Persistent Postural Perception Dizziness (PPPD)

Today we're going to talk about a very strange condition which is PPPD. It stands for persistent, which means it has to be chronic. It's generally greater than three months in the duration or more, and it is a postural problem. What that means is they feel like they're gonna fall down, so they have postural sway, and that might be interpreted to the patient as vertigo or dizziness. That means they're gonna end up with the vestibular workup, both peripheral and central. Their vertigo in PPPD is usually nonrotational, which means they just feel like they're moving but they don't actually have the subjective illusory sensation of rotation. It's a perception disorder because there's no structural lesion, and as opposed to peripheral and central vestibulopathies where there's actually a sign, there's no sign here. So there's no peripheral finding, there's no nystagmus, there's no Dix-Hallpike maneuver positivity, there's no other neurologic focal sign, and it causes dizziness, and that normally does not come to me. Normally that goes ENT, but the reason you need to know it is one of the precipitants of persistent postural perceptional perception dizziness is the visual stimuli. So they have some sort of mismatch between the vision stimuli and the vestibular stimuli, and when you have that mismatch you'll get the perception of dizziness. You can watch the visual variant vertigo video if you want to see what that looks like in terms of just the vision symptoms, but this is one step further than just having the vertigo. Their posture isn't right, so they feel like they're gonna fall down all the time, and so the patients have very specific complaints. The effect is triggered by visual stimuli, so usually it's motion in their environment. It can be "I'm watching a television show and someone's dancing", that can precipitate it, or even walking in the supermarket because they are going down the aisles and the canned food is kind of just inducing a full field optokinetic nystagmus response, or driving. So the differentiating features are you can't have any peripheral vestibulopathy finding, and that means it's not positional. So it's not a "position of their head" problem, like benign positional paroxysmal vertigo, it's posture is the symptom, not the symptom caused by the posture. The other interesting thing is they're gonna have a negative workup, so ENT is gonna do their usual things: Dix-Hallpike maneuver, rotary chair, calorics, ENG; all that's going to be negative. Neurology is going to see the patient, and there's not going to be any focal finding, and they're going to do an MRI scan and an EEG and a lumbar puncture and a whole bunch of labs; all going to be negative. So this is going to come to the eye doctor, and the eye doctor is not going to find any nystagmus. So as opposed to peripheral and central vestibulopathy-related nystagmus, which is also its own talk and it's on video, this is going to have a normal exam. The whole thing is just talking to the person. They have dizziness that affects their posture precipitated by looking at visual motion. This is the key criteria for diagnosing a persistent postural perception dizziness. There's not going to be any sign, it's just you talking to the patient, but it's a very classic description: motion in my environment triggers my perception of posture to be altered; I have subjective nonrotational vertigo; I feel dizzy; and I've seen ENT, neurology, had an MRI, EEG, lumbar puncture and a million labs; and nothing was found. This is the diagnosis of persistent postural perception disorder relating to dizziness.