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OBJECTIVE: Impairment in the integration of different vestibular stimuli is the proposed mechanisms in vestibular migraine (VM). In this study, it was aimed to assess the vestibulo-ocular reflex (VOR) and dynamic visual acuity (DVA) in patients with VM and to compare the results with migraine without vestibular symptoms (MwoV), and persistent postural-perceptual dizziness (PPPD) to find out if there are discriminative differences and search for a correlation with the levels of anxiety. METHODS: Twenty-two patients with MwoV, 23 patients with VM, 22 patients with PPPD, and 23 healthy controls (HC) were studied. Video head impulse test (vHIT) and functional head impulse test (fHIT) without and with an optokinetic background (OB) were performed. Percentage of correctly identified optotypes (CA%) was considered for the fHIT test. Beck anxiety inventory (BAI) was used to assess anxiety. RESULTS: Lateral canal vHIT gain of the patient groups were not different from the healthy controls (p > 0.05). fHIT and fHIT/OB CA% results of all patient groups were lower than the HC (p < 0.005), and VM patients had the lowest scores for both tests. BAI scores of the PPPD patients were the highest and a correlation between anxiety levels, and fHIT results could not be identified (p > 0.05). CONCLUSION: Prominent CA% drop by the use of an OB was the main finding in patients with VM. This discriminative feature was not correlated with anxiety scores. Difficulty in resolving the conflict between visual and vestibular inputs seem to be the underlying mechanism. LEVEL OF EVIDENCE: 3 Laryngoscope, 2024.

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Persistent Postural-Perceptual Dizziness (PPPD) is a functional vestibular condition. Despite being the most common chronic neuro-otologic disorder, it remains undertreated. The Niigata PPPD Questionnaire (NPQ), developed by Yagi et al. in 2019 to assess the severity of PPPD, could be a useful tool to help in the screening and diagnosis of this condition. This study aimed to validate a French version of the NPQ and make it an available assessment tool. Moreover, we aimed to understand the characteristics of PPPD patients better. The NPQ was translated and adapted into French. 50 PPPD patients, 50 patients with vestibular disorders without PPPD, and 50 healthy controls were included. They answered the adapted NPQ and additional questionnaires assessing trait (STAI) and state anxiety (HADS-A), depression (HADS-D) and handicap related to dizziness (DHI). The NPQ's reliability was assessed by Cronbach's alpha. Intergroup comparisons and multiple linear regressions were conducted to examine the characteristics of PPPD patients compared to vestibular patients and healthy controls, to validate NPQ's reliability, and to explore the effect of clinical parameters and treatment with selective serotonin reuptake inhibitors. Receiver operating characteristic (ROC) curves were carried out to determine the diagnostic values of the NPQ total score and sub-scores. Relations between NPQ and reported handicap, depression and anxiety were evaluated by correlations between questionnaire scores. The internal consistency was high (>0.8) for all NPQ subscales and the total score. Intergroup comparisons showed a significantly higher NPQ total score and sub-scores in the PPPD group compared to the two others. The ROC curve analysis showed a significant, but poor, discrimination of NPQ (AUC = 0.664) and its subscales. DHI scores, depressive symptoms and trait anxiety were significantly higher in PPPD patients than in vestibular patients and healthy controls. State anxiety did not differ between patients with PPPD and vestibular patients without PPPD. Finally, there was a significant correlation between the NPQ and the DHI. Our study provides a better understanding of PPPD symptomatology and its assessment. It showed that the NPQ is a reliable tool that can assist in symptom assessment for a French-speaking population.

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Background: Persistent postural-perceptual dizziness (PPPD) is a chronic vestibular syndrome often triggered by acute or episodic vestibular syndromes, such as Meniere's disease (MD). According to the diagnostic criteria, PPPD may coexist with other structural diseases, and the evidence of another active illness does not necessarily exclude PPPD diagnosis. However, persistent symptoms, even those meeting the PPPD criteria even long after Meniere's attack, are often overlooked as potential PPPD precipitated by MD. Some clinicians overlook PPPD in such patients, treating them solely for MD once diagnosed. Since a treatment strategy for PPPD is completely different from that for MD, this may result in the deprivation of adequate treatments. Objectives: To emphasize the importance of diagnosing PPPD coexisting with MD including not treating such patients solely for MD, and to compare the clinical features of PPPD and MD. Methods: Vestibular function tests, including canal paresis (CP)%, c- and o-vestibular myogenic potentials, vestibulo-ocular reflex-direction preponderance, and posturography and clinical symptom scales, including the Dizziness Handicap Inventory, Niigata PPPD Questionnaire, and Hospital Anxiety and Depression Scale, were compared between 105 PPPD patients with MD or other precipitants and 130 patients with MD alone. The clinical symptom scales were further compared between 23 patients with PPPD coexisting with MD and those with MD alone. Results: The CP% was significantly higher in patients with MD than in those with PPPD. However, the total and subscores of all three clinical symptom scales were higher in patients with PPPD than in those with MD. The total score on all clinical symptom scales was higher in patients with PPPD coexisting with MD than in those with MD alone. Conclusion: Persistent postural-perceptual dizziness development from a precipitating MD may be associated with more severe clinical symptoms. Thus, clinical symptom scales may be useful for detecting PPPD in patients with Meniere's disease.

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BACKGROUND: Patients with long-COVID suffer from symptoms that continue or develop after a COVID-19 or SARS-CoV-2 infection and are present for four or more weeks after the initial infection. This case series describes a group of previously healthy adolescent patients with long-COVID who were seen in a pediatric vestibular clinic for evaluation of severe dizziness and were diagnosed with persistent postural-perceptual dizziness (PPPD). By presenting their symptoms, management and treatment effects, this study aims to provide a diagnostic and therapeutic framework for providers who encounter these patients. METHODS: Patient records were reviewed for past medical history, symptoms, physical exam findings, results of audiometric and vestibular testing, dizziness handicap inventory for patient caregiver (DHI-pc) scores, and treatment recommendations. Parents of patients were contacted for a follow up survey to assess treatment adherence and outcomes including changes in symptoms and return to activity. RESULTS: A series of 9 adolescent patients were referred from a multidisciplinary long-COVID clinic and diagnosed with PPPD. Recommended treatment included vestibular physical therapy, selective serotonin reuptake inhibitor medication, and cognitive behavioral therapy. The majority of patients experienced an improvement in their symptoms, and all patients had improved activity levels and DHI-pc scores after treatment. CONCLUSION: To the best of our knowledge, no previous reports exist discussing PPPD in long-COVID patients. This case series provides insight into symptom evolution and treatment efficacy in this patient population.

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Introduction: The patho-psychological mechanisms of persistent postural-perceptual dizziness (PPPD) appear to be very complex, and a multimodal, multidisciplinary approach is suggested for treating patients with PPPD. The aim of this review was to provide a comprehensive overview of non-pharmacological treatments and their comparative effectiveness in patients with PPPD. Methods: Scopus, Web of Science, PsycINFO, Medline, Embase, CINAHL, Cochrane Library and ClinicalTrials.gov were searched in April 2022 with a search update in August 2023. Only randomized controlled trials (RCTs) were included. There was no restrictions regarding publication date. Two reviewers independently identified eligible trials, extracted data, double-checked all extracted information from the included articles and assessed the risk of bias using the Cochrane risk of bias tool. A qualitative synthesis was performed, considering methodological heterogeneity between trials. Finally, an effect size analysis was performed for each treatment comparison. The standardized mean differences (SMD) and their corresponding 95% confidence intervals (95%CI) were calculated for each trial using Review Manager 5.4. Results: Thirteen RCTs (618 patients with moderate or mild dizziness) out of 1,362 references describing seven different non-pharmacological comparisons were selected. Nine trials included patients with PPPD, and four trials included patients with functional dizziness. The trials used different interventions that were classified as: (1) psychotherapeutic interventions (cognitive behavioral therapy, patient education), (2) physiotherapeutic interventions/training (vestibular rehabilitation, optokinetic stimulation), (3) stimulation procedures (vagus nerve stimulation, transcranial direct current stimulation) and (4) device application (visual desensitization using personalized glasses). However, most of the trials investigated the effects of single interventions, rather than multimodal interdisciplinary treatment of patients with PPPD. The SMD for dizziness handicap and severity was between 0.04 and 0.52 in most trials. In one trial using visual desensitization, the SMD was 1.09 (strong effect on the severity of dizziness) and 1.05 (strong effect on dizziness handicap). Discussion: Several individual interventions have shown benefits in the treatment of patients with PPPD with small to moderate effects. However, the multimodal treatment or a combination of vestibular rehabilitation with visual desensitization, cognitive behavioral therapy including patient education, and medication support should be further investigated. Future trials should include a large sample size with severe dizziness, and provide a longer follow-up period. Clinical trial registration: PROSPERO CRD42022320344.

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Persistent postural-perceptual dizziness (PPPD) is a chronic and disabling disorder characterized by persistent dizziness, unsteadiness, and imbalance. It often arises without an identifiable cause and is exacerbated by upright posture, active or passive movement, and exposure to moving or complex visual stimuli. This complex pathophysiology and the psychological dimensions of its symptomatology pose a significant challenge to clinicians. PPPD presents diagnostic challenges and a lack of standardized treatment options, underscoring the need for multidisciplinary approaches encompassing pharmacotherapy, vestibular rehabilitation, and psychological interventions for effective management. Bridging the gaps in understanding PPPD requires collaborative efforts across disciplines, emphasizing integrated research approaches and patient support networks to enhance care and improve outcomes. This review explores the challenges, controversies, and clinical complexities of PPPD, highlighting the importance of a patient-centered approach.

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Patients with persistent postural-perceptual dizziness (PPPD) perceive postural instability larger than the observed sway. It is unknown whether the concept of postural misperception prevails during vestibular stimulation and whether it may account for the unsteadiness patients complain during body movements. We tested the hypothesis of an abnormal sensory-perceptual scaling mechanism in PPPD by recording objective, perceived, and the reproduced postural sway under various standing conditions, modulating visual and proprioceptive input, by binaural galvanic vestibular stimulation (GVS). We related postural sway speed to individual vestibular motion perceptional thresholds and disease-related PPPD questionnaires in 32 patients and 28 age-matched healthy control subjects (HC). All participants showed normal vestibular function tests on quantitative testing at the time of enrollment. The perception threshold of GVS was lower in patients. Compared to HC, patients showed and perceived larger sway on the firm platform. With GVS, posturo-perceptual ratios did not show group differences. The ratio of reproduced to real postural sway showed no group differences indicating normal postural sway perception during vestibular stimulation. Noticeably, only in patients, reproduced postural instability became larger with lower individual thresholds of vestibular motion detection. We conclude that posturo-perceptual (metacognitive) scaling of postural control seems to be largely preserved in PPPD during GVS. Vestibular stimulation does not destabilize patients more than HC, even in challenging postural conditions. Low individual thresholds of vestibular motion perception seem to facilitate instability and postural misperception on solid grounds. This conclusion is important for an effective physical therapy with vestibular exercises in PPPD.

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PURPOSE: To review the vestibular, aural, and perceptual symptoms of vestibular migraine (VM) that may present alongside vertigo. RECENT FINDINGS: Increased research attention to the wide spectrum of symptoms presenting in VM patients has improved understanding of this disorder, with recent identification of five different VM phenotypes. Research into the clinical overlap between VM and other chronic vestibular syndromes such as persistent postural-perceptual dizziness and mal-de-debarquement syndrome reveals a range of vestibular symptoms and hints at pathophysiological connections between migraine and vestibular dysfunction. Studies of migraine treatment for hearing loss suggest patients presenting with aural symptoms may have an underlying diagnosis of migraine and deserve a trial of migraine preventives. Research into the neurologic basis of the perceptual disorder Alice in Wonderland syndrome has revealed brain areas that are likely involved and may help explain its prevalence in VM patients. VM is a sensory processing disorder that presents with more than just vertigo. Understanding the range of potential symptoms improves diagnosis and treatment for migraine patients whose diagnosis may be missed when only the symptoms identified in the diagnostic criteria are considered.

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INTRODUCTION: Persistent postural-perceptual dizziness (PPPD) and vestibular migraine (VM) share symptoms of visual vertigo and motion sickness that can be confusing for clinicians to distinguish. We compare the severity of these symptoms and dynamic subjective visual vertical (dSVV) in these two common vestibular conditions. METHOD: Twenty-nine patients with PPPD, 37 with VM, and 29 controls were surveyed for subjective symptoms using the visual vertigo analogue scale (VVAS) and motion sickness susceptibility questionnaire during childhood (MSA) and the past 10 years (MSB). dSVV is a measure of visual dependence measures perception of verticality against a rotating background (5 deg./s). RESULTS: VVAS revealed contextual differences for dizziness between those with PPPD and VM. Ratings of visual vertigo were most severe in PPPD, less in VM, and mild in controls (VVAS PPPD 27.1, VM 11.2, control 4.6, p < 0.001). MSA was more severe in VM than in PPPD or control (12.8 vs 7.6 vs 8.5, p = 0.01). MSB was more severe in VM than controls (MSB score 12.9 VS 8.1 p = 0.009) but was not different than PPPD (MSB score 10.0, p = 0.10). dSVV alignment was similar among the three groups (p = 0.83). Both VM and PPPD groups had greater simulator sickness than controls after completing the dSVV. CONCLUSIONS: Patients with PPPD report more visual vertigo than those with VM, but a history of motion sickness as a child is more common in VM. Additionally, the environmental context that induces visual vertigo is different between PPPD and VM.

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Objective: To investigate differences in the clinical characteristics of patients with persistent postural-perceptual dizziness (PPPD) according to age. Methods: We retrospectively reviewed 143 patients diagnosed with PPPD. Patients were classified into three groups by age: young group (19 to 44 years, n = 60), middle-age group (45 to 64 years, n = 56), old group (65 to 85 years, n = 27). Demographic data, scores of the Dizziness Handicap Inventory (DHI), the Niigata PPPD Questionnaire (NPQ), the Hospital Anxiety and Depression Scale (HADS), precipitating conditions, and the results of vestibular function tests including caloric testing, video head impulse test (vHIT), cervical and ocular vestibular evoked myogenic potentials (cVEMPs and oVEMPs), and posturography, were compared among the three groups. Results: While there were no significant differences in the scores of the DHI or NPQ, the total score and anxiety score in HADS in the young group were significantly higher than in the old group (p < 0.05, each). On the other hand, for precipitating conditions, the rate of peripheral vestibular diseases was significantly greater in the old group (77.8%) compared to the young group (41.7%, p < 0.01). There was no significant difference in the results of caloric testing, vHIT, cVEMPs, or oVEMPs among the three groups. For posturography, the velocity of the center of pressure with eyes-open as well as with eyes-closed was significantly greater in the old group compared to the young group and the middle-age group (p < 0.005, respectively). Conclusion: The clinical characteristics of PPPD were different according to age. Young patients tended to have stronger anxiety than old patients whereas the old patients had a higher proportion of peripheral vestibular diseases among the precipitating conditions compared to young patients.

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Purpose: Persistent postural-perception dizziness (PPPD) is a chronic subjective form of dizziness characterized by the exacerbation of dizziness with active or passive movement, complex visual stimuli, and upright posture. Therefore, we aimed to analyze the resting-state functional magnetic resonance imaging (fMRI) in patients with PPPD using fractional amplitude of low-frequency fluctuation (fALFF) and voxel-mirrored homotopic connectivity (VMHC) and evaluate the correlation between abnormal regions in the brain and clinical features to investigate the pathogenesis of PPPD. Methods: Thirty patients with PPPD (19 females and 11 males) and 30 healthy controls (HCs; 18 females and 12 males) were closely matched for age and sex. The fALFF and VMHC methods were used to investigate differences in fMRI (BOLD sequences) between the PPPD and HC groups and to explore the associations between areas of functional abnormality and clinical characteristics (dizziness, anxiety, depression, and duration). Result: Compared to the HC group, patients with PPPD displayed different functional change patterns, with increased fALFF in the right precuneus and decreased VMHC in the bilateral precuneus. In addition, patients with PPPD had a positive correlation between precuneus fALFF values and dizziness handicap inventory (DHI) scores, and a negative correlation between VMHC values and the disease duration. Conclusions: Precuneus dysfunction was observed in patients with PPPD. The fALFF values correlated with the degree of dizziness in PPPD, and changes in VMHC values were associated with the duration of dizziness, suggesting that fMRI changes in the precuneus of patients could be used as a potential imaging marker for PPPD.

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Persistent postural-perceptual dizziness (PPPD) is a chronic disorder of perceived unsteadiness. Symptoms can be exacerbated in visually complex stationary or moving environment. Visual dependence and increased motion sensitivity are predictors for PPPD but its pathophysiology remains unknown. We hypothesized an abnormal sensory-perceptual scaling mechanism in PPPD and tested visual- and vestibular perceptional thresholds in 32 patients and 28 age-matched healthy control subjects (HC). All participants showed normal vestibular function tests on quantitative testing. Visual motion coherence thresholds were assessed by random dot kinetomatograms. Vestibular perceptional thresholds of egomotion were assessed by binaural galvanic vestibular stimulation (GVS) and passive chair rotation around an earth-vertical axis. Chair rotation trials were contrasted with no-motion (sham) stimulus trials. Mean thresholds of visual motion perception were higher in patients compared to HC. The perception threshold of GVS was lower in patients but the threshold of correctly perceived egomotion during chair rotation did not differ. Interestingly, the number of trials with correct perception in the no-motion condition increased with the threshold of correct responses for rotatory egomotion in patients. Unlike expected, PPPD patients required more coherently moving random dots than HC to perceive visual motion. A poorer complex visual motion recognition, e.g., traffic visual stimuli, may increase anxiety and levels of uncertainty as visuomotor reactions might occur delayed. The vestibular rotatory perception threshold predicted the probability of making false assignments in the sham condition in PPPD, i.e., patients who readily recognize the correct egomotion direction are prone to perceive egomotion in the no-motion condition. As this relation was not found in healthy subjects, it may reflect an abnormal sensory-perceptual scaling feature of PPPD.

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OBJECTIVES: Persistent postural-perceptual dizziness (PPPD) is a chronic functional vestibular disorder for which the Bárány Society has established diagnostic criteria. This nationwide multicenter study aims to investigate the clinical features of individuals with definite PPPD and clinical variant PPPD who do not fully meet the diagnostic criteria, with a particular focus on visual exaggeration. METHODS: Between September 2020 and September 2021, a total of 76 individuals with definite PPPD and 109 individuals with clinical variant PPPD who did not meet all three exacerbating factors outlined in Criterion B were recruited from 18 medical centers in South Korea. The study gathered information on demographic factors, clinical manifestations, balance scales, and personality assessments. RESULTS: Comparative analysis between groups with definite PPPD and clinical variant with visual exacerbation revealed no significant differences in sociodemographic characteristics, clinical course, dizziness impact, and specific precipitants. Only disease duration was significantly longer in definite PPPD compared with variant with visual exacerbation. However, the variant without visual exacerbation displayed significantly reduced rates of panic disorder, diminished space-motion discomfort, lesser impact of dizziness, and decreased prevalence of depression when compared with the definitive PPPD. CONCLUSION: This is the first comprehensive nationwide study examining clinical features of both definite PPPD patients and its clinical variants, considering visual exacerbating factors. Differences in dizziness and personality traits emerged between definite PPPD and its potential variant without visual issues. Our results highlight the possibility of a distinct clinical variant of PPPD influenced by visual dependency.

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BACKGROUND: Persistent postural-perceptual dizziness (PPPD) is a functional vestibular disorder that causes chronic dizziness and limits daily activities. Although pharmacology, vestibular rehabilitation, and cognitive behavioral therapy have been proposed to have some efficacy, they have certain limitations. Some patients with PPPD report that public square dancing can effectively relieve the symptoms of dizziness and instability, and their mood improves. OBJECTIVE: To evaluate the effects of combining public square dancing with serotonin reuptake inhibitors (SSRIs/SNRIs) on the subjective sensations of dizziness, balance enhancement, anxiety, and depressive symptom regulation in middle-aged and older women with PPPD. MATERIALS AND METHODS: In this trial, 124 patients diagnosed with PPPD were enrolled. Among them, 64 patients were randomly assigned to the experimental group (EG), where they received square dance training combined with serotonin reuptake inhibitors. The remaining 60 cases were randomly assigned to the control group (CG), where they received only serotonin reuptake inhibitors and did not participate in organized sports activities, allowing them freedom in their daily lives. Data from the Dizziness Handicap Inventory (DHI), Hospital Anxiety and Depression Scale (HADS), Active-specific Balance Confidence Scale (ABC), and Vestibular Disorder Activities of Daily Living Scale (VADL) were collected and compared at the beginning, 3 months, and 6 months of the trial to evaluate the effect of public square dancing on middle-aged and older women with PPPD. RESULTS: There were no significant differences between the EG and CG before the trial. Compared with baseline measures, DHI, HADS, ABC, and VADL scores improved as the experiment progressed, and the improvements were more pronounced in the EG. CONCLUSION: Public square dancing combined with serotonin reuptake inhibitors has a positive impact on the subjective sensations of dizziness, balance enhancement, anxiety, and depressive symptom regulation in middle-aged and older women with PPPD.

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PURPOSE: To evaluate the efficacy of vestibular rehabilitation therapy (VRT) for management of patients with persistent postural perceptual dizziness (PPPD) utilizing subjective and objectives outcome measures and to study the effect of degree of both anxiety and depression in patients on the response of vestibular rehabilitation therapy. METHODS: Thirty-three PPPD patients participated in this study. Selection of patients was based on the diagnostic criteria for PPPD stated by Barany society in the International Classification of Vestibular Disorders (2017). Every patient was subjected to history taking, anxiety and depression assessment, Arabic version of Dizziness Handicap Inventory (DHI), and sensory organization test (SOT). All patients received vestibular rehabilitations therapy. Assessment of VRT outcome was conducted after 6 weeks of VRT. RESULTS: The mean patients' age was 40.9 ± 16.3 years, and nearly equal gender distribution. Vestibular migraine was the most precipitating condition (24.2%) in patients with PPPD. (39.4%) of patients had abnormal scores of anxiety and depression tests, all patients had from moderate to severe degrees of handicap caused by dizziness as measured by DHI, most of patients had abnormal findings in all conditions of SOT. After vestibular rehabilitation therapy, DHI and SOT scores showed significant improvement after VRT. More improvement was found among the group with no anxiety and depression. CONCLUSION: VRT were effective in improving balance abnormalities in patients with PPPD evidenced by subjectively by DHI scores and objectively by SOT results. PPPD patients with concomitant psychiatric disorders; anxiety and depression experienced the least degree of improvement.

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Introducción: El mareo perceptual postural persistente (MPPP) es, probablemente, la causa más prevalente de mareo crónico. Sin embargo, su fisiopatología es aún motivo de duda y debate. En el presente artículo, proponemos que el MPPP se caracteriza por disfunciones cognitivas de orden superior, al punto de diferenciarse en estas dimensiones de controles sanos y pacientes con patologías vestibulares no-MPPP. Objetivo: Determinar si pacientes con MPPP presentan alteraciones discriminantes respecto a grupos controles, en ámbitos de atención, memoria de trabajo visoespacial, planificación espacial, funciones ejecutivas y rendimiento cognitivo global. Material y Método: Estudio descriptivo transversal con sujetos de entre 18 y 65 años, reclutados de una unidad de otoneurología ambulatoria. Se aplicaron pruebas Montreal Cognitive Assessment (MoCA), tarea de retención de dígitos, Trail Making Test, Corsi Block-Tapping Task y Torre de Londres. Resultados: 30 pacientes fueron categorizados en tres grupos: grupo MPPP (n = 14), grupo vestibular no-MPPP (n = 11) y grupo control (n = 5). El grupo MPPP exhibió un rendimiento significativamente inferior en pruebas de planificación, velocidad de procesamiento y funciones ejecutivas en ámbitos visoespaciales, mientras que en atención y memoria visoespacial no hubo diferencias entre grupos. Conclusión: El MPPP podría caracterizarse por una disfunción de procesos cognitivos superiores de construcción espacial de mayor complejidad, respetando funciones visoespaciales de menor orden como la memoria de trabajo. Estos hallazgos ofrecen nuevas luces para comprender la fisiopatología del MPPP y sus implicancias clínicas.

Introduction: Persistent postural-perceptual dizziness (PPPD) is probably the most prevalent cause of chronic dizziness. However, its pathophysiology is still a matter of uncertainty and debate. In this article, we propose that PPPD is characterized by higher-order cognitive dysfunctions, to the point of differentiating it from healthy controls and patients with non-PPPD vestibular pathologies. Aim: To determine whether patients with PPPD exhibit discriminant alterations compared to control groups in the areas of attention, visuospatial working memory, spatial planning, executive functions, and global cognitive performance. Materials and Methods: A cross-sectional descriptive study was conducted with subjects between the ages of 18 and 65 years, recruited from an outpatient otoneurology unit. Tests included the Montreal Cognitive Assessment (MoCA), digit retention task, Trail Making Test, Corsi Block-Tapping Task, and the Tower of London. Results: 30 patients were categorized into three groups: PPPD group (n = 14), non-PPPD vestibular group (n = 11), and control group (n = 5). The PPPD group showed significantly lower performance on tests of planning, processing speed, and executive function in visuospatial domains, while there were no differences between groups in attention and visuospatial memory. Conclusion: PPPD may be characterized by dysfunction of higher-order cognitive processes related to spatial construction of greater complexity, while sparing lower-order visuospatial functions such as working memory. These findings offer new insights into the pathophysiology of PPPD and its clinical implications.

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OBJECTIVE: Persistent postural-perceptual dizziness (PPPD) is a syndrome described as secondary, when it is the consequence of an organic disorder (s-PPPD), or primary, when no somatic triggers can be identified. We evaluated a group of patients diagnosed as s-PPPD, with Benign Positional Paroxysmal Vertigo (BPPV) as the main somatic trigger, with the aim of identifying the predictive clinical elements of evolution towards PPPD. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: We evaluated 126 patients diagnosed with PPPD; 54 patients were classified as p-PPPD (43%) and 72 as s-PPPD (57%). Of these, 51 patients had BPPV as a somatic trigger of PPPD, and in this group, we evaluated the prevalence of some clinical features (age, sex, latency between the onset of BPPV and the final diagnosis, recurrence of BPPV and the presence of migraine headache) for comparison with a group of patients who suffered from BPPV without an evolution towards PPPD (control group). RESULTS: In the group with PPPD secondary to BPPV, we found a significantly higher mean age and a longer latency between the onset of BPPV and the final diagnosis compared to the control group. No difference between the two groups was found regarding sex, recurrence rate and the presence of migraine headache. CONCLUSIONS: The parameters most involved as potential precipitants of PPPD after BPPV were the age of the patients and a long latency between the onset of BPPV and the final diagnosis; the mean age of the subjects who developed PPPD following BPPV was significantly higher. These findings lead us to emphasize the importance of the early identification and treatment of BPPV, especially in older patients.

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Persistent postural-perceptual dizziness (PPPD) is a functional neuro-otologic (vestibular) disorder manifesting dizziness, unsteadiness, or nonspinning vertigo lasting 3 months or more and exacerbated by upright posture, active or passive motion, and complex visual stimuli. PPPD is the most common cause of chronic vestibular symptoms. Early pathophysiologic models of PPPD emphasized the adverse effects of anxiety on postural control and spatial orientation. More recent concepts added predictive processing of sensory inputs and alterations in motion perception. Herein, a third-generation model incorporates prioritization of postural stability over fluid locomotion to explain symptoms, physiologic and neuroimaging data, and effects of current treatments.

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Functional neurological disorder (FND) is a neuropsychiatric condition. In this field, prospective psychotherapy trials and consensus recommendations for physiotherapy, occupational therapy, and speech language therapy have been published. However, significant clinical complexities remain. "Rule in" signs - while critical for making a positive diagnosis - do not equate to a personalized treatment plan in many instances. Here, we propose that the neuropsychiatric assessment and real-time development of a work-in-progress biopsychosocial clinical formulation aids the development of a patient-centered outpatient treatment plan. This precision medicine approach is based on the literature, expert opinions and our clinical experience working in an interdisciplinary FND service.