Understanding PPPD: When Dizziness Won't Go Away

A modern understanding of chronic dizziness through the lens of neuroplasticity

Dr. David Traster DC, MS, DACNB

There is a certain kind of patient who walks into the clinic with a story that doesn’t quite fit.

They are not spinning like classic vertigo.
They are not fainting.
Their scans are normal.

And yet—every day—they feel off.

Not dizzy in the way people expect.
But unsteady. Foggy. Disconnected.

As if the brain itself is struggling to find solid ground.

This is often where the story of Persistent Postural-Perceptual Dizziness (PPPD) begins.

What Is PPPD?

PPPD is a chronic functional dizziness disorder.

It is not caused by structural damage.
It is not explained by a lesion, tumor, or stroke.

Instead, it reflects a problem of how the brain processes balance, motion, and sensory information.

Patients typically describe:

• Persistent non-spinning dizziness

• A sense of rocking, swaying, or internal motion

• Unsteadiness, especially when standing or walking

• Visual overwhelm in busy environments (stores, crowds, screens)

One of the defining features:

The symptoms are present most days for at least 3 months and fluctuate in intensity—but rarely fully go away.

A Brief History: From “Phobic Postural Vertigo” to PPPD

PPPD did not appear overnight. It is the result of decades of clinicians trying to describe a pattern they kept seeing—but couldn’t fully explain.

Earlier labels included:

• Phobic Postural Vertigo (PPV) – described in the 1980s

• Chronic Subjective Dizziness (CSD)

• Visual Vertigo

• Space-motion discomfort

Each captured part of the picture—but none unified it.

In 2017, the Bárány Society formally defined PPPD as a single diagnostic entity.

This was a turning point.

It acknowledged something important:

Not all dizziness comes from the inner ear.
Some comes from how the brain learns to interpret motion after a disruption.

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Diagnostic Criteria: What Defines PPPD?

PPPD is a clinical diagnosis, based on history and symptom pattern—not a single test.

The core criteria include:

1. Persistent Symptoms

• Dizziness, unsteadiness, or non-spinning vertigo

• Present on most days for ≥ 3 months

2. Worsened by Specific Triggers

Symptoms are exacerbated by:

• Upright posture (standing, walking)

• Active or passive motion (moving yourself or being moved)

• Visual complexity (crowds, scrolling, busy patterns)

3. Triggered by an Initial Event

PPPD typically begins after something disrupts the system:

• Vestibular disorders (BPPV, vestibular neuritis, vestibular migraine)

• Concussion or brain injury

• Panic attacks or acute anxiety episodes

• Medical illness or significant stress

4. Functional, Not Structural

• Symptoms are not better explained by another condition

• Testing may be normal—or show remnants of the original trigger

The Real Problem: Pathophysiology of PPPD

To understand PPPD, you have to shift away from the idea of “damage” and toward the idea of adaptation gone wrong.

1. A Trigger Disrupts the System

Something initially destabilizes the brain:

• The inner ear sends abnormal signals

• The brain experiences vertigo or imbalance

• The system enters a state of uncertainty

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2. The Brain Compensates—But Overcorrects

Instead of restoring normal balance processing, the brain adopts a high-alert strategy:

• Increased reliance on visual input

• Reduced trust in vestibular signals

• Stiffened posture and movement patterns

• Heightened attention to internal sensations

This is a survival response.

But it comes at a cost.

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3. Sensory Reweighting Becomes Maladaptive

Normally, the brain seamlessly integrates:

• Vestibular input

• Vision

• Proprioception

In PPPD:

• Vision becomes overweighted

• Motion sensitivity increases

• Busy environments become overwhelming

The world begins to feel unstable—not because it is, but because the brain’s interpretation has changed.

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4. The Brain Gets Stuck in Prediction Error

At a deeper level, PPPD involves dysfunction in:

• Cerebellar prediction systems

• Cortical sensory integration networks

• Threat and salience networks (insula, limbic system)

The brain is constantly asking:

“Am I stable?”

And constantly answering:

“Not quite.”

This persistent mismatch creates a loop of:

• Sensation → attention → amplification → more sensation

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5. Anxiety Is Not the Cause—But It Becomes Part of the Loop

This is critical.

PPPD is not purely psychological.

But over time:

• The brain associates movement and environments with discomfort

• Anticipation increases

• Autonomic arousal rises

The system becomes self-reinforcing.

Treatment: Rewiring the Brain, Not Just Treating Symptoms

If PPPD is a disorder of maladaptive learning, then treatment must focus on retraining the system.

There is no single intervention—but there is a clear framework.

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1. Vestibular Rehabilitation (Core Treatment)

The goal is to recalibrate how the brain processes motion and sensory input.

This includes:

• Gaze stabilization exercises

• Motion desensitization

• Balance and postural training

• Gradual exposure to visually complex environments

Done correctly, this helps the brain:

Re-learn what is safe, stable, and predictable.

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2. Sensory Reweighting and Visual Dependence Training

• Reducing over-reliance on vision

• Enhancing vestibular and proprioceptive integration

• Training in controlled, progressively challenging environments

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3. Cognitive and Behavioral Strategies

Not because the problem is “in your head”—
but because the brain’s interpretation matters.

• Education about the condition

• Reducing fear-avoidance behaviors

• Gradual exposure to triggers

• Cognitive behavioral therapy (CBT) when appropriate

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4. Medication (Selective Use)

In some patients, medications can help regulate network activity:

• SSRIs / SNRIs

• Used to reduce sensory amplification and anxiety loops

These are not always required—but can be useful in persistent cases.

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5. Autonomic Regulation

Many PPPD patients have:

• Heightened sympathetic tone

• Poor vagal regulation

Interventions may include:

• Breathing exercises

• Heart rate variability training

• Graded physical activity

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The Bigger Picture: PPPD as a Disorder of Learning

PPPD is not a failure of the brain.

It is a reflection of how powerful the brain’s learning systems are.

The brain encountered instability…
adapted to protect itself…
and then got stuck in that adaptation.

But the same principle that created the problem can solve it.

The brain can learn again.

With the right inputs—
the right exposures—
and the right understanding—

The system can recalibrate.

Stability can return.

And what once felt like a constant state of imbalance
can become something the brain no longer needs to hold onto.

References

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