The Best Steps to Treating PPPD (Persistent Postural Perceptual Dizziness)

What is Persistent Postural Perceptual Dizziness (PPPD)?

In general, Persistent Postural Perceptual Dizziness (3PD or PPPD) is a condition resulting in long term dizziness that fluctuates in severity after an initial event or vestibular condition. Let’s break down the diagnostic criteria to better understand what 3PD and if this is something to seek out treatment for. 

PPPD Diagnostic Criteria

Here’s the check list your provider is looking at to determine if 3PD is the correct diagnosis and to then proceed with the most up to date treatment for this condition. 

All five criteria must be met for a PPPD diagnosis so let’s take a look: 

  1.  One or more symptoms of dizziness, unsteadiness, or non-spinning vertigo are present on most days for 3 months or more.

  • a. Symptoms last for prolonged (hours-long) periods of time, but may wax and wane in severity.

  • b. Symptoms need not be present continuously throughout the entire day


Translation: The dizziness does not have a spinning component and has lasted longer than 3 months. The dizziness or unsteadiness can vary in severity and get better or worse over hours or days, but is present a majority of the time. 

  1.  Persistent symptoms occur without specific provocation, but are exacerbated by three factors: 

  • a. Upright posture,

  • b. Active or passive motion without regard to direction or position, and

  • c. Exposure to moving visual stimuli or complex visual patterns.


Translation: Upright positions like sitting or standing feel worse than lying down. Both active motion (walking, bike, jogging) and passive motion (riding in a car or being pushed in a wheelchair) can both be aggravating no matter the position or direction you are in during the movement. And finally, busy environments or patterns can make symptoms worse (ex: busy crowds, walking by fences, changing sunlight from bright to shadows). 

  1. The disorder is precipitated by 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.

  • a. When the precipitant is an acute or episodic condition, symptoms settle into the pattern of criterion 1 as the precipitant resolves, but they may occur intermittently at first, and then consolidate into a persistent course.

  • b. When the precipitant is a chronic syndrome, symptoms may develop slowly at first and worsen gradually.

Translation: There must be another condition or cause that occurs first that results in dizziness or unsteadiness. This includes vestibular condition (BPPV, migraine, neuritis etc) or a different medical condition (neurologic, psychological etc). The underlying condition can be acute or chronic and may change how your symptoms feel. If it is a new condition  that suddenly happened there may be some resolution of symptoms and gradually become more constant. If the underlying condition is chronic then there might be more of a constant presence of your symptoms that gradually get worse over time. 

  1. Symptoms cause significant distress or functional impairment.

Translation: Is my life being impacted by my symptoms? Are you limited in your ability to work, perform household tasks or hobbies? 

  1. Symptoms are not better accounted for by another disease or disorder. 1

Translation: Does any other condition better explain what you’re experiencing?


Can You Treat PPPD?

Yes yes yes!

Personally, we have found high PPPD treatment success when we stick to the four general steps to treating PPPD: 

  1. Find the underlying cause 
  2. Treat the anxiety 
  3. Initiate Vestibular Rehabilitation Therapy 
  4. Reduce safety behaviors (return back to daily life) 

1. Treat the underlying cause. It’s important to treat the underlying cause that started the dizziness and imbalance to begin addressing the core of 3PD. This is where treatment begins to get customized for the person because different underlying causes (BPPV, neuritis, migraine, panic attacks, neurologic conditions) require different interventions for best results. 

2. Treat the anxiety. If you’ve read this far, you might be wondering “What does anxiety have to do with this, this is the time this is being mentioned”. Research has shown an anxiety component with 3PD and those with more anxious or nervous personalities are more likely to develop 3PD. This research shows that addressing anxiety through therapy and/or medication is highly recommended for best results in the treatment and management in 3PD. If you aren’t a fan of medications, have a conversation with your doctor, sometimes meds can be useful in starting treatment and weaning off them once you’re further along in VRT. 2,3

3. Initiate Vestibular Rehabilitation Therapy (VRT). VRT is to help address the movements and situations that worsen your symptoms or you’re completely avoiding due to concerns of safety or making your symptoms worse. This is done with gradual progression of exercises based on your specific response and recovery. This helps get you to step number 4 as your sx reduce in frequency and intensity. 

4. Reduce safety behaviors (return back to daily life). Once symptoms are improving, the goal is to get you back to your typical movements and activities. This is done with exercises or practice of activities in a safe environment like in VRT. This may be practicing walking in open spaces or uneven ground without a cane or walking stick, or returning to activities like biking, driving your usual routes. 

Want to Learn More About Treating PPPD?

If you’re interested in learning more about the specific factors address in VRT to reduce PPPD symptoms, reach out to a vestibular therapist or consider joining our vestibular community that includes dozens of premium content modules of information and resources and a great community to support you! 


Remember: this post is for informational purposes only and may not be the best fit for you and your personal situation. It shall not be construed as medical advice. The information and education provided here is not intended or implied to supplement or replace professional medical treatment, advice, and/or diagnosis. Always check with your own physician or medical professional before trying or implementing any information read here. 




  1. Staab JP, Eckhardt-Henn A, Horii A, Jacob R, Strupp M, Brandt T, Bronstein A. Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the committee for the Classification of Vestibular Disorders of the Bárány Society. J Vestib Res. 2017;27(4):191-208. doi: 10.3233/VES170622. PMID: 29036855; PMCID: PMC9249299. 
  2. Probs t T, Dinkel A, SchmidMühlbauer G, Radz iej K, L imburg K, Pieh C, Lahmann C. Psychological di s tres s longitudinal ly mediates the effect of vertigo symptoms on vertigo-related handicap. J Psychosom Res . 2017 Feb;93:62- 68. doi : 10.1016/ j . jpsychores .2016.11.013. Epub 2016 Nov 30. PMID: 28107895.
  3. Chiarel la, Giuseppe & Petrolo, C. & Riccel l i , Roberta & Giofrè, L . & Ol ivadese, G. & Gioacchini , F .M. & Scarpa, Alfonso & Cas sandro, E ttore & Pas samonti , Luca. (2016) . Chronic subjective di z z ines s : Analys i s of underlying per sonal ity factor s . Journal of Ves tibular Research. 26. 403- 408. 10.3233/VES-160590.

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