Dizzy All The Time? — Let’s Talk About Persistent Postural-Perceptual Dizziness (PPPD)

Written By Justin Martin, PT, DPT

Does Your Dizziness Just Not Go Away?

If you've been dealing with persistent dizziness, unsteadiness, or a vague sense of imbalance for months—and it seems to get worse when you're moving around, or in busy visual environments like grocery stores—you may have a condition called Persistent Postural-Perceptual Dizziness, or PPPD. As a vestibular therapist, I often work with patients who have this condition, and I want to help you understand what's happening and what we can do about it.

What Is PPPD?

PPPD (pronounced “three-P-D” or "triple-P-D") is a chronic, but treatable, vestibular disorder that was officially defined by the international medical community in 2017. It's actually the most common cause of chronic dizziness symptoms.

The key features of PPPD are:

  • Dizziness, unsteadiness, or non-spinning vertigo present on most days for at least 3 months

  • Symptoms that last for hours at a time (though they wax and wane throughout the day)

  • Symptoms that get worse with three specific triggers: standing upright, moving around (or being moved, like in a car), and being in environments with lots of visual motion or complex patterns

Who Gets PPPD?

PPPD affects people of all ages but is most common in adults in their 40s to 60s, with about twice as many women affected as men. It's estimated that PPPD accounts for about 20% of all patients seen for dizziness.

How Does PPPD Start?

Almost everyone with PPPD can point to something that triggered it. Common triggers include:

  • Inner ear problems like BPPV (benign paroxysmal positional vertigo) or vestibular neuritis

  • Vestibular migraine

  • Panic attacks or periods of significant anxiety

  • Mild head injuries or concussions

  • Other medical conditions that caused dizziness or imbalance

Here's what typically happens: You experience an acute episode of vertigo or dizziness from one of these triggers. Your brain naturally responds by becoming more vigilant about balance and more cautious in how you move. For most people, once the original problem resolves, the brain relaxes and returns to normal. But in PPPD, the brain gets "stuck" in this high-alert, protective mode, even after the original trigger has healed.

What's Happening in Your Brain?

PPPD is what we call a "functional" vestibular disorder. This doesn't mean your symptoms aren't real—they absolutely are. It means that the problem isn't structural damage to your inner ear or brain, but rather how your brain is processing balance information — I see this as a good thing.

Research has shown several things happen in PPPD:

  • Visual dependence: Your brain starts relying too heavily on vision for balance, which is why busy visual environments are so challenging

  • Stiffened posture: You unconsciously adopt a more rigid stance and shorter steps to feel more stable

  • Heightened body awareness: You become hyper-aware of every sensation related to balance

  • Altered motion perception: Your brain becomes overly sensitive to detecting motion, even very small movements

Think of it like a smoke detector that's overly sensitive… it starts going off even when there's no fire. To take the analogy one step further, lets say the alarm going off has now made the people living in the house even more worried about fires… so, worried about the danger, they make the detector even more sensitive. This is what happens in PPPD, as our motion detectors become overly sensitized, we begin to associate movement with dizziness/“danger”, and the sensitivity increases to protect us—that is, until we break down that cycle both physically and emotionally.

What PPPD Is NOT

Let me clear up some common misconceptions:

  • PPPD is not "all in your head" or imaginary

  • PPPD is not a psychiatric disorder, though anxiety can be a trigger and often accompanies it

  • PPPD is not caused by ongoing damage to your inner ear

  • PPPD does not mean you're going crazy or doomed for good.

How Is PPPD Diagnosed?

PPPD is diagnosed based on your symptoms and history—there's no blood test or scan that shows it. In fact, standard vestibular testing (like hearing tests and balance tests) is often normal in PPPD, or may show findings from a previous vestibular problem that has since healed.

Your doctor will want to rule out other conditions that could cause similar symptoms, but the diagnosis is made by recognizing the characteristic pattern of symptoms.

How Is PPPD Treated?

The good news is that PPPD responds well to treatment. The best results come from a combination approach:

1. Vestibular Rehabilitation Therapy (VRT)

This is where I come in as your vestibular therapist. VRT for PPPD is different from traditional vestibular exercises—we need to adapt our approach specifically for this condition.

The goals of therapy include:

  • Gradually exposing you to movements and environments that trigger symptoms (in a controlled, progressive way)

  • Retraining your brain to rely less on vision and more on your vestibular and body-position senses

  • Reducing the stiffness in your posture and helping you move more naturally

  • Building your confidence in movement

Studies show that vestibular rehabilitation significantly improves dizziness, quality of life, and even anxiety levels in those with PPPD. Improvements can be seen within 4-5 weeks and are maintained over time.

2. Medications

Certain medications can help reduce PPPD symptoms:

  • SSRIs (like sertraline, escitalopram, or paroxetine) are the most commonly used medications

  • SNRIs (like venlafaxine or duloxetine) are another option

These medications work on serotonin pathways in the brain that affect both mood and balance processing. Studies show response rates of around 65% with these medications. They're typically started at low doses and increased gradually.

Important: Traditional "dizziness medications" like meclizine are NOT helpful for PPPD and may actually slow your recovery.

3. Cognitive Behavioral Therapy (CBT)

CBT can be very helpful, especially if anxiety is a significant part of your presentation. It helps you:

  • Identify and change unhelpful thought patterns about your symptoms

  • Reduce avoidance behaviors

  • Manage the anxiety that often accompanies chronic dizziness

Research shows that combining vestibular rehabilitation, medication, and CBT produces better results than any single treatment alone.

What Can You Do Right Now?

While you're working with your healthcare team, here are some things that can help:

  • Keep moving: Avoiding activity makes PPPD worse. Gentle, regular movement is important

  • Don't avoid triggers completely: Gradual, controlled exposure to challenging situations helps your brain recalibrate

  • Manage stress: Stress and fatigue typically worsen symptoms

  • Be patient: Recovery takes time—usually months, not weeks

  • Stay hopeful: Most people with PPPD improve significantly with proper treatment

What's the Outlook?

PPPD is treatable. While it can be a frustrating condition that takes time to improve, the majority of patients see meaningful improvement with the right combination of therapies. Some people recover completely; others have significant reduction in symptoms that allows them to return to normal activities.

The key is getting the right diagnosis and the right treatment. If you've been told your tests are "normal" but you're still struggling with chronic dizziness, ask your doctor about PPPD.

A Final Thought

Living with chronic dizziness is physically and emotionally exhausting. If you're reading this and recognizing yourself, please know that what you're experiencing is real, you’re not alone, it has a name, and there are effective treatments. You don't have to just "live with it” which unfortunately remains a common belief.

As a vestibular therapist, one of the most rewarding parts of my job is watching patients with PPPD gradually regain their confidence and return to the activities they love. With the right approach and some patience, that can be you too.

At StillPoint Balance & Dizziness, we specialize in helping people in Austin and across Texas understand and recover from conditions like PPPD through personalized, thoughtful vestibular care. Take the first step toward feeling better by scheduling a free consultation.

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This information is intended for educational purposes and should not replace medical evaluation or diagnosis. If you are experiencing new or severe dizziness, consult a qualified healthcare professional.

Justin Martin, PT, DPT

Justin Martin is a vestibular physical therapist and the founder of StillPoint Balance & Dizziness in Austin, Texas. He specializes in the evaluation and treatment of vertigo, dizziness, and balance disorders, helping people regain stability, confidence, and comfort in their daily lives.

Justin is known for his patient, thoughtful approach to care. He takes time to carefully listen to each patient’s experience, identify the underlying causes of dizziness, and create individualized treatment plans that support lasting recovery. His work focuses on combining evidence-based vestibular rehabilitation with tailored education so patients understand what is happening in their bodies and how to move forward with confidence.

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