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PPPD - A newly defined dizziness syndrome (triplePD or 3PD)

Diagnostic Criteria

  • One or more symptoms of dizziness, unsteadiness or non-spinning vertigo on most days for at least 3months.
    • Symptoms last for prolonged (hours-long) periods of time, but may wax and wane in severity
    • Symptoms need not be present continuously throughout the entire day.
  • Persistent symptoms occur without specific provocation, but are exacerbated by three factors: upright posture, active or passive motion without regard to direction or position, and exposure to moving visual stimuli or complex visual patterns.
  • The disorder is triggered by events that cause vertigo, unsteadiness, dizziness, or problems with balance, including acute, episodic or chronic vestibular syndromes, other neurological or medical illnesses, and psychological distress.

    • When triggered by an acute or episodic precipitant, symptoms settle into the pattern of criterion A as the precipitant resolves, but may occur intermittently at first, and then consolidate into a persistent course.

    • When triggered by a chronic precipitant, symptoms may develop slowly at first and worsen gradually

  • Symptoms cause significant distress or functional impairment.

  • Symptoms are not better accounted for by another disease or disorder

Recent research gives the impression that this central disorder is related to a change in the feed forward or predictive pathways in the brain for spatial and movement sense and increased reliance on visual rather than vestibular cues. When these predictions disagree with the visual, vestibular and somatic afferents the sensation of “dizziness” is produced. The afferent sensory information may in fact be normal but the disagreement gives rise to the symptoms.

Narrowing the differential list:

  • Rule out peripheral and central vestibular
  • Specifically explore the history of Migraine, panic attack and general anxiety (most commonly associated coDx)
  • Psychiatric disease
  • Medication side effects
  • Recognize that PPPD may occur as a comorbidity (when other Dx confirmed, consider the severity or the signs/ symptoms that don’t fit)


  • Vestibular rehabilitation exercise under the guidance of an experienced vestibular therapist
  • Good results with SSRI’s or SNRI’s
  • Cognitive behavioural therapy

Popkirov S, et al. Persistent postural-perceptual dizziness (PPPD): a common, characteristic and treatable cause of chronic dizziness. Pract Neurol 2018;18:5–13. doi:10.1136/practneurol-2017-001809

Seemungal BM, Passamonti L. Persistent postural-perceptual dizziness: a useful new syndrome Practical Neurology 2018;18:3-4.

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