinning.”
“I feel like drunk, like floating.”

Physical Examination

• Neurological examination is generally normal.
• No abnormality or nystagmus is observed in eye movements.
• However, there may be mild instability in balance tests (for example, standing on one foot, Romberg, tandem walking).

Vestibular Tests

• Tests measuring inner ear functions (e.g., caloric test, vHIT, VEMP) generally come out normal.
• This supports that the disease is a functional (non-structural) problem.

Posturography (Balance Analysis)

• Shows which sensory system balance depends on.
• In PPPD patients, excessive dependence on visual stimuli (visual dependence) can be detected.
• This situation is objectively measured especially with Sensory Organization Test (SOT).

Psychological Evaluation

• Anxiety levels, depression, and vestibular stress levels are also evaluated.
• Daily life impact is measured with questionnaires such as “Dizziness Handicap Inventory (DHI)“.

3. Differential Diagnosis (Other Possibilities)

Before diagnosis is made, the following diseases must be excluded:

• Meniere’s disease
• Vestibular migraine
• BPPV (ear crystal disease)
• Central nervous system diseases (for example, brainstem lesions)

Brain MRI generally comes out normal, which supports that PPPD is a “functional” (that is, originating not from a structural disorder but from the way brain signals are processed) disease.

To summarize briefly;

• Generally no abnormality is found in tests when diagnosing PPPD.
• The most important criterion is duration of complaints (3 months) and increase with certain situations.
• Diagnosis is made by considering clinical evaluation, balance tests, and psychological factors together.

Treatment of Persistent Postural-Perceptual Dizziness (PPPD)

Since persistent postural-perceptual dizziness (PPPD) occurs with the effect of many factors, its treatment also depends on a holistic approach.
The aim of treatment is to correct the wrong adaptation in the brain’s balance system, alleviate symptoms, and increase the person’s quality of life.
Generally, medication treatment, balance exercises (vestibular rehabilitation), and psychological support are applied together.

1. Vestibular Rehabilitation (Balance Exercises)

Vestibular rehabilitation forms the foundation of PPPD treatment.
These special exercise programs help re-educate the brain’s balance system.

Aim:

• To enable the brain to reprocess balance signals correctly,
• To reduce hypersensitivity to visual movements,
• To regain confidence in daily activities.

Applied exercises:

• Gaze stabilization: Develops eyes’ ability to focus on a fixed point together with movement.
• Balance training: Strengthens balance while standing, walking, or changing direction.
• Habituation therapy (exposure therapy):
  Patients are gradually exposed to environments that increase dizziness (for example, shopping mall, crowded places).
  This way, the brain “gets used to” these stimuli and reduces reaction.
• Virtual reality exercises can also be effective in this process.

2. Visual Sensitivity Reduction Exercises

In PPPD, the brain becomes excessively dependent on visual information.
Therefore, tolerance to moving images is increased with special visual exercises called “optokinetic training“.
These trainings can initially cause mild dizziness but over time reduce visual imbalance sensation.

3. Cognitive Behavioral Therapy (CBT)

Cognitive Behavioral Therapy (CBT) is one of the most effective psychological approaches in PPPD treatment.
The aim is to change thought patterns that misinterpret the disease.

CBT’s contributions:

• Reduces fear of “loss of control” developed against dizziness sensation,
• Reduces anxiety and panic attack risk,
• Breaks “movement avoidance” (fear-avoidance) cycle,
• Provides patient with strategies to learn coping with symptoms.

It has been proven that CBT programs specific to vestibular disorders provide faster recovery compared to classic therapy.

4. Medication Treatment

Medications are generally used as supportive in PPPD treatment.
The aim is to help rebalance the brain’s balance centers and control accompanying anxiety/depression.

Most frequently used medications:

• SSRI group antidepressants: Sertraline, escitalopram.
  Reduces anxiety, facilitates brain’s balance adaptation.
• SNRI group antidepressants: Venlafaxine, duloxetine.
  Effective in presence of accompanying depression.
• Anticonvulsants: Gabapentin or pregabalin can be used especially if neural sensitivity is pronounced.
• Benzodiazepines: Generally not recommended. Because they can be habit-forming and may delay balance adaptation.
  However, in short-term excessive anxiety situations, can be used under doctor control.

5. Detection and Treatment of Accompanying Diseases (Comorbidities)

PPPD often doesn’t appear alone; in many patients, it progresses together with other medical or psychiatric conditions.
These comorbid diseases can both increase symptom severity and slow treatment response.
Therefore, early recognition and management of accompanying disorders in each PPPD patient is an inseparable part of treatment.

1. Migraine and Vestibular Migraine

• Approximately one-third of PPPD patients have migraine history
• Vestibular migraine attacks can trigger or maintain PPPD by sensitizing the balance system.
• In this case, prophylactic treatment of migraine (for example, propranolol, topiramate, flunarizine) and trigger avoidance strategies should be planned together with PPPD treatment.
• Getting migraine under control generally provides significant improvement in PPPD symptoms as well.

2. Anxiety Disorders and Depression

• Anxiety or depression symptoms accompany in the majority of PPPD patients.
• This situation causes the patient to focus excessively on imbalance sensation and increases movement avoidance behaviors.
• Therefore, psychological evaluation (for example, DHI, HADS scales) should be done to patients;
  if necessary, SSRI/SNRI group medications or cognitive-behavioral therapy (CBT) should be added to treatment.
• Effective management of psychiatric comorbidities significantly increases treatment success.

3. Autonomic Nervous System Disorders and Postural Hypotension

• In some PPPD patients, disruption in blood pressure regulation, tachycardia, or postural hypotension is seen.
• These conditions can increase dizziness and imbalance sensation when standing up.
• Therefore, cardiological evaluation should be done when necessary, fluid intake, salt balance, and medical treatment should be arranged if needed.

4. Sleep Disorders

• Deterioration of sleep quality (for example, insomnia or restless leg syndrome) makes vestibular system adaptation difficult.
• Establishing sleep hygiene, creating regular sleep hours, and getting sleep medicine support when necessary contribute to treatment.

5. Neck and Musculoskeletal System Problems

• Cervical muscle tension or posture disorders can increase PPPD symptoms.
• In these patients, physiotherapy, posture exercises, and manual therapy can be used as supportive.

6. Mindfulness and Lifestyle Adjustments

Mindfulness-based approaches (mindfulness, meditation, breathing exercises)
→ reduce excessive focus on bodily sensations,
→ break “excessive attention” cycle on balance.

Daily life recommendations:

• Regular sleep and nutrition,
• Regular physical activity (for example, walking or yoga),
• Stress management,
• Not avoiding social activities (isolation can increase symptoms).

7. Multidisciplinary Treatment Approach

Best results are obtained with team work.
Cooperation of the following specialists may be needed in the treatment process:

• Neurology or neurotology specialist,
• Vestibular rehabilitation therapist,
• Psychiatrist or clinical psychologist,
• Physical therapy specialist.

Treatment Process and Success Rate

• Treatment process is generally long and gradual; requires patience.
• Significant improvement is achieved with correct treatment in 60-80% of patients.
• Best results are obtained with early diagnosis, regular exercise, medication compliance, and motivation.

Frequently Asked Questions About Persistent Postural-Perceptual Dizziness (PPPD)

1. Does PPPD completely pass?

Yes, significant improvement can be achieved with appropriate treatment in most patients.
PPPD is not a permanent disease but since there is an incorrectly learned balance response in the brain’s balance system, it returns to normal over time and with correct treatment.
When vestibular rehabilitation, psychotherapy, and medication treatment are applied together, long-term recovery is achieved in approximately 70-80% of patients.
If not treated, symptoms can continue in a fluctuating manner.

2. How long does PPPD treatment last?

Treatment duration varies from person to person.
Generally, significant improvement begins within 3 to 6 months, but complete recovery can take 9-12 months in some patients.
Early diagnosis, regular exercise, and treatment compliance shorten the process.
PPPD is a condition that requires patience but gives quite encouraging results with the right approach.

3. Does PPPD pass spontaneously?

Complaints may lighten over time in some patients, but mostly professional treatment is needed.
Because in PPPD, the brain makes misinterpreting balance signals a “habit.”
This faulty cycle can only be corrected with special balance exercises and psychological support.
Just waiting without treatment generally causes symptoms to be prolonged.

4. Can PPPD be treated without medication?

In some mild cases, yes.
Many patients can recover without medication with vestibular rehabilitation exercises, studies reducing visual sensitivity, and cognitive-behavioral therapy (CBT).
However, if significant anxiety or depression accompanies, SSRI or SNRI group antidepressants can be used as supportive to treatment.
The neurology specialist decides which method is appropriate.

5. Does PPPD recur?

In patients who achieve complete recovery after treatment, recurrence rate is low, but situations such as intense stress, sudden illness, or migraine attack can temporarily retrigger imbalance sensation.
Therefore, continuing balance exercises occasionally and stress management are recommended even after treatment.

6. Can PPPD patients exercise?

Absolutely yes.
Avoiding movement strengthens the disease.
Regular walking, yoga, pilates, and light balance exercises help the brain relearn correct balance adaptation.
However, exercises should be prepared specifically for the person and should not be too challenging.

7. Which doctor treats PPPD?

PPPD diagnosis and treatment are generally the responsibility of neurology specialist or neurotology (balance diseases) specialist.
When necessary, vestibular physiotherapist, psychologist, and psychiatrist are also included in the treatment process.
Most effective results are obtained with multidisciplinary (team) approach.

8. Is PPPD a psychological disease?

No. PPPD is not psychological, but the brain’s way of interpreting balance signals is disrupted. This situation includes both physiological (adaptation disorder in vestibular system) and psychological (anxiety, excessive attention) components.
That is, PPPD is a “functional” disorder occurring with overstimulation of the brain’s perceptual balance mechanism.

9. Is PPPD related to migraine?

Yes, PPPD frequently develops after migraine types progressing with dizziness such as vestibular migraine.
Migraine attacks can affect the way balance signals are processed in the brain.
Therefore, migraine control should also be considered when planning PPPD treatment.

10. Is it possible to protect from PPPD?

Since PPPD generally develops after a vestibular disease or stressful period, it may not be completely preventable.
However, the following measures can reduce risk:

• Starting early vestibular rehabilitation after acute dizziness attacks,
• Paying attention to stress management and sleep routine,
• Not using unnecessary medication,
• Maintaining physical activity (immobility delays brain adaptation).

11. What Is PPPD and What Is Its Difference from Other Dizziness Types?

Persistent postural-perceptual dizziness (PPPD) is characterized by continuous imbalance and swaying sensation developing without a structural ear disease.
That is, there is no disorder in the ear, brain, or inner ear fluids; the problem is the brain’s misinterpretation of balance signals.

Its difference from other dizziness diseases:

• BPPV (Positional Vertigo): Rotational vertigo lasting several seconds with head movement occurs. In PPPD, there is continuous imbalance sensation, not related to head movement.
• Meniere’s Disease: Comes in attacks and hearing loss is seen. In PPPD, hearing is normal and there is continuously fluctuating imbalance instead of attack.
• Vestibular Migraine: Dizziness comes with migraine attacks. In PPPD, there is not attack but continuous “swaying sensation”.

The most distinctive feature of PPPD is that imbalance sensation increases when standing, walking, or in crowded and moving environments (for example, in market, mall).
Classic balance tests generally come out normal; therefore diagnosis is made according to patient’s history and symptoms.

12. What Kind of Complaints Does PPPD Cause? How Do I Feel?

People experiencing PPPD generally describe as follows:

“As if I’m not on the ground”,
“I feel as if a boat is swaying at sea”,
“Surroundings aren’t spinning but inside my head is spinning”,
“I feel like drunk, ground is slipping from under my feet.”

In this disease, dizziness is not “spinning” but in the form of swaying or floating sensation.
Symptoms increase when standing or walking, generally decrease when sitting or lying down.

Situations that increase patient’s complaints:

• Crowded environments, markets, shopping malls, cinema halls,
• Fast-moving visuals (for example, metro, traffic, screens),
• Stress, fatigue, or sleep irregularity.

Patients frequently report that they fear walking unbalanced, cannot concentrate, avoid fast head movements. Over time, this situation can lead to anxiety, fatigue, and social withdrawal tendency. Symptoms are generally mild in mornings, become more pronounced as movement increases during the day.