Understanding Persistent Postural Perceptual Dizziness (PPPD)
Why you feel dizzy even though tests are normal
If you have been told your tests and scans are clear, your inner ear has recovered, yet you still feel unsteady or “off,” you are not alone.
Persistent Postural Perceptual Dizziness, or PPPD, is a real and recognized disorder of how the brain processes balance information. It is common, treatable, and improvement is possible.
What does PPPD mean?
Let’s break down the name.
Persistent → symptoms have been present for a long time. It does not mean permanent.
Postural → symptoms are usually worse when upright or moving.
Perceptual → the brain’s interpretation of motion and balance is altered.
Dizziness → feelings of rocking, swaying, floating, heaviness, or imbalance (not usually spinning).
What is happening in PPPD?
PPPD usually starts after something happens that threatens your balance, such as:
an inner ear problem
a concussion
a panic episode
a fainting episode
or another event that made you suddenly feel unsafe in your body
Even when that original problem improves, the brain can remain in protection mode. Your system becomes extra vigilant, constantly scanning for danger. Small, normal body movements or busy visual environments are treated like threats.
The result?
The brain overestimates how much you are moving.
There is a mismatch between actual motion and perceived motion.
You feel dizzy and unsteady
An example many people understand
Imagine stepping onto an escalator you expect to be moving. Your brain predicts motion and prepares your body.
But the escalator is broken. For a moment, you lurch or feel off balance.
That happens because your prediction didn’t match reality. In PPPD, the brain keeps making these kinds of threat predictions long after the danger has passed.
Why do tests often look normal?
MRI and other investigations are important because they rule out serious disease.
But they show the brain’s hardware.
PPPD is a software problem - a change in how networks are processing and prioritizing sensory information.
This is also why people may notice:
brain fog
difficulty concentrating
fatigue
sensitivity to busy environments
Common symptom pattern
People with PPPD often notice:
symptoms are present on most days but can fluctuate in intensity
worse when upright or moving
worse in visually busy places (grocery stores, crowds, scrolling on screens)
a feeling they must carefully monitor their balance
avoiding situations that might provoke symptoms
If this sounds familiar, you are not imagining it - this is a well-described clinical pattern.
Why avoidance makes it worse
In the early stages after a dizzy event, it makes sense to slow down, be cautious, or hold onto things. That is smart and protective.
But if the brain stays in this strategy too long, it never relearns that movement is safe. It’s like your brain thinks you are permanently walking on ice.
Your posture stiffens.
Your steps get smaller.
Vision works overtime.
What was once helpful becomes counterproductive.
How we assess PPPD
Most strength, nerve, and inner ear tests are often normal. What we really look at is posture, balance behaviour, and perception.
For example, someone might rate their balance as 8/10 terrible, yet our posturography assessments that measure sway, show very little body sway.
That tells us the alarm system is louder than the actual risk.
Explaining the mechanism in simple terms
Your balance comes from three systems:
👁 vision
👂 vestibular (inner ear)
🦶 body sensation
In PPPD, the brain often:
relies too much on vision
under-uses vestibular input
increases conscious monitoring
loses the automatic control of posture
You start paying attention to sensations that normally stay filtered out. Remember - your brain is trying to protect you. It’s just being overprotective.
The good news: the brain can relearn
Because PPPD is about processing, it is also changeable. With the right approach, we can help the nervous system:
✅ reduce visual dependence
✅ normalize movement
✅ build tolerance to complex environments
✅ decrease over-monitoring
✅ restore confidence
✅ update those faulty predictions
This takes repetition, gradual exposure, and guidance.
What treatment usually involves
Evidence and expert consensus support a combination of:
vestibular rehabilitation
education about the mechanism
graded exposure to triggers
addressing stress and fear when present
treatment can also include cognitive behavioural therapy and/or treatments with SSRI/SNRI medications. This treatment is offered through our neuro-psychiatry team at the Hertz Clinic for Meniere’s Disease and Vestibular Dysfunction at TGH.
Recovery is rarely instant, but people do get better. Improvement is possible, often even full recovery. But it requires:
✨ time
✨ practice
✨ willingness to face some discomfort
✨ retraining habits the brain has built
You won’t do it alone - we guide you through it.
A message we always want patients to hear
We appreciate how much symptoms affect daily life. We want to reassure you that your symptoms are real. They are common and the result of a known mechanism. And there is a path forward.
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Staab JP. Persistent Postural-Perceptual Dizziness. Neurologic Clinics. 2023;41(4):647-664. [link]
Özdemir HN, Charlton J, Cortese E, Di Stadio A, Herdman D, Kaski D. Persistent Postural‐Perceptual Dizziness: A Practical Approach to Diagnosis and Patient Communication. Euro J of Neurology. 2026;33(2):e70494. [link]