Handling Persistent Postural-Perceptual Dizziness to stop your world from spinning always

Most people experience dizziness at least once in their lives. Often, it subsides within some time. However, in some people, dizziness and unsteadiness can last for months, sometimes even years. No clear cause can be found in blood tests, scans, ear examinations, or ECGs. Many patients are disappointed to hear an unhelpful diagnosis such as 'all this might just be imagination,' or 'it's due to tension.' For many who experience this condition, the underlying cause is often 'Persistent Postural-Perceptual Dizziness' or PPPD. Dr Bibin Baby, ENT Surgeon at Sunrise Hospital, Erattupetta, explains.

What is Persistent Postural-Perceptual Dizziness?
PPPD is a chronic vestibular disorder. In 2017, the 'Bárány Society', a consortium of prominent vertigo experts worldwide, gave an official definition to this condition. It is not a 'structural' defect in the ear or brain. All the organs that control balance are healthy; however, there is a disruption in how the brain processes balance-related information. This is why nothing shows up in scans or other examinations. However, the patient's discomfort is real, not imaginary.

What are the symptoms like?
The dizziness in PPPD is not the kind that makes a patient feel like they are 'spinning around.' Instead, patients usually report the following experiences:
∙ A feeling of fogginess in the head, like floating on water, or a rocking sensation.
∙ Unsteadiness, as if there is no firmness underfoot, inability to stand firmly on the ground.
∙ A constant discomfort – the feeling of 'never being fully balanced'.
∙ PPPD is suspected when these symptoms persist almost daily for more than three months.
∙ Many report that although it is less in the morning, it increases as the day progresses.

When do the symptoms worsen?
The most significant characteristic of PPPD is that the symptoms clearly worsen in three situations:
∙ It is seen more when standing upright and walking – relief is usually felt when lying down.
∙ When moving oneself or travelling in a vehicle, or when others move past.
∙ When viewing complex visual stimuli – like rows of shelves in a supermarket, a crowded market, rapidly moving screen visuals, traffic, etc.

Why does this happen?
Our balance is maintained by three sources of information: the balance organs in the ear, the eyes, and sensory pressure signals from the body's parts. After an episode of dizziness, the brain shifts into 'hypervigilance'. To maintain balance, it begins to rely excessively on the eyes and touch; this gets stuck and doesn't return to normal even after the causes of dizziness have resolved. Anxiety further strengthens this. Thus, PPPD is a self-perpetuating cycle.

Diagnosis
The diagnosis of PPPD mainly relies on the patient's description of symptoms. When the specific symptoms mentioned above align, an expert can identify it. While some tests may be done to rule out other serious causes, they will mostly be normal. 'Not seeing anything' does not mean there is no disease – unnecessarily repeating tests will only increase the patient's fear.

Treatment
PPPD can be cured with proper treatment. The treatment is mainly based on three components:
Vestibular Rehabilitation: This is the backbone of the treatment. Through specific exercises, the brain is gradually 're-trained' to movement and visual stimuli, and hypervigilance is reduced.
Medications: Certain SSRI/SNRI-class medications are effective at low doses. This is not 'psychiatric' treatment – it helps readjust the brain's rhythmic imbalances.

Awareness and CBT: Half the fear is gone when a clear understanding of the condition is gained. Cognitive Behavioural Therapy (CBT) helps reduce anxiety. Completely avoiding movement and going out due to fear of symptoms will only worsen the condition. Gradually returning to activities with patience is the path to recovery.