Persistent Postural Perceptual Dizziness (3PD)

Question 1

FND Spectrum of disorders

Answer 1

• Functional movement disorders (FMD)
• Complex regional pain syndrome (CRPS)
• Persistent postural perceptual dizziness (3PD)
• Functional seizures
• Functional cognitive disorders
• Persistent post-concussion symptoms (PPCS)

Question 2

What is 3PD

Answer 2

• Falls under the chronic vestibular syndrome
• High predisposing to those who have anxiety or panic disorder
• Precipitants: psychological distress, vestibular, other medical
• Comorbidity: anxiety, phobia, depression
• Predisposing factors: neurotic temperament, preexisting anxiety

Question 3

Pathophysiologic processes in the development of PPPD

Answer 3

• Precipitants: vestibular crisis, medical event, acute anxiety
• Acute adaptation: visual-somatosensory dependence, high-risk postural control strategies, environmental vigilance
• Recovery: neurologic, medical, behavioral
• Failure of re-adaptation: provoking factors include -> upright posture, motion of self (active/passive), visual stimuli (complex/moving)

Question 4

Diagnostic criteria for 3PD

Answer 4

• Duration: 3 months
• Provoking factors: exposures to complex visual motion demands or environments, active/passive head motion w/o directional preponderance, postural relationship (most severe when walking/standing)
• Primary Sx: vague dizziness or non spinning vertigo “walking on ice”, vague unsteadiness
• Tempo: persistent, prolonged (h
• Examination: normal physical exam, normal vestibular testing, normal MRI

Question 5

Main clinical characteristics of 3PD

Answer 5

• Persisting subjective non-rotational vertigo or dizziness
• Hypersensitivity to motion stimuli: pt’s own movement or motion of objects in the visual surround
• Difficulties with precision visual tasks
• Typically have normal values in clinical balance tests
• Some pts may develop 2ndy functional gait disorder with slow or hesitant gait or “walking on ice”
• Objective tests to prove the diagnosis of 3PD do NOT exist

Question 6

Describe visual discomfort for 3PD patients

Answer 6

• Those with 3PD report higher visual discomfort to images that deviate from natural spectra (busy images)
• Images that produce high discomfort tend to share similarities with the types of challenging, highly cluttered environments that trigger 3PD symptoms

Question 7

What is the visual vertigo analogue scale

Answer 7

• Patient rates how severe their symptoms are for each stimuli
• Used to help decide treatment plan/strategy

Question 8

Outcomes for 3PD to guide treatment

Answer 8

• Visual vertigo analogue scale
• Situational vertigo questionnaire
• Patient specific functional scale + fear avoidance

Question 9

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Question 10

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Question 11

Presentation of symptoms for 3PD

Answer 11

• Typically pts don’t experience symptom-free intervals but rather transition from acute to chronic symptoms
• For episodic pts 3PD symptoms may remit & then return with recurrences of the triggering condition before settling into a persistent pattern
• 3PD often follows an acute vestibular disorder: ~3/4 of individuals w/ longstanding 3PD have co-existing anxiety or depressive symptoms

Question 12

Common clinical exam findings for 3PD

Answer 12

• Normal but symptomatic oculomotor testing
• Head impulse & postural vestibular testing normal but symptomatic
• Abnormal & usually severe motion sensitivity
• Overall integrity of postural control w/ weight shifts, single leg, & tandem balance, unless showing some co-morbid functional overlay
• Presence of safety behaviors: frequent touching walls, avoidance of unsupported standing/walking

Question 13

Red flags that are NOT 3PD

Answer 13

• Indistinct onset (possible but not common): early in the course of progressive neurotologic disease, generalized anxiety disorder & dyautonomias may present this way
• Progressive symptoms (slowly worsening over years): neurodegenerative disorder, peripheral neuropathy, progressive vestibular loss, cerebellar degeneration, Parkinson’s disease
• Falls (gait disturbance is not part of 3PD): peripheral/central neurotologic disorder, cardiovascular/autonomic disorder, functional gait disorder
• Constant symptoms (regardless or provocative factors): often with other physical complaints, somatic symptom disorder

Question 14

Treatment options for 3PD

Answer 14

• Medications from the classes of selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs)
• Habituation exercise: chronic hypersensitivity to motion stimuli & visual complexity that are core symptoms of 3PD indicate the need for a habituation/desensitization approach

Question 15

Habituation for 3PD

Answer 15

• Carried out in a graded fashion to motions that increase symptoms
• here motions may be head/body motions or movement of objects in the environment
• The effect of habituation tends to be specific to the motion executed so exercises are specific to motions that aggravate symptoms

Question 16

Habituation versus compensation for 3PD

Answer 16

• Habituation exercises are more appropriate for 3PD than compensation exercises
• Most individuals with 3PD do NOT have vestibular deficits
• Majority of those w/laboratory abnormalities show adequate compensation for deficits in basic oculomotor & postural control reflexes despite their ongoing Sx
• X1/X2 viewing exercises may be appropriate for pts whose Sx are triggered by rapid head movements (HABITUATION)

Question 17

Treatment recommendations for 3PD

Answer 17

• Give pts the diagnostic name & explain that it is well-known, common & potentially treatable cause of chronic dizziness
• Vestibular rehab: to desensitize the vestibular & balance system
• Medications: may alter the tone of interactions among vestibular, visual, & threat systems in the brain
• Psychological therapy: cognitive behavioral ‘reprogramming’ to reduce heightened vigilance about dizziness & lessen worry/demoralization about its consequences
• TEAM APPROACH

Question 18

Outcome measure for anxiety

Answer 18

• Generalized Anxiety Disorder (GAD-7) Item Scale
• Cutoff of ≥10 for identifying generalized anxiety disorder
• 0-5 = mild
• 6-10 = moderate
• 11-15 = moderately severe anxiety
• 15-21 = severe anxiety

Question 19

What is the dizziness handicap inventory

Answer 19

• Measurement of psychiatric symptoms
• Items include: bc of your problem are you depressed?, bc of your problem are you afraid to leave your home w/o having someone accompany you?, bc of your problem are you afraid to stay home alone?

Question 20

Describe the “Vicious Cycle” of anxiety and dizziness

Answer 20

• Dizziness, vertigo, imbalance
• Stress/perception of danger
• Anxiety, hyper vigilance, panic
• Dizziness, vertigo, imbalance

Question 21

Describe negative affectivity

Answer 21

• Strong relationship between:
• Negative affect
• Catastrophizing
• Dizziness handicap

Question 22

What can be used to demonstrate potential reversibility to the patient’s secondary functional gait disorder

Answer 22

• Temporary improvements of standing or walking during distraction on examination