Persistent Posturo-Perceptual Dizziness
Dizziness is a common symptom and has a lot of difference causes. This can include things such as migraines, inner ear problems (such as labyrinthitis or BPPV), and drug side effects. Dizziness occurring as part of a functional disorder is also relatively common and is called Persistent Postural Perceptual Dizziness (PPPD).
PPPD is defined by the World Health Organization as ‘Persistent non vertiginous dizziness, unsteadiness, or both lasting three months or more.Symptoms are present most days, often increasing throughout the day, but may wax and wane. Momentary flares may occur spontaneously or with sudden movement. Affected individuals feel worst when upright, exposed to moving or complex stimuli, and during active or passive head motion. These situations may not be equally provocative. Typically, the disorder follows occurrences of acute or episodic vestibular or balance- related problems. Symptoms may begin intermittently, and then consolidate.’
PPPD is defined by the World Health Organization as ‘Persistent non vertiginous dizziness, unsteadiness, or both lasting three months or more.Symptoms are present most days, often increasing throughout the day, but may wax and wane. Momentary flares may occur spontaneously or with sudden movement. Affected individuals feel worst when upright, exposed to moving or complex stimuli, and during active or passive head motion. These situations may not be equally provocative. Typically, the disorder follows occurrences of acute or episodic vestibular or balance- related problems. Symptoms may begin intermittently, and then consolidate.’
Here is an example of someone with PPPD:
Clara is a 24 year old woman who presents with a history of persistent dizziness for the previous two years. She had an initial illness where everything was spinning badly (vertigo) for a week. The doctor diagnosed viral labyrinthitis – a viral infection of the middle ear that causes dizziness and usually resolves in a week or two.
As she recovered, her complain of dizziness changed to a more non-specific feeling of dizziness that she found hard to describe to people. It wasn’t the spinning sensation but instead, she felt lightheaded as if she was swaying and had a feeling of motion present mainly on standing and walking but had noticed when lying in bed also.
Every now and then she felt ‘spaced out’ as if she was floating and people seemed far away. She also found she’d become really sensitive to objects moving in her environment when she was still. It was really difficult for her to use a computer or be in busy environments such as supermarkets.
She found that she was quite often thinking about the possibility of falling. She had only ever fallen once but felt that she had experienced some ‘near misses’ at time. The thought of being embarrassed and falling outside made her feel anxious and so she had tended to avoid busy places and going outside as much as possible.
Over time she had found that the dizziness had started to take over her life. Initially she had become anxious about a possible sinister cause and had found herself looking up possible causes on the internet. She then saw doctors who had carried out detailed balance tests and she had a normal MRI of her brain. Even when she became more confident that it wasn’t a sinister problem she found it very hard to cope with the symptoms. She developed symptoms of fatigue and poor concentration and had various periods of time off work. The whole thing was made worse by regular migraines during which her dizziness often got worse.
She now felt at her wits end. What was causing this dizziness, why couldn’t anyone tell her what was wrong and how to get better?
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How does PPPD develop?Clara’s story is very typical. She started out with an episode of viral labyrinthitis that upset her balance system. Other people with PPPD start off with dizziness from a migraine, or from after a mild hear injury. These causes of dizziness all upset the normal processes that your brain uses to stop you feeling dizzy. Our brains are actually doing a lot of work all the time to stop us from feeling dizzy. Our head, body and eyes can all move independently. Yet our brain is able to sort all this out to make sure that for most of us we don’t get abnormal sensations of movement. It does this through an incredibly complex process using information from the inner ear, our muscles and vision.
In PPPD what happens is that the normal ‘filters’ that the brain uses to suppress feelings of movement go wrong. Instead of the brain being able to balance everything up and give you a nice smooth feeling when you are moving, the person can feel a sense of movement that they shouldn’t. After a while, because the person notices it a lot, they start to wonder what it is. Thinking about dizziness or worrying about it ‘turns up the volume knob’ on the sensation. That makes it even stronger – and so the vicious circle begins. Like all functional disorders this is not dizziness that is ‘all in the mind’. The person can’t just switch it off. In PPPD one things leads to another. Experiencing feelings of dizziness often revolves around concern about the cause, so called health anxiety. In PPPD an initial dizziness trigger sets things off and then other symptoms follow from it leading to hypersensitivity of the nervous system and theexperience of dizziness. Anxiety in PPPD may also be centred around concerns about falling or the consequences of falling such as embarrassment. Not everyone with PPPD has anxiety but it is common. The pathways for dizziness and anxiety in the brain turn out to be quite similar. Anxiety is really tiring for the brain, fatigue is common in PPPD. Often feelings of fatigue and dizziness merge with a ‘cotton wool’ feeling in the head which people sometimes refer to as ‘brain fog’. This is a feeling that merges between all of these symptoms as well as feelings of poor concentration. People with PPPD become sensitive not only to their own movement, but also to things moving around them. They can feel intense discomfort in places like supermarkets or on public transport or with patterned surfaces. This discomfort can lead to avoidance of those places and feelings of fear when asked to endure them. Another consequence of PPPD may be dissociation. This is a feeling of being spaced out or zoned out. Sometimes people describe it as being disconnected or floating. Patients with PPPD may feel that they are walking on spongy ground or that their feet feel spongy. There are other causes for this symptom but PPPD is one of them. Neck movements may trigger feelings of dizziness in some people with PPPD. If you keep avoiding neck movements over a long time period then you may end up with a stiff painful neck of headaches. Worsening headache with dizziness only serves to make everything worse. PPPD is a problem with motion sensitivity. Problems with light and sound sensitivity or even nausea from smell sensitivity are more common in patients with PPPD.
Treatment of PPPD Specific treatment of PPPD takes time and there is no ‘quick fix’ but good recovery is certainly possible even after months or years of symptoms. Treatment includes: 1. A clear positive diagnosis and explanation that you can work with. An understanding of how the nervous system has become sensitised can help you work to desensitize it.2. Recognition during assessment of all various component symptoms that may or may not be going along with your PPPD including dissociation, neck pain, anxiety, fatigue and poor concentration. Some of these problems may have treatment approaches in their own right.3. Physiotherapy/Desensitisation of movement. As the symptoms of PPPD have built up, most people avoid moving their eyes, neck and body as much as they used to. Physiotherapy and specific vestibular physiotherapy can be useful to help desensitize the nervous system and start to overcome ingrained patterns of movement.4. Medication. Some of the medications, such as antidepressants, may be usefull for patients with PPPD.5. Psychological Treatment. Can be helpful in addressing understandable fears of falling, or other sources of anxiety. Treatment from a therapist can help break bad habits that many patients with PPPD get in to with respect to their symptoms. For more information visit the source at www.neurosymptoms.org
In PPPD what happens is that the normal ‘filters’ that the brain uses to suppress feelings of movement go wrong. Instead of the brain being able to balance everything up and give you a nice smooth feeling when you are moving, the person can feel a sense of movement that they shouldn’t. After a while, because the person notices it a lot, they start to wonder what it is. Thinking about dizziness or worrying about it ‘turns up the volume knob’ on the sensation. That makes it even stronger – and so the vicious circle begins. Like all functional disorders this is not dizziness that is ‘all in the mind’. The person can’t just switch it off. In PPPD one things leads to another. Experiencing feelings of dizziness often revolves around concern about the cause, so called health anxiety. In PPPD an initial dizziness trigger sets things off and then other symptoms follow from it leading to hypersensitivity of the nervous system and theexperience of dizziness. Anxiety in PPPD may also be centred around concerns about falling or the consequences of falling such as embarrassment. Not everyone with PPPD has anxiety but it is common. The pathways for dizziness and anxiety in the brain turn out to be quite similar. Anxiety is really tiring for the brain, fatigue is common in PPPD. Often feelings of fatigue and dizziness merge with a ‘cotton wool’ feeling in the head which people sometimes refer to as ‘brain fog’. This is a feeling that merges between all of these symptoms as well as feelings of poor concentration. People with PPPD become sensitive not only to their own movement, but also to things moving around them. They can feel intense discomfort in places like supermarkets or on public transport or with patterned surfaces. This discomfort can lead to avoidance of those places and feelings of fear when asked to endure them. Another consequence of PPPD may be dissociation. This is a feeling of being spaced out or zoned out. Sometimes people describe it as being disconnected or floating. Patients with PPPD may feel that they are walking on spongy ground or that their feet feel spongy. There are other causes for this symptom but PPPD is one of them. Neck movements may trigger feelings of dizziness in some people with PPPD. If you keep avoiding neck movements over a long time period then you may end up with a stiff painful neck of headaches. Worsening headache with dizziness only serves to make everything worse. PPPD is a problem with motion sensitivity. Problems with light and sound sensitivity or even nausea from smell sensitivity are more common in patients with PPPD.
Treatment of PPPD Specific treatment of PPPD takes time and there is no ‘quick fix’ but good recovery is certainly possible even after months or years of symptoms. Treatment includes: 1. A clear positive diagnosis and explanation that you can work with. An understanding of how the nervous system has become sensitised can help you work to desensitize it.2. Recognition during assessment of all various component symptoms that may or may not be going along with your PPPD including dissociation, neck pain, anxiety, fatigue and poor concentration. Some of these problems may have treatment approaches in their own right.3. Physiotherapy/Desensitisation of movement. As the symptoms of PPPD have built up, most people avoid moving their eyes, neck and body as much as they used to. Physiotherapy and specific vestibular physiotherapy can be useful to help desensitize the nervous system and start to overcome ingrained patterns of movement.4. Medication. Some of the medications, such as antidepressants, may be usefull for patients with PPPD.5. Psychological Treatment. Can be helpful in addressing understandable fears of falling, or other sources of anxiety. Treatment from a therapist can help break bad habits that many patients with PPPD get in to with respect to their symptoms. For more information visit the source at www.neurosymptoms.org