The Clinical Presentation, Psychological Characteristics, and Attitude of the Subtypes of Persistent Postural-Perceptual Dizziness (PPPD)

Background: Persistent Postural Perceptual Dizziness (PPPD) unifies several preceding diagnoses that share persistent non-vertiginous dizziness and visually or posturally triggered unsteadiness. Whether clinically meaningful subtypes exist within PPPD remains debated. We aim to characterise demographic, clinical, and psychological profiles of untreated PPPD patients and test for differences across subtypes corresponding to historical entities: Chronic Subjective Dizziness (CSD), Phobic Postural Vertigo (PPV), Space Motion Discomfort (SMD), and Visual Vertigo (VV). Methods: Retrospective observational study of consecutive PPPD patients evaluated in a single neurotology practice (2023–2025). All underwent standard vestibular work-up, symptom profiling, and psychological assessment (Beck Anxiety Inventory, Beck Depression Inventory-II, and clinician-rated attitudes). Results: Eighty-eight patients (mean age 40 years; female predominance) met PPPD criteria. PPV was most frequent (>two-thirds), followed by CSD. Instability predominated (54%), whereas dizziness was less common (19%), indicating mainly postural disturbance. Subtyping showed attitude differences (p=0.0006): SMD/VV patients more often displayed obsessive attitudes and less frequent anxious attitudes, while PPV patients were less often obsessive and more often anxious. Anxiety and depression scores did not differ significantly across subtypes. SMD/VV was strongly linked to acute vestibular triggers (all unilateral vestibular neuritis), whereas CSD frequently occurred without prior vestibular disease. Psychosocial triggers and prior psychiatric diagnoses clustered in specific subgroups. Conclusions: PPPD could be considered a heterogeneous spectrum with subtype-specific clinical–psychological profiles. Integrating subgroup profiling and systematic psychological assessment may guide personalised treatment, prioritising cognitive–behavioural strategies for obsessive/visual profiles and vestibular rehabilitation for postural-dominant presentations; longitudinal studies should validate tailored pathways and refine prognostic stratification.