A Cognitive-Behavioral Model of Persistent Postural-Perceptual Dizziness

Persistent postural-perceptual dizziness (PPPD; previously termed "chronic subjective dizziness") is a frequently observed disorder in patients who present with dizziness to audiology; ear, nose, and throat; or neurology clinics. The primary symptoms are persistent nonvertiginous dizziness, and hypersensitivity to motion and visual stimuli. These occur either in the absence of any active neuro-otologic illness or, where an episodic vestibular disorder exists, symptoms cannot be fully explained by the disorder alone. Diagnosis is necessarily multidisciplinary and proceeds by identification of primary symptoms and exclusion of other neurological or active medical disorders requiring treatment. Psychological processes are implicated in the development and maintenance of PPPD, with similarities to cognitive models of health anxiety and panic disorder, and there is evidence that cognitive-behavioral therapy is an effective treatment. A cognitive-behavioral model of PPPD is presented along with a case example. It is suggested that dizziness becomes persistent when it is processed as a threat, and that it is maintained by (a) unhelpful appraisals, (b) avoidance and safety behaviors, and (c) attentional strategies including selective attention to body sensations associated with dizziness. Once PPPD is identified techniques for its effective treatment fall within the skills mix of qualified cognitive-behavioral therapists or vestibular clinical scientists who have received additional training in cognitive and behavioral treatment.