Three treatments have evidence in persistent postural-perceptual dizziness: vestibular rehabilitation designed for habituation and visual desensitization rather than for compensation of a peripheral deficit, serotonergic antidepressants such as selective serotonin reuptake inhibitors or serotonin-noradrenaline reuptake inhibitors given irrespective of whether depression is present, and cognitive behavioural therapy targeting hypervigilance and avoidance. Combining them is standard practice, and each addresses a different perpetuating factor.
Equally important is what to remove. Vestibular suppressants such as prochlorperazine, cinnarizine and betahistine used chronically prevent central habituation, cause drowsiness and can produce drug-induced parkinsonism, and advising avoidance of visually complex environments reinforces the maladaptive visual dependence and postural over-control that sustain the disorder. Graded exposure is the therapeutic principle. His secondary functional gait disorder is common in this setting and will also respond to the same combination of attention retraining and graded activity.
On the ABPN blueprint this item maps to the Treatment and management axis, because it tests choosing and sequencing therapy while withdrawing harmful medication. Patients with functional disorders are often unusually sensitive to drug side effects, so antidepressants should be started at low dose and increased slowly with an explicit explanation of why they are being used.
Incorrect Answers
- A. Regular vestibular suppressants block central habituation and avoidance reinforces visual dependence, so this plan would worsen the disorder.
- B. His positional vertigo has already resolved and repeating repositioning manoeuvres treats a condition that is no longer present.
- C. Ablative therapy is used for intractable Meniere disease with documented unilateral hydrops, and would be harmful in a patient with normal vestibular function.
- D. Persistent postural-perceptual dizziness is treatable, and a negative "nothing can be done" explanation predicts poorer outcome.
Testing Pearls
- Serotonergic antidepressants help persistent postural-perceptual dizziness regardless of mood.
- Vestibular rehabilitation should target habituation and visual desensitization, not compensation.
- Chronic vestibular suppressants block habituation and should be withdrawn.
- Avoidance of visually busy environments perpetuates the disorder; graded exposure is therapeutic.
- Patients with functional disorders often need low starting doses because of nocebo sensitivity.
References
- Jankovic J, Mazziotta JC, Newman NJ, Pomeroy SL, editors. Bradley and Daroff's Neurology in Clinical Practice. 8th ed. Philadelphia, PA: Elsevier; 2022. p. 2084.
- Popkirov S, Staab JP, Stone J. Persistent postural-perceptual dizziness (PPPD): a common, characteristic and treatable cause of chronic dizziness. Pract Neurol. 2018;18(1):5-13.
- Staab JP, Eckhardt-Henn A, Horii A, Jacob R, Strupp M, Brandt T, et al. Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): consensus document of the Committee for the Classification of Vestibular Disorders of the Barany Society. J Vestib Res. 2017;27(4):191-208.
