“But I’m Not Anxious – Why Do I Need to See a Psychologist for PPPD?”

April 15, 2025
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When you’re living with Persistent Postural-Perceptual Dizziness (PPPD), it’s easy to feel frustrated and misunderstood. You might feel like you’re on a rocking boat, walking on a trampoline, or constantly slightly off-balance. Maybe you’re dizzy all the time, or maybe the world feels visually overwhelming in places like supermarkets, busy streets, or while scrolling on your phone. And then comes the well-meaning but confusing advice:

“You should see a psychologist.”

Wait—what?

“But I’m not anxious. I’m dizzy. Why would I need therapy?”

It’s a completely valid question—and one that many people with PPPD ask. Let’s unpack this step by step.

What is PPPD?

Persistent Postural-Perceptual Dizziness (PPPD) is a relatively new diagnosis in the world of vestibular (balance-related) disorders. It was officially recognized in 2017, although the symptoms have been described under other names for decades.

PPPD is a chronic, functional neurological condition that causes persistent dizziness, unsteadiness, or non-spinning vertigo. It doesn’t show up on MRIs or CT scans, and it’s not caused by an ongoing physical injury to the balance organs—but it feels very real, and it significantly impacts quality of life.

Key Features of PPPD:

Non-spinning dizziness or a rocking sensation (often described like being on a boat or walking on marshmallows).
Triggered or worsened by motion (being upright, standing, turning your head).
Visual overload (bright lights, crowds, scrolling screens, or complex visual environments like grocery stores).
Symptoms worsen with attention or anxiety, but often persist even without any clear stress.
Symptoms last most days for three months or more.

Common Triggers:

PPPD is often triggered by a vestibular event—such as a bout of vestibular neuritis, BPPV (Benign Paroxysmal Positional Vertigo), a concussion, or even Vestibular migraine. Sometimes, there’s no obvious trigger. But after the triggering event resolves, the brain doesn’t “reset” its balance system correctly. Instead, it develops a hyper-vigilant, overprotective response, creating a loop that reinforces the dizzy sensations.

Why is a Psychological Approach Recommended?

Let’s be clear: PPPD is not “all in your head.” It is not imagined, and it is not simply caused by stress or anxiety. But it is a functional disorder, meaning that the brain is working in a maladaptive way, even though there is no structural damage.

Because of this, treatment for PPPD needs to be multidisciplinary—a combination of physical, visual, and psychological strategies to help your brain recalibrate.

This is where therapy—particularly Cognitive Behavioural Therapy (CBT)—comes in.

Although up to 60% of patients with PPPD suffer from anxiety, 40% do not—understandably making a referral to a psychologist confusing for some people. But even for those who don’t experience anxiety in the traditional sense, CBT can still play a vital role in recovery.

What is Cognitive Behavioural Therapy (CBT)?

CBT is a structured, evidence-based form of psychological therapy that helps people identify and change patterns in their thinking, behaviour, and emotional responses.

For PPPD, CBT isn’t used to treat mood disorders (although it can help if they’re present); it’s used to retrain the brain’s overactive balance system, calm its threat response, and break the cycle of chronic dizziness.

CBT helps reduce the brain’s “false alarm system.” In PPPD, the brain is constantly scanning for balance threats, even when you’re safe. CBT works by teaching your brain to deactivate that loop.

Why See a Psychologist if You’re Not Anxious?

You may not feel anxious. But PPPD is deeply tied to the brain’s threat perception system—the same system that responds to stress, fear, or danger. When this system becomes overly sensitised (which can happen after vestibular events), it starts overreacting to movement, visual input, or posture changes—even when there’s no real danger.

This is not “in your head.” This is your autonomic nervous system and vestibular network going into high alert. The result? Dizziness, lightheadedness, and a hyper-awareness of balance.

Even without conscious anxiety, your brain may be subconsciously acting as though you are under threat. That means your balance system stays stuck in a defensive mode. CBT helps gently switch off that alarm.

How CBT Helps in PPPD: A Brain-Based Approach

1. Breaks the Vicious Cycle

With PPPD, you may start to avoid certain places or activities—shopping centres, busy intersections, scrolling on your phone—because they make you feel worse. Unfortunately, this avoidance can actually reinforce the dizziness by making the brain more sensitive to those inputs.

CBT helps you gradually reintroduce these activities in a structured way, teaching the brain that they are safe. This process is called exposure therapy, and it’s very effective in PPPD.

2. Calms the Overactive Balance System

CBT techniques such as breath retraining, mindfulness, and somatic grounding help calm the body’s stress response. These strategies send signals to the brain saying, “You’re safe, you’re stable, and you don’t need to be on high alert.”

The more often your brain gets that message, the more it starts to rewire its response—and the less it reacts with dizziness.

3. Reduces Hypervigilance and Sensory Sensitivity

People with PPPD often become extremely attuned to body sensations—a slight rocking, head movement, or eye strain can feel exaggerated and threatening. This hypervigilance further feeds into the symptoms.

CBT helps you identify thought patterns and beliefs that might be contributing to this sensitivity (“I might fall,” “I can’t cope if I get dizzy,” “I need to avoid that place”), and gently replace them with more balanced, realistic thoughts.

Over time, this reduces the intensity and frequency of dizziness episodes.

4. Improves Neuroplasticity

The brain is always changing. This is called neuroplasticity—and it’s the basis for CBT’s success in PPPD.

Through consistent retraining (mental and physical), CBT supports the brain in forming new neural pathways that reinforce a sense of balance, confidence, and stability.

This is why CBT is often recommended alongside vestibular rehabilitation therapy (VRT) and occupational therapy—they work together to retrain both body and brain.

What if I’ve Tried Everything Else?

Many people with PPPD have seen ENT specialists, neurologists, had MRIs, CTs, and countless balance tests—often all coming back “normal.” This can be incredibly invalidating.

But here’s the thing: PPPD is a diagnosis of function, not structure. That means the issue isn’t damage—it’s a glitch in how your brain is interpreting balance signals.

CBT offers something different: a way to work with your brain, not just treating symptoms but changing the underlying mechanism that sustains them.

What to Expect From Seeing a Psychologist

You don’t need to have a mental illness to benefit from therapy. When seeing a psychologist for PPPD, the sessions are practical, supportive, and tailored to your symptoms.

Here’s what it might involve:

Learning how your balance system and brain interact.
Mapping your dizziness triggers and behavioural responses.
Challenging and reshaping unhelpful thoughts.
Gradually re-engaging with feared or avoided situations.
Using mindfulness and grounding strategies to calm the nervous system.
Building resilience and a toolkit to manage flares.

Therapy isn’t about fixing you—it’s about helping your brain feel safe again.

Real Progress, Real Relief

Studies have shown that CBT is highly effective in reducing PPPD symptoms—often leading to significant improvements in quality of life. In many cases, CBT helps people:

Reduce or eliminate daily dizziness
Feel more confident in busy or visually challenging environments
Reclaim activities they had stopped doing
Reduce fear and stress around flare-ups
Feel heard and validated in their experience

And remember: CBT is not a life sentence. Many people only need a short course (6–12 sessions) to start seeing real results.

Final Thoughts: You Deserve Relief

If you have PPPD, your symptoms are real, your suffering is valid, and your desire to find answers is completely understandable. It’s okay to feel confused, frustrated, or skeptical about being referred to a psychologist—especially when you don’t feel anxious.

But hopefully now, you can see that therapy isn’t about treating anxiety—it’s about treating your brain’s protective response to a past event that set your balance system on high alert.

You’re not making it up. You’re not imagining it.
But you can retrain your brain.
You can feel steady again.
And CBT can help you get there.

Cognitive Behavioural Therapy is a great adjunct to Vestibular Physiotherapy for treatment of PPPD. Feel free to discuss this with your Vestibular Physiotherapist at The Vertigo Co to arrange a referral to a psychologist trained in dealing with these complex symptoms.

References

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World Health Organization. (2017). International Classification of Diseases (ICD-11), 6D11 – Persistent Postural-Perceptual Dizziness.
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