Persistent postural–perceptual dizziness: subjective–objective dissociation and response to neurologist-led multimodal therapy 2026 Kothari et al

[Andy]

Abstract​

Background and objectives​

Persistent postural–perceptual dizziness (PPPD) is characterized by maladaptive central sensory processing and frequent psychiatric comorbidity. Prospective outcome data, particularly from low- and middle-income settings, remain limited. This study evaluated clinical characteristics, psychiatric comorbidity, objective balance findings, and treatment response in patients with PPPD, with emphasis on neurologist-delivered diagnostic explanation within a multimodal treatment framework.

Methods​

Seventy-five consecutive patients fulfilling Bárány Society criteria for PPPD were prospectively assessed using the Dizziness Handicap Inventory (DHI), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and Balance Rehabilitation Unit posturography. All patients received structured, neurologist-delivered diagnostic explanation and education. Treatment consisted of vestibular rehabilitation and cognitive behavioral therapy for all patients, with low-dose antidepressant therapy prescribed when PHQ-9 or GAD-7 scores were ≥ 5. Outcomes were reassessed at 3 months.

Results​

Psychiatric comorbidity was present in 88% of patients, most commonly combined anxiety and depression. Despite moderate to severe subjective disability, objective balance measures were largely normal, demonstrating a characteristic subjective–objective dissociation. Following treatment, median DHI scores improved from 40.4 to 8.0, PHQ-9 from 8.0 to 0.0, and GAD-7 from 8.0 to 0.0 (all p < 0.001).

Conclusions​

PPPD is associated with high psychiatric comorbidity and marked subjective–objective dissociation yet shows substantial 3-month clinical improvement with a structured multimodal treatment approach. Structured diagnostic explanation and education may facilitate treatment engagement and recovery.
https://link.springer.com/article/10.1007/s00415-026-13927-6
Open access

 

[Hoopoe]

Maybe people are anxious because their body senses its own vulnerability towards potential dangers and responds by turning up anxiety to discourage risk taking.

Maybe people are depressed because they find it difficult to do what makes them happy and struggle to envision a good life that includes their current health problems.

 

[Utsikt]

This is the first time hearing about PPPD:

The Bárány Society criteria define PPPD as persistent non-spinning dizziness or unsteadiness present on most days for at least three months, exacerbated by upright posture, motion, or complex visual environments, and often—but not invariably—precipitated by an acute vestibular, medical, or psychological event [2]. PPPD is a positive diagnosis based on characteristic clinical features rather than one of exclusion, and idiopathic onset is explicitly recognized.

As usual, they fail to recognise that an uncontrolled study can’t determine causality of any kind. Apparently, we now know that the treatment is effective, we just don’t know why..

Several limitations should be acknowledged. First, this was a single-center observational study without a control group, limiting causal inference regarding the relative contribution of individual treatment components.

 

[rvallee]

Following treatment, median DHI scores improved from 40.4 to 8.0, PHQ-9 from 8.0 to 0.0, and GAD-7 from 8.0 to 0.0 (all p < 0.001).

This strongly suggests that psychiatric assessment is heavily tilted by disabling illness. Which makes sense, unless someone goes to a lot of trouble to separate them. And since the popular approach is to blend them intentionally...

Psychiatric comorbidity was present in 88% of patients, most commonly combined anxiety and depression

But if it completely disappears if you treat the symptoms then that's obviously an incorrect interpretation. This is what framing symptoms as mental illness inevitably leads to.

This is pretty much in line with everything we have seen in decades of research on chronic illness: treat the illness, the symptoms, and the "mental health" consequences vanish entirely. Which is roughly similar to drunk people being sobered up and no long acting weird, but interpreting the no longer acting weird as causing the sobering up.

It's weird how all the evidence is so perfectly aligned against the popular interpretation, but it never changes anything. What a damn weird ideology.