Understanding and Treating Chronic Dizziness (PPPD)

If you have chronic dizziness but no known structural damage to your brain or inner ear, your dizziness may not be related to biological damage, but rather to the mind's learned response to trauma.

Neural circuit dizziness, also called Persistent Postural-Perceptual Dizziness (PPPD), is a form of phobic vertigo which occurs when the brain is stuck in a state of hypervigilance, and exhibits an anxiety response disproportionate to the environmental stimulus [1]. 

As a consequence of a stressor in the past (e.g. an episode of vertigo, a panic attack, or a whiplash injury) which precipitated dizziness, the mind - faced with some familiarly frightening circumstance - is unable to use its top-down circuits to override the bottom-up fear response mounted by the brain's primal anxiety centers.

Independent of professional assessment, one way to assess whether your dizziness falls into this category is to ask yourself the following question:  

Do I get dizzy just thinking about something stressful? 

Think of a difficult person you have to deal with every day. Think of going to the shopping mall and walking the aisles with all the visual stimuli there. Think of something scary or triggering. Does your dizziness immediately get worse? 

If so, it’s very likely that your brain reacts inappropriately to the present situation because of the way it was “wired” in the past. 

Fortunately, this type of dizziness can be managed and even reversed using behavioural techniques which leverage neuroplasticity, the brain’s ability to change its structure and electrical circuits in response to experience. 

My Experience 

I have had chronic fatigue and dizziness for years, and over time, I have noticed that some activities trigger my dizziness more than others. For example, just thinking about going to any crowded place will make it worse. Shopping malls, in particular, are a major trigger.

The moment I walk through that sliding door (actually, even before it) and look at the aisles full of bright flashy wrappings, I immediately feel faint.

In other words, my brain learned an association some time in the past between intense visual stimuli and dizziness. Even though the primary cause of my dizziness has improved significantly, my brain can still get stuck in the danger mode, and reactivate those circuits.  

But thanks to neuroplasticity, it can be reprogrammed!  

How to Manage an Episode

Since Persistent Postural-Perceptual Dizziness (PPPD) is not caused by physical damage to the brain or inner ear but by our psychology becoming hyper-alert, we can significantly lessen the sensation of dizziness by monitoring our self-talk, telling our brain that there is no danger.  

Here's a protocol to implement whenever a situation is triggering your dizziness: 

1. Notice your body tensing up, constricting as if wanting to push away this sensation away.
2. Instead of pushing the sensation away, intentionally relax into it. Welcome it, saying: “Welcome, dizziness. I will not fight you or push you away. I will allow you to be. I will not resist.” 
3. Trust your body to fix the balance by itself. 
4. “Allow” yourself to feel what you feel (in my case, I often allow myself even to be pulled to one direction). 
5. As you relax into the feeling, you will be surprised how quickly your symptoms start lessening in intensity.

Why Does This Work? 

As soon as we stop resisting, the anxious part of our mind gets the signal from the body that it is not in danger, and there's no need to escalate our symptoms.

Sometimes, when an episode is emerging, I tell myself: "You are a surfer. Feel those waves coming over you. Go up and down with the waves – play with it.”  

The effect is almost immediate. With relaxation, the dizziness fades, and my balance improves. The brain starts trusting the body to do what it’s supposed to do – maintain the balance automatically. 

The more frequently we are able to short-circuit this fear-induced dizziness response, the less likely it is to kick in moving forward.

Don't Hesitate to Seek Professional Help

If this protocol doesn't work for you, you may benefit from performing lower level vestibular exercises, promoting habituation and graded exposure to the types of stimuli that you find triggering [2]. 

There is also strong evidence that structured cognitive behavioral therapy is effective at treating PPPD. If you can't get over it on your own, don't hesitate to seek professional help [3].

Here's a useful summary video describing PPPD: 

References 

[1] Popkirov, S., Staab, J. P., & Stone, J. (2018). Persistent postural-perceptual dizziness (PPPD): a common, characteristic and treatable cause of chronic dizziness. Practical neurology, 18(1), 5-13.

[2] Whitney, S. L., Alghwiri, A. A., & Alghadir, A. (2016). An overview of vestibular rehabilitation. Handbook of clinical neurology, 137, 187-205.

[3] Mahoney, A. E., Edelman, S., & Cremer, P. D. (2013). Cognitive behavior therapy for chronic subjective dizziness: longer-term gains and predictors of disability. American journal of otolaryngology, 34(2), 115-120.