What is the recommended treatment for persistent perceptual postural dizziness?

Treatment of Persistent Perceptual Postural Dizziness (PPPD)

The most effective treatment for persistent perceptual postural dizziness (PPPD) is a combination of vestibular rehabilitation therapy (VRT) with cognitive-behavioral therapy (CBT), potentially augmented with serotonergic medications. 1, 2

Understanding PPPD

PPPD is a functional vestibular disorder characterized by:

• Persistent dizziness or unsteadiness occurring on most days for more than 3 months
• Symptoms exacerbated by upright posture, active or passive motion, and visual stimuli
• Often develops following a triggering event (vestibular disorder, medical condition, or psychological stressor)

Treatment Approach

First-Line Treatment: Vestibular Rehabilitation Therapy (VRT)

VRT has been shown to significantly improve quality of life, dizziness handicap, depression, and anxiety levels within 3 months in PPPD patients 3. The effectiveness of VRT includes:

• Home-based VRT programs are as effective as hospital-based programs 3
• Customized VRT exercises targeting specific symptoms
• Habituation exercises to reduce sensitivity to movement and visual stimuli
• Balance retraining to improve postural control
• Gaze stabilization exercises

VRT should be personalized to address the specific triggers and symptoms of the individual patient, with gradual progression in exercise difficulty 4.

Second-Line Treatment: Cognitive-Behavioral Therapy (CBT)

CBT should be integrated with VRT for optimal outcomes 1, 2. The INVEST trial demonstrated promising benefits of CBT-informed vestibular rehabilitation compared to standard VRT alone 2. CBT components include:

• Addressing maladaptive thoughts and behaviors related to dizziness
• Reducing symptom hypervigilance and catastrophizing
• Exposure therapy to feared movements or environments
• Anxiety management techniques
• Behavioral activation to reduce avoidance behaviors

Pharmacological Treatment

Serotonergic medications may facilitate rehabilitation in PPPD 1, although evidence level is low:

• Selective Serotonin Reuptake Inhibitors (SSRIs)
• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
• Start with low doses and gradually increase to minimize side effects
• Allow 4-6 weeks for therapeutic effect

Treatment Algorithm

1. Initial Phase (Weeks 1-4):

   • Begin customized VRT program focusing on habituation exercises
   • Introduce basic CBT concepts to address anxiety and avoidance behaviors
   • Consider starting low-dose SSRI if significant anxiety/depression present

2. Intermediate Phase (Weeks 5-8):

   • Progress VRT exercises in complexity and duration
   • Intensify CBT interventions focusing on exposure therapy
   • Adjust medication dosage if needed

3. Advanced Phase (Weeks 9-12):

   • Challenge patient with more complex VRT exercises
   • Focus CBT on relapse prevention strategies
   • Assess medication effectiveness and continue if beneficial

Monitoring Treatment Response

Evaluate treatment effectiveness using validated assessment tools:

• Dizziness Handicap Inventory (DHI)
• Depression, Anxiety and Stress Scale (DASS-21)
• Quality of life measures (EQ-5D)

Important Considerations and Pitfalls

• Rule out organic causes: Before diagnosing PPPD, ensure thorough evaluation to exclude central vertigo or other neurological disorders 5
• Treatment resistance factors: Patients with longer duration of PPPD, complex aggravating factors, and higher initial DHI scores may have poorer response to VRT 4
• Recurrence risk: Similar to BPPV, PPPD may have recurrences requiring ongoing management strategies 5
• Elderly patients: May require modified approaches with gentler progression of exercises and careful medication management 5

Patient Education

Patient education is crucial for treatment success:

• Explain the functional nature of PPPD without dismissing symptoms
• Emphasize that PPPD is a real condition with effective treatments
• Set realistic expectations about treatment timeline (typically 3 months)
• Encourage adherence to home exercises and CBT techniques

By implementing this comprehensive approach, most patients with PPPD can experience significant improvement in symptoms and quality of life.