Persistent Postural Perceptual Dizziness

(3PD or PPPD)

This information sheet explains 3PD, what it is, how it arises and possible treatments.

It is important to know that 3PD:

 has a specific set of symptoms

 may arise by itself, or be related to another condition
 is not completely understood, but CAN be treated
 many patients’ symptoms improve or resolve with treatment
 Is NOT all in your head or made up

SYMPTOMS

The dizziness in 3PD:

 Is often described as feeling lightheaded, foggy, rocking, swaying, like being drunk, or just having
bad balance
 Is felt almost every day, with good and bad days, for at least 3 months

You will find your dizziness is worse with:

 Your own body and head movements

 Movement of things around you
 Busy environments like grocery stores, shopping malls, parties
 Traffic movement

Your dizziness will often be worse with visual tasks and environments like:

 Reading
 Using a computer or device, especially when scrolling text
 Watching TV especially shows with lots of movement (like basketball, action movies)
 Playing video games
 Patterns on walls/carpets

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You may also have some or all of the following symptoms:

 headaches or migraines
 feelings of anxiety or depression
 cognitive symptoms (poor concentration, bad memory, feeling dazed)
 poor sleep quality, feeling tired all the time

CAUSES

3PD may develop on its own, or be triggered by other problems, including:

 an inner ear (vestibular) or other balance issue in the brain

 migraines (either classic painful migraines or migraines that cause dizziness)
 anxiety or panic
 stress (personal stress, work stress, bereavement, etc.)
 concussion
 heart problems resulting in dizziness or faints
 effects of medications

After having 3PD for some time, patients often develop:

 feelings of frustration after having multiple negative tests and seeing many specialists
 anxiety and/or panic attacks
 depression and/or feelings of hopelessness
 social isolation from giving up enjoyed activities, social events, etc.

TREATMENTS

3PD is often a result of multiple issues happening all at the same time. Your treatment plan will likely
involve multiple appointments with different health professionals. It is important to realize that your
recovery will take time and effort and patience, but that most patients DO IMPROVE or have their
symptoms resolve completely with the right treatments.

Physiotherapy

Vestibular Rehabilitation Therapy (VRT) can help re-train the brain to be less sensitive to stimuli that
make you dizzy. This is called Habituation. This kind of therapy exposes you to things that cause your
dizziness or make it worse. The idea is that repeated, brief exposures aimed at making you a little bit
dizzy will build your tolerance, so that in the future they won’t make you dizzy anymore.

You will be given a list of experienced physiotherapists who specialize in this kind of habituation therapy.
You only need to see them occasionally; you will be asked to do these exercises every day at home. You
may not see any significant improvement for weeks, perhaps even 2-3 months, but it is important to keep
doing them every day.

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Medications

Although there is no medication that “cures” 3PD you may be prescribed medications that help with some
of the symptoms. Medications such as venlafaxine (Effexor), sertraline (Zoloft), citalopram (Celexa) and
other similar medications may be prescribed to help you with your symptoms. They are antidepressants,
may work to reduce the symptoms of dizziness in 3PD. Medications are often prescribed for several
months, but eventually they can be stopped when symptoms have improved.

It is important to not take too many medications that suppress the inner ear, such as Gravol, Serc
(betahistine), or other antihistamines. This may limit the effectiveness of physiotherapy.
If you are having lots of headaches/migraines, it is important to treat these. You may be started on
lifestyle changes for headaches, along with vitamin supplements. Migraine medications may be
recommended to help with headaches, or you may be referred to a neurologist who specializes in
headaches and migraines.

Psychology

Many patients with 3PD suffer from anxiety or depression. This can result from 3PD even if you have
never suffered with these issues before. Often patients need help in managing the anxiety or behaviors
that come from negative thinking or worry about dizziness. You may be recommended to seek help from
a counsellor/psychologist for these issues. It is important to address the psychologic side of 3PD as it is
often the missing component of an otherwise successful treatment plan.

Things You Can Do

There are some lifestyle modifications you can make that might help. This includes:

 eating regular meals

 don’t limit your activities – a little bit of dizziness is ok; but do take breaks when you feel too dizzy
(i.e.: don’t overdo it, activities that require hours or a day to recover from are too much)
 sleep well and address sleep issues (you may have sleep apnea – ask your doctor)
 de-stress or manage stress (relaxing activities, meditation, etc.)
 exercise regularly (3-5x / week)

In addition, it is important to try and set small goals for yourself, and celebrate your successes when you
reach them. Don't be too disappointed with small failures either, as you will certainly have good days and
bad days. Improvements in PPPD usually occur over months, and keeping this long-term perspective in
mind is important as you journey on your own road to recovery.

Future Directions

PPPD is still a poorly understood disorder, and there is a large amount of research happening now into its
diagnosis and treatment. Some of the research is being done right here at The Ottawa Hospital. If you are
interested in taking part in research on this topic, or other topics about dizziness, please let the clinic
doctor or staff know.

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FREQUENTLY ASKED QUESTIONS

Is 3PD a psychiatric illness?

No, 3PD is not a psychiatric illness, though behavioral changes do occur as a result of 3PD. As such,
seeking help from a psychologist/counsellor is often beneficial.

Why do I have 3PD?

We do not really know why some people develop 3PD and others do not. Some research shows it is more
common in:
 women
 people with motion sensitivity
 people with headaches or migraines
 people with anxiety or depression
 those with certain types of personalities (anxious, catastrophizing, etc.).

Will I get better?

Most patients do improve or have their symptoms resolve completely if they follow the outlined
treatment plan. It is important to have patience with the treatment as it does require effort and can take
weeks or months to notice improvement. Some patients will not get rid of all their dizziness, but their
symptoms will improve a lot. Most importantly, most patients go back to having a good quality of life.

How can I be sure 3PD is what I have?

Research shows that if you have symptoms that fit the diagnostic criteria for 3PD, and you have had a
thorough clinical evaluation, that is it very unlikely that other diagnoses have been missed. Here at the
Ottawa Hospital Multidisciplinary Dizziness Clinic, we see many patients with similar symptoms and have
experience in diagnosing and managing 3PD.

Ver 2.0 – Oct 22 2018