PPPD (persistent postural-perceptual dizziness) is a chronic balance disorder that causes a constant sense of unsteadiness, rocking, or swaying that is present on most days and tends to get worse when you stand, move, or are surrounded by busy visual environments. It is the most common cause of chronic dizziness in adults, and it is widely missed because the inner-ear organs themselves usually look normal on testing. At Vertigo Atlanta & Physical Therapy, Dr. Jose Crespo DPT provides dedicated PPPD treatment. He uses infrared Video Frenzel assessment to rule out the structural causes of dizziness, identify the PPPD pattern, and build the vestibular rehabilitation that retrains the brain to stop amplifying the sensation.
Persistent postural-perceptual dizziness (PPPD) is a chronic functional disorder of the balance system. “Functional” means the parts are intact but the processing has gone wrong: the inner-ear organs, the eyes, and the position sensors in the body are usually working, but the brain has locked into an over-sensitive, high-alert way of reading their signals. The result is a near-constant feeling of unsteadiness, rocking, or swaying — a non-spinning dizziness that is present on most days, often lasting for hours and frequently building as the day goes on.
PPPD is the most common cause of chronic dizziness in adults and the most common chronic functional vestibular disorder. It almost always starts after something else: a bout of BPPV or vestibular neuritis, a vestibular migraine, a concussion, a panic attack, or another illness that disturbs balance. The original trigger settles, but the brain never stands down from its high-alert posture, and the dizziness persists long after the thing that caused it has resolved. The reassuring part is that because the organs are not damaged, PPPD is treatable: the goal of care is to retrain the brain out of the pattern it got stuck in.
PPPD does not spin the room the way BPPV does. It is a steadier, grinding sensation — being on a boat that never docks, or walking on a surface that won’t hold still. It is there most days, it rarely lets up completely, and three specific things reliably make it worse.
The core symptom is a persistent, non-spinning dizziness: rocking, swaying, bobbing, or a floating sense of imbalance that is present on most days for three months or more.
Symptoms intensify with upright posture and with movement — your own or the world’s. Many people feel least dizzy lying down and worst when standing and walking.
Complex or moving visual environments amplify the dizziness. This “visual dependence” is a hallmark of PPPD and a frequent clue.
There is no single scan or blood test that says “PPPD.” It is a clinical diagnosis made from a recognizable pattern: non-spinning dizziness on most days for three months or more, reliably worse with upright posture, movement, and busy visual environments, that started after a balance-related event and has outlasted it. The Bárány Society — the international body that defines vestibular disorders — set out the formal criteria, and the diagnosis is made when that whole picture fits and structural causes have been excluded.
That second half is where the assessment earns its keep. Because PPPD so often follows another condition, the job is to confirm there isn’t an active, treatable structural problem still driving the dizziness — leftover BPPV crystals, an uncompensated vestibular loss, or a central sign that points elsewhere. This is where infrared Video Frenzel recording matters: under infrared lenses, with visual fixation removed, Dr. Crespo can see whether the eyes betray a peripheral or central cause, or whether — as in PPPD — the structural exam comes back clean and the pattern points to a brain that hasn’t recalibrated. Identifying PPPD correctly is what redirects a patient away from years of repeat scans and toward the rehabilitation that actually helps.
| PPPD | BPPV | Vestibular Migraine | |
|---|---|---|---|
| Trigger | Upright posture, motion, busy visual environments | A specific change in head position | Migraine triggers (stress, sleep, diet, hormones); often spontaneous |
| Episode length | Persistent; present most of the day, most days | Seconds to about a minute per position change | 5 minutes to 72 hours |
| Tell-tale feature | Constant rocking or swaying that worsens with activity | Brief, intense spinning tied to rolling over or looking up | May include headache, light/sound sensitivity, or visual aura |
| First-line care | Vestibular rehab, often with CBT and/or medication | Canalith-repositioning maneuvers (e.g., Epley) | Migraine management + vestibular rehab + trigger control |
PPPD does not usually resolve on its own, but it responds well to the right treatment — and the evidence points to a combination rather than any single fix. There are three mainstays, and the strongest results come from using them together. Dr. Crespo’s role is the first one, and he coordinates with the patient’s physician and, where helpful, a therapist for the other two.
Targeted, graded exercises retrain the balance system and reduce the brain’s over-reaction to motion and visual movement. This is the part Dr. Crespo delivers, and it is the evidence-based foundation of PPPD care.
Because PPPD runs on a threat-and-anxiety loop, CBT is one of the most effective tools for breaking it. Delivered by a mental-health professional, it addresses the avoidance and hyper-vigilance that keep the cycle going.
Low-dose serotonergic medications (SSRIs or SNRIs) help many people with PPPD turn down the over-sensitivity. These are prescribed and managed by the patient’s physician — not by a physical therapist.
The most common story in PPPD is a patient who has seen several providers, had scans and bloodwork come back clean, and been left with no diagnosis and no plan. Naming the condition is the turning point.
Confirming PPPD (and ruling out an active structural cause) ends the cycle of repeat imaging and tells you exactly what you’re treating. For many people, simply learning the condition is real and named is part of the relief.
PPPD is a recalibration problem, so the treatment is recalibration: graded vestibular rehabilitation that retrains the system instead of medicating the symptom into silence. It is the same core therapy used across the conditions Dr. Crespo treats, tuned to the PPPD pattern.
Left alone, PPPD tends to deepen — the more you brace and avoid motion, the more sensitized the system gets. Starting structured treatment sooner generally means a shorter, smoother recovery.
These are real infrared recordings from assessments, not stock footage. PPPD itself has no dramatic eye sign to film — that’s part of the point. The assessment works by confirming the eyes don’t show an active peripheral or central cause, so the diagnosis lands on PPPD by pattern and exclusion rather than guesswork. These clips show the structural findings Dr. Crespo is checking for and ruling out.
The honest answer is hopeful. PPPD does not tend to go away on its own, but it responds well to treatment: across the published studies, most patients improve substantially when vestibular rehabilitation, CBT, and (where appropriate) medication are used together. What it is not is an overnight fix. Retraining the balance system takes weeks to months of consistent work, progress can come in steps with the odd setback, and some people keep a degree of sensitivity they learn to manage. Starting earlier, before deep avoidance sets in, generally makes the road shorter.
What that means in practice: PPPD is one of the more frustrating dizziness diagnoses to live with and one of the more rewarding to treat, because the trajectory usually bends the right way once the plan is in place. The first step is confirming that’s what you have.
Normal scans don’t mean nothing is wrong. They often mean it’s PPPD — and PPPD is something we can actually treat.
PPPD usually starts after another vestibular problem, and it often coexists with one. If your dizziness doesn’t fully fit the constant, non-spinning PPPD pattern, one of these may be involved — an assessment confirms which.
Dr. Jose Crespo is a Doctor of Physical Therapy specializing in vestibular rehabilitation in Atlanta. People with PPPD often arrive worn down — months or years of daily dizziness, a stack of normal scans, and no clear answer. Dr. Crespo uses infrared Video Frenzel recording to confirm there’s no active structural cause still driving the symptoms, identifies the PPPD pattern, and builds the graded rehabilitation that retrains the balance system, coordinating with the patient’s physician and therapist on the medical and CBT pieces of the plan. Every visit is direct, one-on-one care.
PPPD patients have usually been told what they don’t have. My job is to tell them what they do have, and what we’re going to do about it.
PPPD (persistent postural-perceptual dizziness) is the most common cause of chronic dizziness in adults. It is a functional disorder of the balance system: the inner-ear organs are usually intact, but the brain gets stuck in an over-sensitive way of processing balance and motion. The result is a constant, non-spinning sense of unsteadiness, rocking, or swaying that is present on most days for three months or more and gets worse with upright posture, movement, and busy visual environments.
A persistent feeling of rocking, swaying, or floating unsteadiness — like being on a boat that never docks — rather than the room spinning. It is usually present most of the day, most days, and often builds as the day goes on. It gets worse when you stand or walk, when you or things around you are moving, and in visually busy places like supermarkets, crowds, or while scrolling a screen.
PPPD almost always starts after another event that disturbs balance, such as a bout of BPPV, vestibular neuritis, a vestibular migraine, a concussion, or a panic attack. The original problem settles, but the brain stays on high alert and keeps generating the dizziness after the trigger is gone. It is not caused by a damaged inner ear, and it is not “all in your head” — it is a real, recognized disorder of how the brain processes balance signals.
PPPD is a clinical diagnosis based on a recognizable pattern, not a single test. The criteria, set by the Bárány Society, require non-spinning dizziness or unsteadiness on most days for three months or more, made worse by upright posture, motion, and complex visual stimuli, usually following another balance-related event. A key part of the assessment is using infrared Video Frenzel testing to rule out active structural causes — leftover BPPV, an uncompensated vestibular loss, or a central sign — so the diagnosis is confirmed by pattern and exclusion.
PPPD is treated with a combination of three things: vestibular rehabilitation, cognitive behavioral therapy (CBT), and, when appropriate, low-dose serotonergic medication (SSRIs or SNRIs). Vestibular rehabilitation — graded habituation and visual-motion desensitization — is the physical-therapy core and the part Dr. Crespo delivers. CBT is provided by a mental-health professional and medication is prescribed by the patient’s physician; the strongest results come from using the three together.
Most people with PPPD improve substantially with treatment, though “cured” is the wrong frame — it is a retraining process. Recovery is gradual, typically over weeks to months, and can come in steps with occasional setbacks; some people keep a degree of sensitivity they learn to manage. PPPD does not usually resolve on its own, and starting treatment earlier — before avoidance becomes entrenched — generally makes recovery faster.
No, but they’re related. Mal de débarquement syndrome (MdDS) is a persistent sensation of rocking or swaying that begins after prolonged passive motion, classically a cruise, flight, or long drive, and characteristically eases when you’re back in motion (for example, while driving). PPPD is broader: it can follow many different triggers and is made worse, not better, by motion. Both are chronic non-spinning dizziness disorders, both are treated with vestibular rehabilitation, and an assessment distinguishes them.
No. PPPD is a functional disorder of the balance system, not a psychiatric condition. Anxiety often accompanies it — both because constant dizziness is distressing and because anxiety can help maintain the high-alert state — which is why CBT is part of treatment. But the dizziness is a real, physical sensation generated by the brain’s processing of balance signals, and patients are not imagining it.
Real Google reviews from people who came in dizzy and left with a plan.
Call or request an appointment. Your assessment records what your eyes do under infrared lenses, rules out the structural causes of dizziness, identifies whether the pattern fits PPPD, and starts the rehabilitation that retrains your balance system — so daily dizziness becomes something you treat instead of something you wait out.
