Persistent Postural Perceptual Dizziness (PPPD)

What are the signs and symptoms of PPPD?

• Non-spinning dizziness or unsteadiness
• Symptoms are usually present at least 50% of the time and may worsen as the day goes on
• Momentary flares of intense symptoms may occur
• Usually there is an initial event that causes dizziness, and symptoms remain rather than improve with treatment

What are the triggers of PPPD?

• Overstimulating environments, including crowds, department stores, movie theaters and loud restaurants
• Busy patterns on carpets or walls, or items stocked on the shelves of a grocery store
• Moving objects such as cars, bicycles or people
• Scrolling on a phone, tablet or computer
• Stressful situations that provoke anxiety

What tests are used to diagnose PPPD?

There is no single test to diagnose PPPD. At Children’s Hospital Colorado, experts at our Pediatric Mental Health Institute (PMHI) help to diagnose and treat PPPD, while our Pediatric Balance and Vestibular Disorders Clinic work together to diagnose and treat the symptoms and underlying causes.

Your child will have a comprehensive neurologic and vestibular testing to rule out other causes of dizziness. We may also recommend evaluation by an ear, nose and throat (ENT) doctor and imaging tests such as an MRI or CT scan.

If possible, we ask that you keep a journal of your child’s episodes. Details including time and length of episodes, symptoms and events that may have triggered an episode can help us make a diagnosis.

We follow diagnostic criteria formulated by the Committee for Classification of Vestibular Disorders of the Bárány Society. The criteria to diagnose persistent postural perceptual dizziness are: 

• One or more symptoms of dizziness, unsteadiness, or non-spinning vertigo are present on most days for 3 months or more.
  • Symptoms last for prolonged (hours-long) periods of time but may get more or less severe.
  • Symptoms need not be present continuously throughout the entire day, but often worsen throughout the day.
• Persistent symptoms occur without specific cause, but are exacerbated by three factors:
  • Upright posture
  • Active or passive motion without regard to direction or position
  • Exposure to moving visual stimuli or complex visual patterns
• The disorder develops after conditions that cause vertigo, unsteadiness, dizziness, or problems with balance including acute, episodic, or chronic vestibular syndromes, other neurologic or medical illnesses, or psychological distress.
  • When the cause is an acute or episodic condition, symptoms settle into a pattern. They may occur intermittently at first, and then become persistent.
  • When the cause is a chronic syndrome, 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.

What can I expect from PPPD testing?

The first step is a vestibular evaluation, which may require a referral to Audiology Services from your child’s doctor. This evaluation varies depending on your child’s age and developmental level and will be scheduled for 1.5 - 2.5 hours.

Depending on the evaluation results, your child may be referred to the Pediatric Balance and Vestibular Disorders Clinic for a multidisciplinary exam by doctors from Otolaryngology (ENT), Audiology, Physical Therapy and Neurology. If there are concerns for PPPD or general mental health concerns, your child may also be referred to the Pediatric Mental Health Institute (PMHI).

How is PPPD treated?

Treatment for PPPD varies from person to person depending on how much symptoms affect daily life. It is important to identify the trigger or event that caused PPPD symptoms while also treating those symptoms. People who are diagnosed and treated quickly have better outcomes and recovery than those who wait longer to seek treatment.

For the most severe cases, we usually recommend vestibular physical therapy, cognitive behavioral therapy and medication:

• Vestibular physical therapy to desensitize and promote habituation to triggering stimuli or movements
• Cognitive behavioral therapy (CBT) to reduce chronic subjective dizziness and the anxiety that comes with a fear of things like falling as a result of dizziness
• Medical treatment using selective serotonin reuptake inhibitors (SSRI) or serotonin–noradrenaline reuptake inhibitors (SNRI) are the most effective medications for PPPD, even for people who don’t experience anxiety or depression

Why choose us for treatment of PPPD?

Dizziness in children can be the result of many different conditions. The Pediatric Balance and Vestibular Disorders Clinic and the Pediatric Mental Health Institute at Children’s Colorado specialize in conditions like PPPD in children.

Children’s Colorado is the only center in the state that has an enclosed rotary chair, necessary for assessing vestibular disorders in young children or children with developmental differences. Without this testing, it is difficult to completely rule out inner ear disorders in some children.

Helpful resources

The Vestibular Disorder Association (VeDA) provides a lifeline of support to anyone affected by vestibular (inner-ear and brain balance) disorders by providing information and community resources.

Contacting us and making an appointment

Talk to your child’s doctor or neurologist about your concerns. We usually require a referral to both audiology and ENT departments by a physician or advanced practice provider for vestibular testing and diagnostic exams.

We also want to be sure that the symptoms your child is experiencing do not require urgent medical attention. You can discuss these symptoms with an ENT nurse and get advice by calling 720-777-8501.

They may recommend that your child be evaluated by an ENT first, and then if appropriate, follow up with vestibular testing to gather more information. If a vestibular evaluation is recommended, a scheduler will contact you to set up an appointment and provide additional instructions on how to prepare for the evaluation.