Understanding PPPD: How Anxiety, Attention and the Nervous System Keep Dizziness Going

Persistent Postural-Perceptual Dizziness (PPPD) can be confusing, frustrating, and often frightening to live with. Many people describe feeling as though they are constantly rocking, swaying, off-balance, or disconnected from their surroundings. These symptoms can persist even after medical tests show no ongoing physical cause.

One of the most important things to understand about PPPD is that the symptoms are real. They are not imagined, exaggerated, or "all in your head." However, the nervous system can become stuck in a pattern that keeps symptoms going long after the original trigger has passed.

The diagram below explains how this cycle can develop and why symptoms often continue.

How the Cycle Begins

PPPD often starts after an event that causes dizziness or imbalance, such as:

• Vestibular illness

• Vestibular migraine

• Benign Paroxysmal Positional Vertigo (BPPV)

• A period of significant stress or anxiety

• Illness, injury, or a health scare

Although the original trigger may improve, the brain can remain highly sensitive to movement, balance information, and bodily sensations.

The Threat System Becomes Activated

When dizziness occurs, the brain naturally tries to protect us.

The nervous system begins scanning for danger and becomes more alert to balance sensations, movement, and visual information. This is part of the body's normal threat response.

Unfortunately, the brain may begin interpreting dizziness as a sign that something is wrong or unsafe.

Thoughts such as:

• "What if I fall?"

• "What if this gets worse?"

• "What if I can't cope?"

• "What if people notice?"

can increase anxiety and keep the nervous system on high alert.

Increased Attention Creates Increased Symptoms

When we become concerned about symptoms, our attention naturally shifts inward.

Many people with PPPD find themselves:

• Checking their balance

• Monitoring dizziness levels

• Watching how they walk

• Constantly assessing whether symptoms are improving or worsening

Although this is understandable, increased monitoring often makes symptoms feel stronger and more noticeable.

The brain effectively becomes stuck searching for signs of danger.

Safety Behaviours and Avoidance

As symptoms become uncomfortable, many people start making adjustments to feel safer.

Examples include:

• Avoiding busy environments

• Holding onto walls or furniture

• Sitting down quickly

• Limiting movement

• Avoiding supermarkets, shopping centres, or crowds

• Seeking frequent reassurance

While these behaviours may reduce anxiety in the short term, they can unintentionally teach the brain that these situations are dangerous, preventing confidence from rebuilding.

The Role of the Drive, Threat and Soothing Systems

In my work with PPPD, I often integrate Cognitive Behavioural Therapy with Paul Gilbert's Emotional Regulation Model.

Many people with PPPD become stuck between:

An overactive threat system

• Constant vigilance

• Fear of symptoms

• Worry about what dizziness means

An overactive drive system

• Pushing through symptoms

• High self-expectations

• Frustration when recovery is not happening quickly enough

An underactive soothing system

• Difficulty relaxing

• Reduced self-compassion

• Feeling disconnected from safety and enjoyment

Recovery often involves rebalancing these systems by reducing threat, calming the nervous system, and gradually reconnecting with meaningful activities.

How CBT Can Help

CBT does not aim to convince you that symptoms are not real.

Instead, CBT helps you understand the factors that may be maintaining symptoms and develop new ways of responding.

This may include:

• Reducing symptom monitoring

• Understanding the role of attention

• Challenging catastrophic predictions

• Gradually reducing avoidance

• Building confidence through behavioural experiments

• Developing self-compassion

• Learning skills to regulate the nervous system

Over time, the brain can learn that movement, sensations, and environments are safe again.

Recovery Is Possible

PPPD recovery is rarely about eliminating every symptom immediately.

Instead, it is often about helping the nervous system become less sensitive, reducing fear around symptoms, rebuilding confidence, and gradually returning to the activities that matter most.

The symptoms may feel frightening, but they are not dangerous.

With the right support, understanding, and gradual change, many people find that their symptoms become far less intrusive and that they are able to return to a fuller and more meaningful life.

Looking for support with PPPD?

I offer specialist CBT therapy for Persistent Postural-Perceptual Dizziness (PPPD), integrating Cognitive Behavioural Therapy, nervous system regulation, and vestibular-informed approaches to help individuals regain confidence and reduce the impact of symptoms.

Book a free consultation to learn more.