Persistent Postural-Perceptual Dizziness (PPPD) can be one of the most confusing vestibular conditions to experience.
A person may initially develop dizziness following Vestibular Neuritis, BPPV, Vestibular Migraine, concussion, illness, panic or another event that disrupts balance. The original trigger may subsequently resolve, yet months later the person continues to experience dizziness, rocking, swaying, unsteadiness or visual sensitivity.
Patients often ask:
“Why am I still dizzy when my vestibular tests are normal?”
“Why do supermarkets make me feel so unsteady?”
“Why does thinking about my dizziness sometimes make it worse?”
“Why do I feel better in places where I feel safe?”
PPPD is a chronic functional vestibular disorder. It is not imaginary, and it is not simply anxiety. Rather, research suggests that PPPD involves altered processing across networks responsible for vestibular information, vision, postural control, spatial orientation, attention and emotional processing.
Understanding the interaction between these systems—and the brain’s normal mechanisms for detecting and responding to potential danger—can help explain why symptoms sometimes continue long after the initial vestibular event has settled.
What is PPPD?
PPPD is characterised by persistent dizziness, unsteadiness and/or non-spinning vertigo occurring on most days for at least three months.
Symptoms are typically exacerbated by three situations:
- Upright posture
- Active or passive movement
- Exposure to complex or moving visual environments
This can make activities such as walking through a supermarket, shopping centre or crowd, scrolling on a phone, watching traffic or travelling in a car particularly difficult.
The Bárány Society diagnostic criteria recognise that PPPD can be precipitated by conditions that cause vertigo, unsteadiness, dizziness or balance disturbance—including peripheral and central vestibular disorders, other medical conditions and psychological distress. Bárány Society PPPD diagnostic criteria
The initial dizziness is therefore frequently very real and physiologically appropriate.
The question is why it sometimes persists.
What Happens When Dizziness First Begins?
Imagine developing an acute episode of Vestibular Neuritis.
Suddenly, movement makes you extremely dizzy.
Turning your head feels terrible.
Walking becomes difficult.
You may feel nauseated and frightened that you’re going to fall.
Your brain appropriately concludes:
“Something is wrong. I need to protect myself.”
You might begin:
- Walking cautiously
- Stiffening your body
- Moving your head less
- Watching the ground
- Holding onto furniture
- Relying more heavily on vision
- Monitoring sensations of dizziness
- Avoiding provocative environments
Initially, many of these responses are understandable protective adaptations.
As the vestibular system recovers, however, the brain normally needs to recalibrate.
Movement needs to become automatic again.
With PPPD, some protective strategies can persist beyond the period in which they were originally useful.
The brain may remain excessively attentive to balance, visual information and potential instability.
The Brain’s Threat-Detection System
The brain is constantly evaluating information from the body and environment to determine what is important and what may require a response.
Information arrives from:
Vision + vestibular system + proprioception + internal bodily sensations + memory + emotion + environment.
Dizziness is particularly capable of attracting the brain’s attention.
From an evolutionary perspective, that makes sense.
If your brain thinks you’re falling or cannot accurately determine your position in space, it needs to respond.
The problem in PPPD isn’t that the brain has a threat-detection system.
We all need one.
The difficulty may arise when sensations or environments that are no longer dangerous continue to be interpreted as requiring increased attention and protective behaviour.
The Autonomic Nervous System and PPPD
The autonomic nervous system helps regulate functions that occur largely automatically, including:
- Heart rate
- Blood pressure
- Breathing
- Digestion
- Sweating
- Pupil responses
- Physiological arousal
Two major components are the sympathetic and parasympathetic nervous systems.
The Sympathetic Nervous System: Fight or Flight
The sympathetic nervous system helps mobilise the body when we encounter a challenge or potential threat.
This is commonly described as fight or flight.
Activation can produce:
- Increased heart rate
- Faster breathing
- Increased muscle tension
- Sweating
- Heightened alertness
- Increased attention to the environment
- Changes in gastrointestinal activity
This isn’t inherently harmful.
It is an essential survival system.
But imagine experiencing these changes while already feeling unsteady.
You become dizzy.
Your brain interprets the dizziness as potentially threatening.
Arousal increases.
You become more vigilant.
You monitor your balance more closely.
You stiffen your walking.
And suddenly the dizziness becomes even more prominent.
This can contribute to a self-reinforcing cycle.
The Parasympathetic Nervous System
The parasympathetic nervous system contributes to autonomic regulation and functions associated with rest, digestion, recovery and energy conservation.
It is often described as the “rest-and-digest” system.
However, it would be inaccurate to describe PPPD simply as:
Sympathetic = bad
and
Parasympathetic = good.
Both systems are necessary.
Healthy autonomic regulation requires flexibility—the capacity to appropriately increase physiological arousal when required and subsequently regulate it when the challenge has passed.
Likewise, PPPD is not simply an imbalance between sympathetic and parasympathetic activity. Its recognised mechanisms are considerably more complex and involve interactions between vestibular, visual, postural, attentional and emotional networks.
The Amygdala: Is This Dangerous?
The amygdala participates in emotional learning and the processing of biologically important information, including potential threat.
It is sometimes called the brain’s “alarm system.”
Although this is an oversimplification, it provides a useful analogy.
Imagine experiencing severe dizziness in a supermarket.
You feel unsteady.
Your heart races.
The lights and shelves become overwhelming.
You feel as though you’re going to fall.
You leave.
When you return the following week, your brain has information from the previous experience.
The lights, shelves, people and movement may now be associated with:
“Last time I was here, I became extremely dizzy.”
Your threat and attentional systems may therefore become engaged before you’ve actually lost your balance.
This is learned prediction—not imagination.
The Hippocampus: Memory, Context and Spatial Orientation
The hippocampus plays important roles in memory, learning and spatial navigation.
It also has important interactions with vestibular processing.
Your vestibular system doesn’t simply keep you upright. Vestibular information contributes to the brain’s representation of where your body is in space.
The hippocampus also provides context.
For example:
Supermarket → I became dizzy here previously.
Freeway → I felt as though the car was moving sideways here.
Escalator → I nearly lost my balance here.
This doesn’t mean that the hippocampus is damaged in PPPD.
Rather, neuroimaging research suggests alterations in functional connectivity across networks involving vestibular, visual, spatial and emotional processing.
The Hypothalamus: Turning Threat Perception Into a Body Response
The hypothalamus plays an important role in regulating:
- Autonomic nervous system activity
- Hormonal responses
- Temperature
- Hunger and thirst
- Sleep and wakefulness
- Physiological responses to stress
It communicates with brain regions involved in emotional processing and helps coordinate bodily responses when something is perceived as significant or threatening.
This helps explain why dizziness can be accompanied by very physical sensations such as:
racing heart + nausea + sweating + shaking + altered breathing + muscle tension.
The experience is not simply occurring “in the mind.”
The brain and body are interacting continuously.
The Insular Cortex: What Am I Feeling Inside My Body?
The insula, or insular cortex, is particularly interesting in PPPD because it participates in several relevant processes, including:
- Vestibular processing
- Interoception
- Autonomic processing
- Emotional processing
- Salience
- Sensory integration
Interoception refers to the brain’s perception of internal bodily sensations.
These include:
- Heartbeat
- Breathing
- Nausea
- Muscle tension
- Temperature
- Internal sensations of movement or dizziness
If someone becomes highly vigilant towards these sensations, small changes can become extremely salient.
The person may repeatedly check:
“Am I dizzy?”
“Am I swaying?”
“Is my heart racing?”
“Does the floor feel strange?”
Attention doesn’t create PPPD, but excessive attention towards balance and bodily sensations can potentially contribute to the persistence and amplification of symptoms.
The “Limbic Loop” Theory and PPPD
There is not a formally established PPPD mechanism called the limbic loop.
Rather, it is a conceptual way of describing how dizziness, threat appraisal, memory, autonomic arousal, attention and behaviour can reinforce one another.
A simplified cycle might look like this:
Dizziness or visual movement
↓
Brain evaluates potential threat
↓
Previous experiences influence the prediction
↓
Autonomic arousal increases
↓
Attention becomes focused on balance
↓
Movement becomes more cautious
↓
Visual dependence and symptom monitoring increase
↓
Dizziness becomes more noticeable
↓
Brain interprets this as further evidence of danger
↓
Avoidance
↓
Reduced opportunity to learn that movement is safe
↓
Persistent dizziness
This is broadly consistent with the existing understanding that avoidance can provide immediate symptom relief while reducing opportunities for habituation and safety learning.
Nervous System Dysregulation and PPPD
The phrase “nervous system dysregulation” has become increasingly popular.
It can be useful clinically, provided it isn’t presented as the complete biological explanation for PPPD.
PPPD appears to involve alterations across interacting:
vestibular + visual + sensorimotor + attentional + spatial + emotional networks.
So rather than telling someone:
“Your nervous system is dysregulated.”
a more useful explanation may be:
“Your brain has become overly protective around balance and movement.”
The protective response is real.
But the danger prediction may no longer accurately represent the environment.
And importantly:
Predictions can be updated.
Why Do Supermarkets Trigger PPPD?
Supermarkets provide an enormous amount of visual information.
There are:
- Repeating shelves
- Bright lights
- Patterns
- Signs
- People moving
- Shopping trolleys
- Peripheral visual motion
- Frequent head turns
- Changes in visual depth
- Walking while simultaneously scanning shelves
Someone with PPPD may have become more dependent on visual information for balance.
The result can be:
visual overload + postural vigilance + increased attention + threat response + dizziness.
If the supermarket has previously produced severe symptoms, contextual learning may further amplify the response.
Why Avoidance Can Maintain the Cycle
Suppose turning your head makes you dizzy.
You stop turning your head.
You immediately feel better.
Your brain learns:
“Avoiding head movement kept me safe.”
Then supermarkets provoke dizziness.
You stop going.
Again, symptoms improve.
The brain receives another powerful message:
“Avoidance prevented danger.”
The person’s world can gradually become smaller.
Avoidance is therefore understandable—but excessive avoidance can prevent the nervous system from obtaining the information it needs:
“I can experience movement and remain safe.”
This is why graded exposure is so important in PPPD rehabilitation.
Vestibular Rehabilitation Therapy: Retraining Movement and Sensory Processing
Vestibular Rehabilitation Therapy (VRT) is an important component of PPPD management.
Treatment is individualised and may include:
- Habituation
- Balance retraining
- Sensory integration
- Head and body movement
- Dynamic balance
- Reduced-visual-input balance exercises
- Visual-motion or optokinetic exposure
- Gradual exposure to visually complex environments
- Return to previously avoided activities
The goal isn’t necessarily to avoid provoking any dizziness.
Instead, carefully graded rehabilitation can provide repeated experiences of:
Movement → temporary symptoms → nothing dangerous happens → symptoms settle.
Repeated over time:
Movement → familiarity → reduced threat → more automatic movement.
Recent systematic reviews and meta-analyses suggest VRT can improve dizziness-related outcomes in PPPD, although treatment protocols and the quality of the available studies vary. VRT and PPPD systematic review and meta-analysis
Your existing article describes this particularly well as providing the brain with repeated evidence that movement can occur without catastrophe.
Cognitive Behavioural Therapy and PPPD
Cognitive Behavioural Therapy (CBT) can address another part of the cycle.
It may be particularly useful when PPPD involves:
- Fear of dizziness
- Fear of falling
- Panic
- Agoraphobia
- Hypervigilance
- Catastrophic interpretations
- Avoidance
- Safety behaviours
CBT does not mean telling someone that their dizziness is psychological.
Instead, it can help change the interpretation of the sensation.
For example:
“I’m dizzy. I’m going to collapse.”
might gradually become:
“I’m experiencing my familiar dizziness. It is uncomfortable, but I can tolerate it and continue safely.”
CBT can also help reduce behaviours that inadvertently reinforce the belief that movement or dizziness is dangerous.
Research suggests CBT can be beneficial as part of PPPD management, particularly in combination with conventional treatment, although larger high-quality studies are still needed. CBT for PPPD systematic review and meta-analysis
Where Does Somatic Therapy Fit?
Somatic Therapy is a broad term for psychological approaches that incorporate greater awareness of bodily sensations and the relationship between physical sensations, emotion and perceived safety.
This has obvious conceptual relevance to PPPD because dizziness is an intensely body-based sensory experience.
Someone with PPPD may become extremely vigilant towards:
- Dizziness
- Swaying
- Heartbeat
- Breathing
- Nausea
- Muscle tension
- Internal sensations of movement
- Feelings of disconnection or instability
A body-oriented psychological approach may help some patients learn to notice these sensations without immediately responding:
“Something is wrong.”
Instead, the therapeutic process may encourage:
Notice the sensation
↓
Remain present
↓
Reduce automatic threat interpretation
↓
Allow the sensation to exist without immediately escaping
↓
Recognise that the sensation can be experienced safely
This may be particularly relevant where PPPD coexists with significant anxiety, panic, previous trauma or difficulty tolerating bodily sensations.
However, this needs an important qualification:
Somatic Therapy is not currently an established evidence-based treatment specifically for PPPD.
There is much stronger direct evidence for VRT and CBT.
Somatic Therapy should therefore be considered a potential adjunctive psychological approach for appropriately selected patients, rather than a replacement for vestibular rehabilitation or established psychological treatment.
VRT + CBT + Somatic Therapy: Different Parts of the Same Puzzle
For selected patients, it can be helpful to conceptualise treatment like this:
Vestibular Rehabilitation Therapy
Retrains the brain’s response to movement, balance and sensory information.
It teaches:
“Movement is safe.”
Cognitive Behavioural Therapy
Addresses thoughts, predictions, avoidance and behaviours surrounding dizziness.
It teaches:
“Feeling dizzy does not automatically mean I am in danger.”
Somatic Therapy
May help selected patients change their relationship with uncomfortable bodily sensations and physiological arousal.
It may help reinforce:
“I can notice this sensation without immediately needing to escape from it.”
These approaches don’t need to compete with each other.
They can address different factors contributing to an individual’s presentation.
The Goal Isn’t to Permanently “Calm the Nervous System”
This is another important distinction.
The aim of PPPD treatment isn’t to keep someone permanently in a relaxed or parasympathetic state.
If a patient believes:
“I must regulate my nervous system before I can go into the supermarket,”
this can inadvertently become another safety behaviour.
The patient may begin believing:
“The supermarket really is dangerous unless I’m perfectly calm.”
Instead, rehabilitation should progressively teach:
“My heart can race and I can still be safe.”
“I can feel dizzy and remain safe.”
“I don’t have to feel perfectly calm before I move.”
“These sensations can occur without catastrophe.”
Breathing, mindfulness, relaxation and body-based strategies can certainly help.
But they should ideally support engagement with life and movement, rather than becoming prerequisites for feeling safe.
From Danger Learning to Safety Learning
This may be one of the most helpful ways to understand recovery from PPPD.
Following the original event, the brain may have learned:
Head movement = danger.
Dizziness = danger.
Supermarket = danger.
Crowds = danger.
Visual movement = danger.
Unsteadiness = danger.
Treatment provides new information.
Head movement → safe.
Walking → safe.
Visual movement → safe.
Supermarket → safe.
Temporary dizziness → uncomfortable but safe.
Bodily sensations → tolerable and safe.
This is safety learning.
Importantly, safety learning doesn’t mean convincing yourself intellectually that you’re safe.
The brain needs experience.
It needs repeated, appropriately graded experiences in which the predicted catastrophe doesn’t occur.
A More Complete Model of PPPD
PPPD shouldn’t be viewed as purely an inner-ear disorder.
But it also shouldn’t be reduced to anxiety, trauma, “vagus nerve dysfunction” or a dysregulated nervous system.
A more complete model considers interactions between:
Vestibular processing
Visual processing
Postural control
Spatial orientation
Attention
Interoception
Memory
Emotional processing
Threat perception
Autonomic arousal
Behaviour and avoidance
This explains why two people with PPPD may require quite different rehabilitation programs.
For one patient, the predominant problem may be visual dependence and motion sensitivity.
For another, significant avoidance and fear of dizziness may be maintaining disability.
For another, Vestibular Migraine may continue to contribute.
And for some patients, significant anxiety, panic or trauma-related responses may warrant additional psychological support.
PPPD Treatment at The Vertigo Co
At The Vertigo Co, PPPD treatment is individualised according to the factors contributing to each person’s symptoms.
Vestibular Physiotherapy may include:
- Education about PPPD
- Habituation
- Balance retraining
- Sensory integration
- Visual-motion rehabilitation
- Graded head and body movement
- Dynamic balance
- Gradual exposure to challenging environments
- Reducing avoidance
- Building confidence with movement and balance
Where appropriate, a multidisciplinary approach may include collaboration with a GP, Neuro-Otologist, Psychologist or other suitably qualified healthcare professional.
CBT may be particularly valuable when fear, hypervigilance, panic, agoraphobia or avoidance are prominent.
Somatic or body-oriented psychological approaches may also be considered as an adjunct for selected patients, particularly where bodily sensations themselves have become strongly associated with danger, although research specifically examining Somatic Therapy for PPPD is currently limited.
The Key Message
PPPD is real dizziness.
It is not imaginary, and it does not mean that someone is simply anxious.
PPPD appears to involve changes in the way the brain processes and integrates vestibular information, vision, movement, spatial orientation, attention and emotion.
The brain’s threat and autonomic systems can potentially become part of this process.
Following an initially frightening episode of dizziness or instability, the brain may become overprotective around movement and balance.
Movement is monitored.
Dizziness becomes highly salient.
Protective behaviours develop.
Avoidance provides temporary relief.
And the brain receives fewer opportunities to learn that movement is safe.
This can create a self-reinforcing cycle:
Dizziness
↓
Threat
↓
Hypervigilance
↓
Protective movement
↓
Avoidance
↓
Increased sensitivity to dizziness
↓
More perceived threat
Treatment aims to interrupt this cycle.
VRT helps recalibrate movement, balance and sensory processing.
CBT can address fear, catastrophic interpretation, hypervigilance and avoidance.
Somatic Therapy may provide an additional body-oriented psychological approach for selected patients, although it does not currently have the same direct evidence base for PPPD as VRT and CBT.
Polyvagal Theory may also provide some people with a useful framework for understanding perceived safety, fight-or-flight and shutdown experiences. However, it should not be presented as the established neurophysiological mechanism of PPPD, and there is currently no evidence that PPPD represents a person being “stuck” in a dorsal vagal state.
Ultimately, recovery is not simply about calming the nervous system.
It is about helping the brain recalibrate balance, reduce excessive threat monitoring, restore automatic movement and update its predictions about danger.
Through appropriately graded movement and exposure, patients can gradually learn:
“I can move.”
“I can experience these sensations.”
“I don’t need to avoid them.”
“Movement is safe.”
And as the brain receives repeated evidence of safety, dizziness can gradually become less threatening, less intrusive and less dominant in everyday life.
The Vertigo Co Vestibular Physiotherapy
This article provides general educational information and does not replace individual medical or psychological assessment. PPPD should be appropriately diagnosed, and persistent or unexplained dizziness should be assessed to exclude other vestibular, neurological, cardiovascular or medical causes.
