Prevalence and Clinical Characteristics of Persistent Postural Perceptual Dizziness (PPPD) in South Indian Population: A Preliminary Cross-Sectional Study

Abstract

Persistent Postural Perceptual Dizziness (PPPD) is a frequently encountered cause of chronic dizziness, significantly impacting daily life. Despite its prevalence, PPPD remains underdiagnosed, particularly in South India, where clinical data are limited. This study aims to assess the prevalence of PPPD and its clinical characteristics in this region. A cross-sectional study was conducted among 237 individuals aged 18 to 60 years using online surveys and in-person interviews with clinical evaluation. Diagnostic tools included the Niigata Persistent Postural-Perceptual Dizziness Questionnaire (NPQ), Dizziness Handicap Inventory (DHI), and Patient Health Questionnaire for Somatic Symptoms (PHQ-SADS) and GANS-SOP (Gans Sensory Organisation Performance) Test. Among the participants, 46 (22 females, 24 males) were diagnosed with PPPD, with a mean age of 37.80 ± 12.84 years. Visual dominance was a primary exacerbating factor in 18 individuals, while others were affected by upright posture and movement. DHI scores indicated significant emotional and functional impairment, with 22 reporting mild disability, 14 moderate, and 2 severe. PHQ-SADS revealed associations between PPPD and anxiety and depression symptoms. Findings on the GANS- SOP revealed the presence of a multifactorial pattern indicative of the deficits across vestibular, visual and proprioceptive systems. In conclusion, PPPD presents a considerable burden, affecting individuals across different age groups and genders. Improved awareness and diagnostic strategies are needed to address the challenges of diagnosing and managing PPPD effectively. Further research is warranted to refine diagnostic approaches and develop targeted interventions for this complex disorder.

Introduction

Persistent Postural Perceptual Dizziness (PPPD) has been identified to be one of the most frequently occurring causes of chronic dizziness. It adversely affects an individual’s daily functioning [1]. Characterized by non-spinning, persistent vertigo, it becomes the cause of significant distress and functional impairment [2]. Most often, acute vestibular episodes cause hypervigilance due to fear of an attack of vertigo, maladaptive postural strategies and reduced integration of spatial orientation with threat assessment networks [3]. This leads the individual into the spectrum of symptoms, causing an increase in the disease burden and reducing the quality of life [4]. Recognized by the WHO (World Health Organisation) and included in the 11th edition of the ICD (International Classification of Diseases), PPPD is identified as a chronic, functional disorder [2, 3, 7–9].

This particular condition presents a significant diagnostic challenge despite its prevalence. Currently, there are no specific physical or clinical examinations, laboratory tests, or neuroimaging techniques that can definitively identify PPPD [1, 3]. However, these diagnostic tools are essential for excluding other potential comorbidities. Importantly, PPPD is not a diagnosis of exclusion; it frequently coexists with other vestibular disorders, complicating the differential diagnosis. Although additional tests can identify coexisting conditions, they cannot rule out the presence of PPPD [2, 5, 9].

In order to diagnose PPPD, a comprehensive case history is crucial, focusing on both primary and secondary aspects of the disorder. Primary symptoms include dizziness, unsteadiness, and hypersensitivity to self-motion and complex visual stimuli. These primary symptoms can trigger secondary symptoms, such as phobic avoidance of provoking situations and functional gait abnormalities [2, 7, 9]. The diagnosis relies heavily on the criteria established by the Bárány Society’s International Classification of Vestibular Disorders. Additionally, tools such as the Niigata PPPD Questionnaire (NPQ) are used to aid in the diagnostic process [10]. This multifaceted approach underscores the importance of detailed patient history and the utilization of standardized criteria and questionnaires in accurately diagnosing PPPD.

Nevertheless, PPPD is a relatively new diagnosis, and there is a paucity of clinical data in the Indian population, particularly in South India. Despite being very common, it is often underrecognized among chronic causes of dizziness [6]. Clinical examinations seldom help in distinguishing PPPD as most results are generally normal [2]. Additionally, a lack of awareness leads to delays in identification and treatment in this population.

The current study aims to examine the prevalence of PPPD in the current clinical context and explore the factors to be considered during assessment and treatment. This study provides valuable insights into the prevalence and impact of PPPD among individuals experiencing dizziness within a specified age range, shedding light on the clinical manifestations and implications of this condition on patients’ daily lives.

Method

In this cross-sectional investigation, data was collected from individuals aged 18 to 60 years between November 2021 and November 2022. A total of 237 reports detailing episodes of dizziness were obtained through both online surveys and in-person interviews and evaluations in a clinical set-up. Specifically, 84 individuals completed the online survey, while 153 reports were gathered during in-person visit to the outpatient department. Participants for the online surveys were recruited through digital platforms, including social media channels and email communications, to reach a wide and diverse audience quickly and cost-effectively. Additionally, in-person recruitment to complete the online survey was done by approaching students and teachers in colleges within the university campus. Furthermore, a snowball sampling method was employed, where initial participants were asked to refer the survey to their family and friends, thereby expanding the reach to a broader network. Instructions in the online survey recommended completing the questionnaires if participants had a history of dizziness or were currently experiencing dizziness and the case history was tailored to gather information relating to their experience of dizziness and its impact on daily life. The NPQ and DHI questionnaires were also completed as part of the survey.

The rest of the reports were collected from individuals visiting the outpatient unit. Most of the 153 patients presenting to the outpatient unit expressed dizziness or imbalance as a primary concern, prompting them to seek medical evaluation. Markedly, many had previously sought medical attention for their symptoms. Through a comprehensive examination of case histories and self-reported responses to the Niigata Persistent Postural-Perceptual Dizziness Questionnaire (NPQ), 38 individuals received a diagnosis of Persistent Postural-Perceptual Dizziness (PPPD). All patients diagnosed with PPPD met the Bárány Society criteria for the international classification of vestibular disorders as given below.

• A.One or more symptoms of dizziness, unsteadiness, or non-spinning vertigo are present on most days for 3 months or more.
  1. Symptoms last for Prolonged (hours-long) Periods but may wax and wane in Severity.
  2. Symptoms need not be Present Continuously throughout the Entire day.

• B.Persistent symptoms occur without specific provocation, but are exacerbated by three factors:
  1. Upright posture.
  2. Active or passive motion without regard to direction or position.
  3. Exposure to moving visual stimuli or complex visual patterns.
• C.The disorder is precipitated by conditions that cause vertigo, unsteadiness, dizziness, or problems with balance including acute, episodic, or chronic vestibular syndromes; other neurologic or medical illnesses; or psychological distress.
• D.When the precipitant is an acute or episodic condition, symptoms settle into the pattern of criterion A as the precipitant resolves, but they may occur intermittently at first, and then consolidate into a persistent course.
  1. When the precipitant is a chronic syndrome, symptoms may develop slowly at first and worsen gradually.
• E.Symptoms cause significant distress or functional impairment.
• F.Symptoms are not better accounted for by another disease or disorder.

(Source: Staab JP, Eckhardt-Henn A, Horii A, et al. Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): consensus document of the Committee for the Classification of Vestibular Disorders of the Barany Society. J Vestib Res 2017;27(4):191–208)

Furthermore, assessments of the impact of dizziness on daily functioning were conducted using the Dizziness Handicap Inventory (DHI) and the Patient Health Questionnaire for Somatic Symptoms (PHQ-SADS). Following the reports on the self-reported questionnaires mentioned above, patients seen in the outpatient department were clinically assessed using the GANS-SOP (Gans Sensory Organisation Performance) Test. Patients were excluded from this study if they had serious medical conditions requiring continuous medical intervention, relied on vestibular suppressants for daily functioning, exhibited very recent onset of imbalance or vertigo symptoms, or were under psychiatric treatment involving medication and had a primary diagnosis of a psychiatric condition.

Results and Observation

In the comprehensive screening process, consisting of evaluations conducted both online and in outpatient departments, 237 reports were meticulously analyzed. The online survey identified 5 females and 3 males who reported symptoms of PPPD, while the outpatient department assessments identified 17 females and 21 males with PPPD diagnoses. Consequently, the aggregate figures indicate a total of 22 females and 24 males diagnosed with PPPD, culminating in a cumulative total of 46 individuals with a mean age of 37.80 ± 12.84 years diagnosed with PPPD. Respondents included individuals primarily from cities and towns in and around Tamil Nadu, Kerala, Karnataka, Andhra Pradesh, and Telangana.

Among the 237 reports scrutinized, 84 (36.7%) were sourced from online surveys. Among these online respondents, 8 individuals (9.52%) self-reported symptoms indicative of PPPD on their case history, NPQ, and DHI. Subsequently, these individuals were invited for online interviews upon confirmation of their self-reported PPPD symptoms to elaborate on their experience.

Each interviewee recounted experiencing dizziness as the primary symptom, prompting them to seek medical attention. Notably, 4 participants had previously received a diagnosis of Benign Paroxysmal Positional Vertigo (BPPV) and had undergone rehabilitation at least five years before experiencing a recurrence of symptoms indicative of general unsteadiness. Two individuals reported experiencing unexplained dizziness persistently and had utilized vestibular suppressants during the initial incident, albeit with incomplete recovery. Additionally, one individual was diagnosed with Meniere’s disease, while another was diagnosed with postural hypotension based on their medical history. All these individuals experienced persistent dizziness after their initial diagnosis.

Among the 153 individuals who presented to the outpatient department, 38 (24.83%) were diagnosed with PPPD based on thorough evaluations of their case histories, fulfilling the criteria outlined by the Barany Society for PPPD diagnosis and NPQ reports. These individuals exhibited diverse profiles characterized by variations in the duration, frequency, severity, and exacerbating factors associated with their dizziness. They had previously undergone various clinical examinations including vestibular evaluation and received probable diagnosis. Notably, there was a variation in patient’s precipitating factors and diagnoses: 12 patients (31.57%) had BPPV, 3 patients (7.89%) had Meniere’s disease, 2 patients (5.2%) had vestibular neuritis, 4 patients (10.52%) had migraine, and 6 patients (15.78%) had metabolism-related disorders (e.g., high blood pressure, diabetes). Additionally, 11 individuals (28.94%) within this cohort underwent unsuccessful treatment without receiving a definitive diagnosis. The findings and observations from the reports on self-reported questionnaires and evaluations done using GANS-SOP are elaborated below.

Profile Based on NPQ

The NPQ evaluates 3 distinguishing factors that contribute to exacerbating the symptoms of PPPD [10]. Each sub-scale is rated from 0 (none) to 6 (unbearable) to understand the severity. Based on the observations in the current study, 18 (7 males and 11 females) of the 38 individuals showed the presence of visual dominant PPPD while 4 (3 males and 1 female) of them were identified with upright posture/ walking to be the most common exacerbating factor. Movement as a dominant exacerbating factor for PPPD was reported by 6 (4 males and 2 females) of these individuals. This is graphically represented in Fig. 1.

Fig. 1.

Gender-based distribution of the average scores of NPQ for each exacerbating factor

Concerning the severity rating, most of these individuals rated mild to moderate while 2 individuals rated severe.

Profile Based on DHI

The DHI is a 25-item questionnaire that assesses the changes and handicaps caused by dizziness. This popular questionnaire checks 3 domains: functional, emotional, and physical aspects of dizziness [11]. Concerning the DHI reports, all these individuals reported high scores on the emotional and functional sub-scales of the DHI. The mean total score was observed to be 32.92 ± 11.78 with the average score for each of the subscales being; the emotional subscale was about 12.75 ± 5.15, followed by the functional subscale averaging 11.22 ± 4.95, and the physical subscale averaging 9.95 ± 4.50, as represented in Fig. 2. For the severity rating, 22 of these individuals rated mild, 14 individuals rated moderate and 2 individuals rated severe.

Fig. 2.

Representation of the average scores obtained on DHI subscales

Profile Based on PHQ-SADS

The PHQ-SADS is a valuable clinical tool that measures the presence, severity, and impact of various aspects of mental health such as anxiety, depression, and somatic symptoms. The self-administered scale incorporated measures from three other scales (PHQ-9; GAD-7, PHQ-15) to understand an individual’s everyday functioning and impact on the quality of life [12]. In the current study, the individuals scored highly on the anxiety subscale (GAD-7) with an average score of 7.54 ± 2.87, followed by the somatic subscale (PHQ-15), mean score being 5.45 ± 3.01, and the depression subscale (PHQ-9) with an average of 3.27 ± 0.90.

Profile Based on GANS-SOP

The Gans Sensory Organization Performance (SOP) test is a clinical tool used to evaluate a patient’s ability to integrate sensory information from the visual, vestibular, and somatosensory systems to maintain balance. In the context of PPPD, the Gans SOP specifically assesses several key aspects related to the disorder: Sensory Dependency, Postural Stability, Sensory Reweighting, and Functional Balance.

The test involves three main components: the Romberg Test (Conditions 1–4), the Modified Clinical Test for Sensory Integration of Balance (Modified CTSIB, Conditions 5–6), and the Fukuda Stepping Test (Condition 7). Each of these conditions was tested for 20 s.

The observations from the test were as follows:

• Significant Instability with Eyes Closed: The patient exhibited falls in conditions requiring eyes closed (Conditions 2, 4, 6, and 7). This indicates a dependence on visual input and difficulty in integrating vestibular and somatosensory information.

• Moderate Sway with Eyes Open: Eighteen of the thirty-eight patients who reported visual dominance on the NPQ showed moderate sway in conditions with eyes open (Conditions 1, 3, and 5). This further indicates an over-reliance on visual cues for maintaining balance.

The results of this test indicate a ‘multifactorial pattern’ that reflects deficits across multiple sensory systems, including visual, vestibular, and proprioceptive. This leads to impaired balance and coordination. The observed pattern seems consistent with the symptoms and balance disturbances were typically seen in patients with PPPD.

Taken together, these results paint a comprehensive picture of the psychological and functional burden associated with PPPD. High NPQ scores on the visual stimulation subscale, combined with elevated scores on emotional and functional subscales in the DHI, and generalized anxiety subscales in the PHQ-SADS, highlight the multidimensional nature of PPPD and emphasize the need for integrated interventions targeting both physical and psychological aspects of the condition.

Discussion

PPPD represents a relatively recent addition to medical discourse, and comprehensive epidemiological studies elucidating its prevalence across different regions remain limited [6]. However, as awareness of this disorder grows among healthcare professionals and researchers, there is an escalating interest in investigating its prevalence and characteristics.

Prevalence data highlights the critical need to address the adverse effects of PPPD on quality of life. The current study identifies a notable prevalence rate of 19.40% for PPPD among individuals with dizziness who underwent screening. Although exact prevalence rates may vary due to differences in study methodologies and geographic regions, the burden of PPPD is consistently substantial [3]. The literature also indicates that diagnosing PPPD may be more complex than previously thought, with symptoms present even among the non-clinical general population, showing a wide range of presenting indications [14]. Moreover, distinguishing PPPD among individuals with dizziness also poses a challenge, especially when it coexists with comorbidities. Careful analysis of the patient’s case history to identify symptoms outlined in the diagnostic criteria for PPPD is crucial, particularly in cases of long-term or recurrent dizziness. The presence of conditions such as vestibular migraine further complicates the differential diagnosis due to the similarity of symptoms [17]. In such cases, the use of a validated questionnaire is invaluable. The NPQ is one such tool that aids in discerning not only the presence of PPPD but also the severity of symptoms [10]. Specifically, the NPQ evaluates aspects of PPPD such as dizziness frequency and intensity, balance issues, anxiety levels, visual dependence, and the impact of symptoms on daily functioning and quality of life. The findings from the NPQ in the current study have helped discern a strong relationship between PPPD symptoms and visual dependency. Most individuals reported visually dominant symptoms being the most significant exacerbating factor.

Increased dizziness-related handicap, particularly affecting physical and social functioning as well as elevated stress and anxiety levels, is also well documented in the literature, leading to a significant reduction in quality of life for individuals with PPPD [15]. Studies using the DHI, a validated measure of dizziness-related handicap, consistently show higher scores among individuals with PPPD compared to those without vestibular disorders. These higher scores indicate impairments in physical, emotional, and functional domains, underscoring the extensive impact of PPPD on daily activities and social participation [14]. The present study also demonstrates a similar trend, with elevated DHI scores reflecting a significant impact on the quality of life of affected individuals.

Individuals afflicted with PPPD often endure significant impairments in their quality of life, as evidenced by various assessments such as the DHI and PHQ-SADS [3, 4, 14]. The present study shows that disability related to this disorder can vary widely, ranging from a minimal effect on daily functioning to a severe impact. Furthermore, findings from the PHQ, which assesses depressive and anxiety symptoms, reveal a notable association between PPPD and psychological distress. Individuals grappling with PPPD often report heightened levels of anxiety and depression, which can further exacerbate their dizziness-related symptoms and impairments. Such psychological distress not only compounds the burden of PPPD but also underscores the importance of integrated management approaches that address both the physical and psychological aspects of the condition [8, 14].

Understanding the interplay between predisposing factors and the development of PPPD is crucial for accurate diagnosis and effective management. Pre-existing anxiety and mood disorders increase susceptibility to PPPD by amplifying sensitivity to bodily sensations and promoting maladaptive coping strategies. Similarly, physical or emotional trauma, such as head injuries or significant life stressors, can disrupt vestibular functioning and exacerbate PPPD symptoms [3, 13]. PPPD is considered the most common cause of dizziness in tertiary care, second only to Benign Paroxysmal Positional Vertigo (BPPV). It is often triggered by conditions causing dizziness, usually originating from peripheral or central vestibular disorders [16]. The data from this study indicate that a higher percentage of individuals diagnosed with BPPV are significantly predisposed to developing PPPD. Additionally, a portion of the participants in this study experienced unexplained dizziness for an extended period before receiving an appropriate diagnosis.

PPPD manifests across a broad age range, with a notable prevalence among middle-aged and older adults, as observed in the current study. The likelihood of experiencing a vestibular insult increases with age. However, PPPD is also common among younger individuals, who may be predisposed due to factors such as stress, anxiety, trauma, or underlying vestibular or neurological conditions [6]. Some studies have demonstrated a negative correlation between age and PPPD symptoms [14]. Even in the present study, 14 individuals under the age of 30 reported mild to moderate symptoms, and one individual reported severe symptoms.

Traditionally, this condition is perceived as more prevalent in females [13–15]. However, recent research is also beginning to show an increasingly even gender distribution among PPPD cases. The precise reasons for this gender distribution remain unclear, although variations in health-seeking behaviors, cultural influences, and environmental factors may contribute. Additionally, hormonal fluctuations and differences in stress response may exacerbate this disparity [7]. In the current study, however, no female preponderance was reflected and it is to be noted the majority of the respondents were male. This aspect needs to be studied in larger cohorts to provide a definitive conclusion about gender dominance.

Scientifically analyzing these findings underscores the urgent need for comprehensive interventions aimed at enhancing the quality of life for individuals battling PPPD. Multidisciplinary treatment strategies encompassing vestibular rehabilitation, cognitive-behavioral therapy, and psychosocial support can play pivotal roles in mitigating symptom severity, restoring functional capacity, and ameliorating psychological distress. By integrating evidence-based interventions tailored to individual needs, healthcare practitioners can strive to optimize outcomes and alleviate the profound impact of PPPD on patients’ lives.

In summary, ongoing research into PPPD prevalence and its underlying mechanisms is essential for advancing our understanding and facilitating targeted interventions for individuals affected by this complex disorder.

Conclusion

The epidemiology of PPPD continues to evolve and further research is required to elucidate the patterns and occurrence of this disorder. Variations in PPPD prevalence across regions can be attributed to several factors, including the diagnostic criteria and algorithms employed, healthcare accessibility, and the expertise of healthcare providers. Hence, a comprehensive evaluation of the various physical and emotional aspects is essential for optimizing the treatment outcomes for individuals with PPPD.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declarations

Conflict of Interest

None.