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PPPD (Persistent Postural-Perceptual Dizziness)

PPPD (Persistent Postural-Perceptual Dizziness)

In 2017 the Barany Society ratified the vestibular clinical condition that we refer to as PPPD, or persistent postural-perceptual dizziness. It is a vestibular pathology that can be affected by psychological conditions or psychiatric disorders. However, the fundamental concept that must be understood is that it is vestibular pathology, and not a pathology of the psyche. It is usually triggered by an untreated or unidentified vestibular pathology. PPPD is to be considered a chronic clinical condition characterized by constant instability, or fluctuating unsteadiness with tendential and progressive worsening of the symptoms. It is thought to have a higher incidence in women, especially between the ages of 30 and 50, and to represent up to 20% of all pathologies of a vestibular nature.
PPPD is a disorder recognised by WHO and encoded in ICD 11.


 A– Presence of dizziness or unsteadiness for most days within a time frame of minimum of 3 months.
A-1 Symptoms present for a prolonged period with fluctuating and variable severity over the same day.
A-2 Symptoms not necessarily present throughout the day.

B– Symptoms present without being induced by triggering factors but exacerbated by some factors:
1-Erect Posture.
2-Active and / or passive Movements.
3- Exposure to moving visual stimuli or visual perception of complex environments.

 C– Symptoms aggravated by both acute and chronic vestibular syndromes, isolated or recurrent, or by other internal or neurological pathologies, or by anxiety or stressful factors. When the triggering factor is chronic in nature, the clinical condition undergoes rapid and progressive worsening.
Among these factors, which we can define as precipitating events, stand out vestibular migraine, BPPV, Ménière’s disease, panic attacks, but also head traumas.
D- PPPD induces stress and disability.
E- Symptoms not explainable by other pathologies, syndromes, or disorders.

However, three forms of PPPD are known (cit. Persistent postural-perceptual dizziness; Mandala-Nuti.)

1 – PSYCHOGENIC FORM – Often triggered by disorders such as panic attacks with residual feeling of unsteadiness and light-headedness.
2- OTOGENIC FORM (OR SECONDARY) – Induced by vestibular pathologies.
3- INTERMITTENT FORM – Induced by vestibular pathologies in patients already suffering from states of anxiety.
Patients affected by PPPD report sensations like seasickness, a sense of emptiness, swaying, and chronic inability to maintain balance and postural stability generally when standing still, often worsening when walking. Frequently, the patient’s anxious state is induced by PPPD due to the onset of fear of falling or of vertigo. How does PPPD work? It is noteworthy to be reminded that the balance system is the result of the integration of a series of feedbacks between the labyrinth, the visual system and the vestibule oculomotor reflex, proprioception, and the vestibule spinal reflex. Although it is a vestibular condition, it is strongly favoured in its onset by a fragile or anxious emotional state in general, promoted by a lack of serotonin activity in the patient.

PPPD can result from pathologies such as Ménière, acute vestibular deficits, vestibular migraine, head trauma, untreated BPPV, neurodegenerative pathologies of the central nervous system, or, more rarely, from panic attacks.
PPPD symptoms often worsen:

After light / visual stimuli in general
Exposure to flashing or bright lights, even including sunlight

Observing moving objects or moving perspectives
Examples are the movement of the sea waves, where in many cases there is motion sickness, or the inability to withstand transit in a car, especially during medium-long journeys, situations in which patients, in addition to instability, can manifest hyperemesis up to experiencing true panic attacks.

Observing a screen
PCs, videogames, TV, cinemas. In some instances, even reading can be problematic, a condition which is often mistaken for a visual ability problem.

Stopping or passing through crowded places or environments that are too large or open
Classic examples are those patients who experience unsteadiness, dizziness, vertigo, or spatial and sometimes even temporal disorientation when entering a supermarket, or a crowded open space.

What testing can be done for PPPD?
Vestibular examinations ranging from Videoculonistagmoscopy, Vhit, Fhit, stabilometry and VEMPS are essential, as well as obviously a valid audiometry, which will allow us to identify any vestibular pathology that may have induced the onset of PPPD. Without a complex and complete vestibular examination, accurate diagnosis will be very difficult.

In addition to suffering all the symptoms of the pathology responsible for PPPD, patients have an extremely reduced quality of life, therefore competent vestibular analysis is truly fundamental.
The therapeutic approach is to be divided into two steps:
1-Therapy of the underlying vestibular pathology that has led to PPPD.
2-Vestibular rehabilitation aimed directly at the PPPD.
In some patients, psychological support may be necessary, however, to be effective, this cannot be independent from the above two pivotal therapy points.

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