Persistent Postural-Perceptual Dizziness: The Dizziness That Normal Scans Miss—Vestibular Rehab Roadmap

Persistent Postural-Perceptual Dizziness is a chronic functional vestibular disorder defined by an international Bárány Society consensus in 2017. It causes non-spinning dizziness, swaying or rocking unsteadiness, and a persistent “off-balance” feeling on most days for at least three months. Symptoms classically worsen with three triggers: upright posture, active or passive motion, and moving or complex visual scenes such as supermarket aisles, scrolling screens, patterned floors, or busy traffic. It often begins after an acute vestibular or medical event (for example, vestibular neuritis, benign paroxysmal positional vertigo, vestibular migraine, concussion, panic attack, or illness) and then persists after the original problem settles. ^[1]

Persistent Postural-Perceptual Dizziness is also recognized in ICD-11 as a chronic vestibular syndrome with these hallmark features—persistent non-vertiginous dizziness that is aggravated by upright stance, movement, and visual motion. ^[2]

The big picture: in Persistent Postural-Perceptual Dizziness the hardware (inner ears and structural brain scans) is usually normal, but the software—how the brain weights and integrates visual, vestibular, and proprioceptive inputs—has shifted into a high-alert, visually dependent mode. Mechanistic work shows heightened visual motion sensitivity and altered motion perception, which explains why certain stores, escalators, patterned floors, and screens feel intolerable. ^[3]

• A steady sense of rocking or swaying, often worse later in the day.
• Visual motion sensitivity: aisles, escalators, scrolling, ceiling fans, traffic.
• Worse when upright (standing in lines is harder than lying down).
• Anxiety or hypervigilance around dizziness after a scary vertigo spell.
• A frustrating pattern of normal scans but very real instability and fatigue.

These are core features summarized in consensus criteria and patient-facing medical resources. ^[1]

This is a clinical diagnosis. Clinicians confirm the Bárány Society criteria:

1. Dizziness, unsteadiness, or non-spinning vertigo on most days for ≥3 months.
2. Symptoms worsen with upright posture, movement, and visual motion.
3. Often precipitated by a balance-disrupting event.
4. Causes distress or functional impairment.
5. Not better explained by another disorder. ^[1]

Imaging and routine vestibular tests are frequently normal. The goal of testing is to exclude other diagnoses; once red flags are ruled out, more scans rarely change management. The focus shifts to rehabilitation and retraining rather than repeating imaging. ^[4]

After the initial trigger, the brain often over-weights visual cues and under-uses inner-ear and body cues. This sensory reweighting combines with postural hypervigilance and avoidance of triggering environments. Avoidance reduces short-term discomfort but reinforces the belief that normal motion and visuals are dangerous—keeping the loop alive. Contemporary research documents visual dependence and increased motion sensitivity as key pieces of the puzzle, which is exactly what vestibular rehabilitation and graded exposure are designed to reverse. ^[3]

Evidence syntheses and clinical series show meaningful reductions in Dizziness Handicap Inventory scores and improvements in balance with vestibular rehabilitation tailored to Persistent Postural-Perceptual Dizziness, though protocols must be individualized and research is still evolving. ^[5]

Goals: reduce baseline hypervigilance, map triggers, begin safe exposure.

• Education about the diagnosis reduces threat perception and paradoxically lowers symptoms. Keep a simple diary—what triggered, where, how long, and how quickly you recovered. ^[4]
• Breathing and stance reset: diaphragmatic breathing; relaxed jaw and shoulders; quiet standing with a wider base to reduce unnecessary muscle co-contraction.
• Static balance with reduced vision: feet apart → together → semi-tandem; eyes open → eyes closed.
• Micro-doses of visual motion: 15–30 seconds of controlled exposure (for example, a moving dot or slow scroll), then a recovery period. The rule is symptoms allowed, not overwhelmed. The target is visual-motion desensitization, not “pushing through” to exhaustion. ^[3]

Goals: introduce head–eye tasks, add walking challenges, step into low-complexity environments.

• Gaze-stabilization and head-motion drills seated, then standing: fix gaze on a letter while turning the head gently side-to-side or up-down, keeping the letter clear.
• Walking with head turns and dual-tasking (for example, counting by twos) to mimic real life.
• Exposure hierarchy: short, off-peak visits to a grocery aisle; a quiet escalator ride; brief scrolling sessions—increase duration by 10–20% only if you return to baseline within an hour.
• Strength and posture: hip and trunk conditioning to support balance; gradual challenges on compliant or uneven surfaces. Real-world and self-management studies show benefit, with therapist guidance helping to fine-tune form and progression. ^[7]

Goals: reduce avoidance, normalize daily function, refine recovery skills.

• Crowd and pattern challenges: busier aisles, patterned flooring, open-plan offices, city crosswalks—entered briefly and exited while still in control.
• Transport drills: short public-transport rides or passenger car trips paired with recovery strategies (breath pacing, focusing on stable visual anchors).
• Return-to-work plan: graded screen time and meetings; use frequent visual breaks to prevent wind-up.

Across phases, therapists titrate intensity so symptoms rise modestly (for example, 2–4 out of 10) and settle within 60 minutes. If recovery is slower, scale back and progress more gradually. Meta-analytic and controlled studies report clinically important Dizziness Handicap Inventory improvements after vestibular rehabilitation, but heterogeneity is high—another reason to personalize the plan. ^[5]

Because Persistent Postural-Perceptual Dizziness embeds a threat-anticipation loop, adding cognitive behavior therapy to rehabilitation can enhance outcomes. A randomized trial showed that sertraline plus cognitive behavior therapy reduced symptoms more than sertraline alone. Broader analyses indicate that cognitive behavior therapy in addition to conventional therapy improves results for many patients. In practice this means reframing flares as safe but sensitized responses, using graded exposure scripts, and reducing safety behaviors (for example, gripping rails or shopping carts) that keep the loop going. ^[6]

There is no single “pill for Persistent Postural-Perceptual Dizziness.” However, medications can lower background arousal and visual dependence enough to make rehabilitation doable.

• Selective serotonin reuptake inhibitors and serotonin–norepinephrine reuptake inhibitors have the best evidence in Persistent Postural-Perceptual Dizziness and its precursor constructs (such as chronic subjective dizziness). They are most effective alongside cognitive behavior therapy and vestibular rehabilitation. ^[8]
• Short-term anxiolytics are generally not first-line because they may impair vestibular compensation.

Cleveland Clinic and other specialty centers emphasize combined care: education, rehabilitation, psychological strategies, and medication only when needed to enable retraining—not as a substitute for it. ^[4]

Most people improve over weeks to months with a combined plan. Three concrete markers:

1. Faster recovery after exposures (from half a day down to under an hour).
2. Expanded environments tolerated (for example, a full grocery trip instead of one aisle).
3. Objective scores (Dizziness Handicap Inventory) trending down; this patient-reported tool is widely used to quantify change. ^[9]

Plateaus are common; they usually respond to adjusting the hierarchy, varying tasks, or layering in cognitive behavior therapy elements.

• Flooding yourself in busy environments. One-hour “heroic” supermarket sessions often backfire. Graded exposure with quick exits works better and is aligned with desensitization principles in vestibular rehabilitation studies. ^[10]
• Relying only on rest. Avoidance reduces short-term distress but maintains visual dependence. Consensus guidance and patient resources underscore structured re-entry and movement, not bed rest, once serious causes are ruled out. ^[1]
• Chasing more scans. After red flags are excluded, repeating normal imaging rarely advances care. Focus energy on retraining the system. ^[4]
• Skimping on sleep, hydration, and meals. Physiologic stress intensifies visual sensitivity; steadier routines improve rehabilitation “stickiness.”

• Benign paroxysmal positional vertigo causes brief spinning with certain head positions and is treated with canalith repositioning maneuvers. Persistent Postural-Perceptual Dizziness is non-spinning, persistent, and visually aggravated.
• Vestibular migraine can coexist with Persistent Postural-Perceptual Dizziness; treat migraine attacks, while still doing rehabilitation for visual dependence and postural hypervigilance.
• Orthostatic dizziness relates to blood pressure changes on standing—check orthostatic vitals.

Distinguishing these prevents misdirected therapies and helps the team apply the right roadmap—vestibular rehabilitation tailored to Persistent Postural-Perceptual Dizziness. ^[1]

1. Name it: Read a one-page summary of the Bárány Society criteria so the pattern feels less mysterious and threatening. ^[11]
2. Build an exposure ladder: choose five to seven situations (scrolling, a single aisle, a short escalator ride, a quiet crosswalk) and rank by difficulty.
3. Dose exposures: start with 30 seconds or one aisle, recover, repeat three to five times; increase by 10–20% if you rebound within an hour.
4. Daily gaze and head-motion drills: two to three sets of 30–60 seconds, seated then standing.
5. Track wins: log time-to-recovery and Dizziness Handicap Inventory every two weeks—these show change reliably in research and clinic. ^[9]
6. Call in cognitive behavior therapy if fear or avoidance dominate; discuss selective serotonin reuptake inhibitors or serotonin–norepinephrine reuptake inhibitors if progress stalls despite solid rehabilitation—combined care has supporting evidence. ^[6]

• The precipitating event (for example, vestibular neuritis, concussion, vestibular migraine, panic, illness).
• The three-trigger pattern (upright posture, motion, visual motion) and duration ≥3 months.
• Functional impact (work, commuting, shopping).
• Objective metrics (Dizziness Handicap Inventory scores; posturography when available).
• The rehabilitation program (frequency, hierarchies, progression rules).
• Adjuncts (cognitive behavior therapy, medication) and scheduled reassessments.

This structure mirrors consensus criteria and helps align the team on goals and expectations. ^[1]

Educational content only. If you develop red-flag symptoms—sudden hearing loss, new neurological deficits, severe headache, chest pain, or fainting—seek urgent evaluation. For persistent non-spinning dizziness that worsens in busy visual environments after an illness or vertigo episode, ask your clinician about Persistent Postural-Perceptual Dizziness and a vestibular rehabilitation plan tailored to your triggers.