If you’ve been feeling dizzy, unsteady or like the world is slightly “off” for months — yet medical tests keep coming back normal or don’t fully explain what you’re experiencing — you may be dealing with a condition called Persistent Postural-Perceptual Dizziness, or PPPD.
PPPD is a chronic condition that affects how your brain processes information related to balance, movement and your surroundings. It can develop after an initial episode of vertigo, an inner-ear or vestibular problem, migraine, concussion, illness or even a panic attack.
The original trigger may improve, but your brain can remain on high alert for sensations of dizziness and imbalance.
The good news? Your brain can learn a new response.
Signs You May Be Experiencing PPPD
PPPD can feel different from person to person, but you may notice:
- Feeling dizzy, unsteady, wobbly or “off” on most days
- A rocking, swaying, floating or bobbing sensation rather than the room actually spinning
- Symptoms that have persisted for three months or longer
- Feeling worse when standing or walking
- Increased dizziness when moving your head or body
- Feeling especially uncomfortable in grocery stores, crowds or other visually busy environments
- Increased symptoms while scrolling on your phone, using a computer or watching rapidly moving images
- Feeling worse while riding in a car or other moving vehicle
- Avoiding activities because you’re afraid they will make you dizzy
- Becoming increasingly focused on checking how steady or dizzy you feel
PPPD is a real vestibular condition. These symptoms are not imaginary, and PPPD is not simply another name for anxiety. But anxiety, avoidance and becoming hyperfocused on physical sensations can sometimes become part of a cycle that keeps symptoms going.
How Can CBT Help With PPPD?
Imagine that your brain has become an overly sensitive dizziness alarm.
After experiencing vertigo, dizziness or another frightening physical event, your brain understandably starts paying closer attention to balance and movement.
You may begin thinking:
“What if I get dizzy?”
“What if I fall?”
“What if something is seriously wrong?”
“What if I get dizzy while driving or out in public?”
You may then start avoiding movements, environments and activities that trigger these uncomfortable sensations.
Unfortunately, avoidance can unintentionally teach your brain:
“Good thing we avoided that. It must have been dangerous.”
CBT can help you interrupt this cycle.
Exposure Therapy: Teaching Your Brain That Dizzy Doesn’t Mean Dangerous
One CBT strategy that may be particularly helpful for PPPD is exposure therapy.
Instead of continually trying to prevent uncomfortable sensations, you gradually practice experiencing safe forms of movement, dizziness or visual stimulation.
Depending on your symptoms and medical recommendations, this might eventually include things like:
- Moving your head from side to side
- Walking while turning your head
- Spending time in a visually busy store
- Looking at patterned or moving images
- Riding in a car
- Using screens
- Practicing activities you’ve been avoiding because you’re afraid they will make you feel dizzy
The goal isn’t to make yourself miserable or push through unsafe symptoms.
The goal is to give your brain repeated opportunities to learn:
“I can experience these sensations without treating them like an emergency.”
Over time, your brain can become less reactive to sensations and environments it has learned to fear.
Who Should Be on Your PPPD Treatment Team?
CBT may be one important piece of PPPD treatment, but you don’t necessarily have to tackle PPPD with a therapist alone.
Depending on your symptoms, your care team may include:
- A physician experienced in dizziness and vestibular disorders, such as an ENT, neurotologist or neurologist, to establish the diagnosis and evaluate other possible causes of dizziness.
- A vestibular physical therapist who can provide vestibular rehabilitation therapy (VRT), using specialized exercises to help your brain and balance system adapt to movement and visual stimulation.
- A CBT therapist who understands anxiety, avoidance and exposure therapy and can help you reduce fear of symptoms, decrease safety behaviors and gradually return to activities you’ve been avoiding.
- A psychiatrist or other prescribing clinician when medication is recommended as part of treatment. SSRIs or SNRIs are sometimes used in PPPD treatment.
For many people, the most effective approach isn’t choosing between “physical” and “psychological” treatment. It’s helping your brain and body relearn how to respond to movement, balance information and uncomfortable sensations.
When Dizziness Makes Your World Smaller
One of the hardest parts of chronic dizziness is how easily your world can begin shrinking around it.
Maybe you stop going to the grocery store.
Then you avoid driving.
Then exercising feels too risky.
Then you’re carefully monitoring every movement to make sure you don’t trigger another wave of dizziness.
CBT and exposure-based treatment work in the opposite direction.
Little by little, you begin taking your life back from dizziness.
You don’t have to wait until you feel perfectly steady or symptom-free before returning to the activities that matter to you. With appropriate medical guidance and a gradual treatment plan, you can help your brain become less afraid of feeling off-balance — and more confident in your ability to handle the sensations when they show up.
If chronic dizziness or PPPD is causing anxiety, avoidance or interfering with your daily life, a CBT therapist trained in exposure-based treatment can be an important member of your treatment team.
