PPPD Explained: The Biggest Factor Behind Your Symptoms

TR 3D represents about 20% of all neurology consultations, and yet it's still massively underdiagnosed, poorly treated, and in fact, huge numbers of people don't even know it exists. Most people with dizziness are walking around thinking they've been diagnosed with chronic anxiety, BPD, vestibular migraine, stuff like that. And often the diagnosis of TRPD is massively delayed, which delays their recovery. So there's been a new article that came out in August 2025.

So, it's brand new, part of the press, and hopefully it's going to help us understand a little bit more about why it happens and open a window into what treatment should look like. So, uh, Ben, you know more about this than most people. You had it yourself.

Yeah. Yeah. It could definitely come from a sense of empathy.

Yeah. Absolutely. So, the symptoms of TRPD, I mean, you can describe better than anyone else. So, why don't you tell me about what it's like, Ben?

Yeah. With TRPD, it's a bit of an—it's an odd one because most people will obviously describe it to people as very much an invisible illness because you can't see it. Generally, people's balance is absolutely fine, but you just don't feel like that's the case. Most people will, well, myself included, would have experienced the kind of whether it's like you walk on a trampoline or it's a sense of unsteadiness or you feel like you could fall, but the risk of falling is no higher than anyone else in the general population. But for a lot of people, it's also that internal sense of a swimming feeling or as if they're moving. But it's different from other conditions of dizziness like BPV that people talk about or it's quite a common one where they get that spinning sensation. It's not often people get the spinning, but they'll get some other sensation of movement or imbalance.

Yeah, absolutely. So when we call it that, it's that non-spinning vertigo. So vertigo is that sense of movement. So people might feel like they're bobbing, rocking, swaying. Um, some people—did you ever have this? To get some feeling of dropping? So they'd be on their computer and like scrolling up or down on the screen and suddenly have a sense of like they're dropping forward.

The elevator drop feeling.

Yeah. Horrible. Horrible.

Yeah. So, um, when we're looking at the diagnostic criteria for CHPD, really it's that persistent dizziness that can wax and wane over the day, last for at least hours at a time, but for most people it's most of the day. Now, you can just have to trot the foot bits. Do you know if you go and lie, um, lie down in bed or lie on the sofa, the symptoms stop or get much better? Did you have the same thing, Ben, or was yours just fairly constant whatever you did?

No, very much wax and wane, like you say. I know they talk about upright posture is generally worse. Lying down for most of the time or even sitting down was generally better. But yeah, once you're up, or for me it was passive movement was an unpleasant one or active movement of the head. But you'd often find it would wax and wane a lot, and sometimes we get a lot of people for no apparent reason you can just get a sudden worsening in symptoms out of the blue.

Yeah. And that's, I think, one of the most frustrating bits, right? You could be doing nothing offensive. So you've kind of figured out that being upright is worse than lying down and movement is worse than just staying still like sitting in a chair. Um, and that, you know, if you go to a busy supermarket or somewhere with lots of visual stimulation, it's worse. But so frustrating if you're doing nothing particularly, you're sitting in, in sitting in a chair minding your own business, paper, and then suddenly start feeling like that rocking gets much worse. It can just be so, so frustrating like I haven't even done anything, like I'm not doing anything bad. Um, and unfortunately that psychology starts to build up, right? That frustration aggravates the stress, which aggravates the dizziness, and this thing just winds itself up. And that's the thing because a lot of people do get frustrated with—they may have heard it from other people, well-meaning, where it's, you know, perhaps it's your anxiety and things like that. And, and, and what most people, and myself included, would have been the dizziness often starts sometimes without an obvious cause, sometimes there is an obvious trigger, but sometimes it will start. But often then it's the psychological aspects that then can worsen that and turn it into a spiral. Peril. And as we're now finding, maybe one of the big things is actually persisting as well as amplifying the symptoms as well.

Yeah, absolutely. So this paper, um, is looking at the psychological factors that mediate your PD. So it's a really interesting one, and one of the interesting bits they found there is that in younger populations anxiety can often be the trigger, and in older populations it's often other forms of dizziness. So you have a vestibular migraine or an ear infection like vestibular neuritis or labyrinthitis or maybe BPV, like those crystals in your ear. So you have this onset of disruption in how the vestibular system works, and then the brain has these maladaptive processes. So it then says, okay, well actually I say maladaptive, really it's adaptive. So if I can't trust my ear because it's not working properly, it's totally normal to say, "Right, okay, I can't trust my ear." You know, my right ear is not saying the same as my left.

So I'm going to use my vision more in the short term to try and get me through this.

Exactly the same as if I broke my leg. I'm going to put in a cast, put in a crutch, put in a crutch, start using a crutch, and then once the bone is healed, you know, I'm going to get rid of that and carry on walking. It'd only be maladaptive if my bone was fully healed and I continued to use the cast and I continued to walk with a crutch.

And unfortunately that's what happens in TRPD, is that people have this adaptive response where the system's not working. It hopefully then heals over time, and yet the brain continues to say, I'm going to continue to ignore my vestibular system as much as possible. I'm going to use vision more. Um, and that means you're prone to these tricks of light, color contrast, depth perception, all these sensory reference points. So whenever you're turning your head, your brain is using these reference points around you to understand how fast you're moving. Um, and so if we're someone that has lots of vertical lines or lots of horizontal lines, it gives you that visual sense of acceleration, which is why the supermarket is just so horrible.

Um, so Ben, when you had it, was there any—I remember talking to you about it and you saying just talking to people was making you feel dizzy. Like if you were talking face to face with someone like this, you were like, "Oh, I could just feel myself swaying around the whole time."

Oh, I was going to say I wouldn't have, back then a few years ago, wouldn't have actually been able to do this sort of video call sort of format, combination of people moving but also then me having to move along with it. But is it that combination of like when you see something moving, like you say there's so much overlap with a lot of these chronic conditions where, as you said, it starts adaptive. It's that the body's doing the right thing for you, but after a while, you've had that time.

The original insult, so to speak, is gone. But now you start seeing someone moving in front of you, like say in person over video. And although you might not necessarily notice at the time, but realistically, what's happening is your brain is saying, is that me moving or is that someone else moving? It just can't seem to get those systems to cooperate properly or at least interpret them appropriately. So yeah, people moving was awful, especially because when you're in front of someone, they're usually a lot closer to you. Same with a computer.

business paper and then suddenly start feel like that rocking gets much worse. it can just be so so frustrating like I haven't even done anything like I'm not doing anything bad. Um and unfortunately that psychology starts to build up right

that that frustration aggravates the stress which aggravates the dizziness and this thing just winds itself up and that's the thing because a lot of people do get frustrated with they may have heard it from other people well-meaning where it's you know perhaps it's your

anxiety and things like that and and and what most people and myself included would have been the dizziness often starts sometimes without an obvious cause sometimes there is an obvious trigger but sometimes it will start but often then it's the the psychological

aspects that then can worsen that and turn it into a spiral. peril and as we're now finding maybe one of the big things is actually persisting as well as amplifying the symptoms as well.

Yeah, absolutely. So the this paper um is looking at the psychological factors that mediate your PD. So it's a really interesting one and one of the interesting bits they found there is that in younger populations anxiety can often be the trigger and in older

populations it's often other forms of dizziness. So you have a vestibular migraine or an ear infection like vestibular neuritis or labitis or maybe BPV like those crystals in your ear. So you have this onset of of disruption in

how the vestibular system works and then the brain has these maladaptive processes. So it then says okay my well actually I say maladaptive really it's adaptive. So if my if I can't trust my ear cuz it's not working properly. It's

totally normal to say, "Right, okay, I can't trust my ear." You know, my right ear is not saying the same as my left.

So I'm going to use my vision more in the short term to try and get me through this. Exactly the same as if I broke my leg. I'm going to put in a cast, put in a crutch, put in a crutch, start using a

crutch, and then once the bone is healed, you know, I'm going to get rid of that and and carry on walking. It'd only be maladaptive if my bone was fully healed and I continued to use the cast and I continued to walk with a crutch.

And unfortunately that's what happens in trip is that uh people have this adaptive response where the system's not working. It hopefully then heals over time and yet the brain continues to say I'm going to continue to ignore my

vestibular system as much as possible. I'm going to vision more. Um and that means you're prone to these tricks of light, color contrast, depth perception, all these sensory reference points. So whenever you're turning your head, your brain is using these recept references

around you to understand how fast you're moving. Um, and so if we're someone that has lots of vertical lines or lots of horizontal lines, it gives you that visual sense of acceleration, which is why the supermarket is just so horrible.

Um, so Ben, when you had it, was there any I remember talking to you about it and you saying just talking to people was making you feel dizzy. Like if you were talking face to face with someone like this, you were like, "Oh, I could

just feel myself swaying around the whole time." Oh, I was going to say I wouldn't have back then a few years ago wouldn't have actually been able to do this sort of video call sort of format combination of people moving but also

then me having to move along with it. But is it's that combination of like when you see something moving like you say there's so much overlap with a lot of these chronic conditions where as you said it starts adaptive. It's that the

body's doing the right thing for you, but after a while, you've had that time.

The original insult, so to speak, is gone. But now you start seeing someone moving in front of you, like say in in person over video. And although you might not necessarily notice at the time, but realistically, what's happening is is your brain is saying, is

that me moving or is that someone else moving? It just can't seem to get those systems to cooperate properly or at least interp interpret them appropriately. So yeah, people moving was awful, especially because when they're when you're in front of someone,

they're usually a lot closer to you. Same with a computer screen, it's just filling up so much of that visual field field of vision and it's and again you just get that sensation of hang on, is it me moving or are they moving?

Yeah, exactly right. They found in the young populations, anxiety or stress was one of the big factors. And again, that doesn't mean it's all psychological like it's all in your head type of thing.

What happens when you're anxious and when you're stressed is our pupils are going to dilate so to let more light in.

But the point of letting more light in is it means we get more light to uh the rods that go around our eye that are more sensitive to motion which is really important. Right? So if you imagine our

stress response is the same for a uh tiger being let into this room as a bad uh unwanted email or an unexpected bill or breaking my leg. The stress response is all the same. So unfortunately evolution has primed us so when we have

any kind of stress our pupils dilate so we're more motion sensitive ideal right so if I was talking to you right now and I'm and tie comes into the room I want to see that with mic peripheral vision

as soon as possible so be like whoa what is that rather than waiting it for it to come around to the in front of me so I can be like oh wow Bengal tiger that's pretty scary so unfortunately when we're

when we're stressed we have this increased uh visual perception and and unfortunately the brain the human brain is prone to using our vision for threat detection. So for that exact reason. So if you said, "Hey Jay, I've poised a

snake into your room. I probably wouldn't close my eyes and like listen for the snake and I probably wouldn't reach around my hands and legs and try and feel for it. I'm going to look for it." So unfortunately when we're more

when we're under stress, we start relying more and more on vision. We call it visual dependency. Uh and that can really create this horrible feedback loop that because you're so emotion sensitive, you feel more stressed. And because you feel more stressed, you're

more emotion sensitive. So they found in this study that with younger people, it's often anxiety and stress. But we know that it's been a stressful for years. So So Trip PD has has just absolutely skyrocketed last years.

So this paper is a really fascinating one. So what they did is they took a whole bunch of people um this is from the uh um University College of London. So it's a well established you know respectable place

and they basically took 59 people with triple BD and they compared them to 89 healthy uh control. So people don't have any dizziness at all and uh then did like some extra little tests where they compared it to 16 people with um

bilateral vestibularopathy. Now I tend to get bit tongue tied so I'm going to say vestibular hypounction just to say save me saying that over and over. Vista hypopunction basically means bilateral means that both sides have been damaged.

The reason that's such a good comparator is when you have damage to both sides.

Unfortunately that's a chronic condition very hard to resolve that dizziness. So you've got uh a group of people who are perpetually dizzy, always feel a bit unsteady and and rocking, bobbing, swaying, um very similar symptoms to trip PD. However, in Trip PD, there's

often nothing wrong at all. So there's been no well, it may have been damaged, but it's recovered or there's no finding at all. So that's again why it's so frustrating because you you go to your neurologist and you have all your

testing done. You have the MRI and you have the test and you have the Clorox, you go through all these horrible tests and they're like, "Okay, it's totally normal." So it's a little bit different to um vestibular hyper function where

they do this essay say oh yeah there's actually reduced function there. So they took these given groups and they basically then exposed them to 12 different questionnaires all looking at uh psychological factors, cognitive factors and dizziness severity.

And really interesting they they came out with kind of what the key identifiers were and the the big one really was that people with triple BD have this uh higher significantly higher sense of injustice and that their condition is irreparable. So that they

feel the symptoms are are unfair and that they're never going to get better. And that was the number one finding out of out of all these different psychological assessments they did and all the things. the number one predictor

for um severity of symptoms was how much someone kind of rages against the condition. And that's uh before this paper came out, that's something you and me have discussed quite a few times is you see that personality type and and

and you see that with recovery that the people who really hate their symptoms and really rage against it and spend a lot of time talking to us about, you know, quite bitter about it, they're the ones who take the longest to recover.

the ones who can get into a state of acceptance and start to see it as, yeah, it sucks. I'm not having a good day now, but actually, just like you said at the beginning, Ben, actually, I've never fallen over from this. I've never

actually got hurt. You know, I'm, you know, I'm not the person I want to be, but actually, I'm not in danger. They're the ones who when they can start to get to a point of septum, actually, their symptoms drop off massively. And that's

what this paper found is that, you know, the more you fight it, it's just not fair, but the the more you fight it, the the worse it is.

Yeah, absolutely. So, um, they did a whole bunch of assessments on this and that was the the biggest one really by by far. Um, so nearly everyone, so 89% of people scored very very highly in this uh in this

sense of unfairness. Um and the second one that was the the main differential between um vista hypo function and healthy controls was that visual dependency. So the big one was that basically being in any space where there's lots of visual reference points

makes them feel dizzy. So when you had a Ben did you score I can't remember when we used to we we talked a lot when Ben had did you have that that kind of that feeling of unfairness that because you

were like you were super fit. So for people who don't know Ben Ben is like a national level gymnast. Uh, you know, where did you come in the World Championships Ben?

Uh, third in the Junior World Championships. Yeah. Yeah. Which is just amazing. So, you were super fit. And I remember you sending me these videos you doing these most outrageous like tumbles and flips and all this kind of stuff and

being like, "Yeah, I'm still dizzy." Like what? It definitely highlighted though how like trip it really showed that side of it where there's clearly not a dysfunction in uh how my vista system was working to be able to be able to do

those things but there was a severe uh symptom to it of of the sense of foggess and fuzziness and motion sickness that I had never had prior to um my tumbling career prior to that. So yeah, the the

sense of unfairness was huge given where I'd been, what had then happened, the fact that it stopped me from it took me away from this identity of what I was as kind of, you know, elite athlete at that

point. Um, and took away from that and and it kind of yeah, you can't understand how that can possibly happen to you. And then you realize after a couple months, I think I said to you last week about this, it's like at first

you assume it will just it's fine. It will go away. Then it stays for a couple months and you think, "Oh my god, am I one of these people that ends up with one of these lifelong conditions that

just never goes away regardless of what you do." And yeah, you start to realize particularly obviously from working with you, how many years ago it was when it first kind of began actually realizing to both accept that they were there and

learning to sit with the symptoms. Realize and and admittedly this is easier said than done and takes time but realize that actually this does pass because of its waxing and waning nature.

It does pass. Becoming aware of how many times actually done something and the symptoms weren't triggered. And yes, there were times when of course symptoms were triggered but actually it is just something that's just it is there. It's

not always something that has to be triggered consistently by a certain thing. And actually being able to go and realize that, go out and do things, realize a big part of what makes it so unpleasant is actually the sense of

injustice and the anxiety and the fear response that comes with it and just over time been able to go and do things and eventually leave lead a normal life again.

Yeah, 100%. Yeah. No, you just exactly exactly right. So it's not easy though, is it? It's kind of one of those things that you just say like, "Hey, can you just accept it and move on?" And it's obviously not that easy to do. And

that's why that cognitive behavioral therapy is such an important part of the the vestibular rehab therapy we do that you kind of really have to help people get into that like you can't just I think being zen and being um you know

like present is really easy when life is great and really impossible when life is tough. So basically it just comes down to practicing it a lot of trying to you know take that moment take a breath just when that anxiety starts building up or

that frustration builds up too much just you know actually how am I right now like it's okay I'm not having the best day but I have actually managed to still cook the kids dinner and I still gone for a walk you know that's great so I

know you're not going for a run but I'm taking going for a walk looking after the dog I actually did a you know I managed to do my emails today so it's kind of trying to really make note of

those small wins because actually it's those small wins that are your life. And so it's it's when you look at the big picture and you say, "Oh, I'm not running a marathon anymore." That's when it will really just crush you. But or

for you, you know, you might be saying, "Well, I'm not, you know, I'm not I'm not competing at my highest level." But you're still like way, you know, I I was joking around with you a little while back trying to do some calisthetics and

I can't do at all and you were just like smacking out. So your your your low is still way better than my high. So it's trying to take these little steps and be like actually, you know, what are the

little wins today? And just know that as you start to improve, it won't be linear line. You will have these these little hiccups. The people who do great are the ones who can absorb those those those bumps and be like, "Okay, it's been a

rough couple of days, but actually the last few days were pretty good." The ones who who will struggle more, the ones who are like, "Oh, I've had bad days and now it's going to get back to how it used to be and the symptoms

skyrocket." Absolutely. Unfortunately, those you know, there is a time and place for medication. Um I I don't think that we should be starting front line with medications. We should be doing conduit behavioral therapy, mindfulness, breathing, vestibular rehab that's

graded and just trying to work through these progressively more challenging exercises that are challenging but not stressful. If you increase stress, you increase that visual dependency. Um, and then we want to say if at some point we find someone cannot, you know, the the

psychology uh and and remember it's not just you're thinking badly. Triple PD is a functional disorder. So it's a bit like PTSD. We don't look at someone with PTSD and say like could you not be so stressed like come on just don't don't

think about don't be stressed like we recognize there's functional uh patterns that that are changing their in their brain waves and the way their brain is thinking. It's like that with your PD.

So we kind of don't blame people for it. It's just how it is. The syndrome itself changes the way you think. But we can we can change that again but just these little regular patterns. So Ben, we're going to be keep keep going through the

kind of latest research on different types of chronic dizziness. So we'll we'll get the next one sorted and and see how else we can help people with these conditions. Exercise two.