Cognitive Behavioral Model of Persistent Postural Perceptual Dizziness (PPPD)
Initial or precipitating phase
Persistent phase
Vulnerability
Triggers for current episode
Vulnerability
• Pre-existing anxiety
• Sensitivity to internal sensations
• Illness history
• Beliefs about illness
• Beliefs about coping ability
• High trait anxiety
• Low trait extraversion
Acute vestibular disorder, e.g.
• Benign Paroxysmal Positional
Vertigo (BPPV)
• Vestibular neuritis
• Labyrinthisis
• Vestibular migrane
• Meniere’s disease
or
Panic attack with focus on
balance sensations
• Pre-existing anxiety
• Sensitivity to internal sensations
• Illness history
• Beliefs about illness
• Beliefs about coping ability
• High trait anxiety
• Low trait extraversion
Balance control system
dysfunction resulting in
balance symptoms
Later:
• Acute vertigo
• Imbalance
• Nausea
• Vomiting
• Persistent
dizziness
• Hypersensitivity
to motion and
visual stimuli
• Avoidance of any movements
or activities that may cause
dizziness symptoms - e.g. head
or body movements, walking,
socialising
• Safety behaviours
- Holiding on for safety
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Acute vestibular disorder, e.g.
• Benign Paroxysmal Positional
Vertigo (BPPV)
• Vestibular neuritis
• Labyrinthisis
• Vestibular migrane
• Meniere’s disease
or
Panic attack with focus on
balance sensations
Balance control system
dysfunction resulting in
balance symptoms
Leads to / influences
Initially:
Behavioral
adaptation strategies
Triggers for current episode
Prevents change in
Pathway inactive
ABC
Initially:
Later:
• Acute vertigo
• Imbalance
• Nausea
• Vomiting
• Persistent
dizziness
• Hypersensitivity
to motion and
visual stimuli
Appraisals
Appraisals
• Threat beliefs
• Health beliefs
• Threat beliefs
• Health beliefs
Emotional response to
appraisal (typically anxiety)
Emotional response to
appraisal (typically anxiety)
Attentional
adaptation strategies
Voluntary
• Vigilance to environment for
potential threats to safety or
stability
• Mental checking of bodily
sensations related to balance
Involuntary
• Central ‘up-weighting’ of visual
and somatosensory cues
• Central down-weighting of
vestibular cues
Behavioral
adaptation strategies
• Avoidance of any movements
or activities that may cause
dizziness symptoms - e.g. head
or body movements, walking,
socialising
• Safety behaviours
- Holiding on for safety
Attentional
adaptation strategies
Voluntary
• Vigilance to environment for
potential threats to safety or
stability
• Mental checking of bodily
sensations related to balance
Involuntary
• Central ‘up-weighting’ of visual
and somatosensory cues
• Central down-weighting of
vestibular cues
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