Treatment of Persistent Postural-Perceptual Dizziness (PPPD) and Related Disorders
Purpose of review
Persistent postural-perceptual dizziness (PPPD) is a newly defined disorder of functional dizziness that in the International Classification of Diseases in its 11th revision (ICD-11) supersedes phobic postural vertigo and chronic subjective dizziness. Despite efforts to unify the diagnosis of functional (somatoform) dizziness, patients will present with a variety of triggers, perpetuating factors, and comorbidities, requiring individualized treatment. This article will review different treatment strategies for this common functional neurological disorder and provide practical recommendations for tailored therapy.
An emerging understanding of the underlying pathophysiology that considers vestibular, postural, cognitive, and emotional aspects can enable patients to profit from vestibular rehabilitation, as well as cognitive-behavioral therapy (CBT). Crucially, approaches from CBT should inform and augment physiotherapeutic techniques, and, on the other hand, vestibular exercises or relaxation techniques can be integrated into CBT programs. Antidepressant medication might further facilitate rehabilitation, though the mechanisms are yet to be elucidated, and the level of evidence is low.
In PPPD and related disorders, vestibular rehabilitation combined with CBT, and possibly supported by medication, can help patients escape a cycle of maladaptive balance control, recalibrate vestibular systems, and regain independence in everyday life.
KeywordsPhobic postural vertigo Chronic subjective dizziness Persistent postural-perceptual dizziness Vestibular rehabilitation Cognitive-behavioral therapy Functional neurological disorder
Jon Stone is supported by an NHS Scotland NRS Career Fellowship.
Compliance with Ethical Standards
Conflict of Interest
Stoyan Popkirov and Dagny Holle-Lee each declare no conflicts of interest. Jon Stone reports independent expert testimony work for personal injury and medical negligence claims and royalties from UpToDate for articles on functional neurological disorder, and runs a free non-profit self-help website, www.neurosymptoms.org, that discusses PPPD.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
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