Persistent Postural Perceptual Dizziness (3PD) Flashcards
1
Q
FND Spectrum of disorders
A
- Functional movement disorders (FMD)
- Complex regional pain syndrome (CRPS)
- Persistent postural perceptual dizziness (3PD)
- Functional seizures
- Functional cognitive disorders
- Persistent post-concussion symptoms (PPCS)
2
Q
What is 3PD
A
- Falls under the chronic vestibular syndrome
- High predisposing to those who have anxiety or panic disorder
- Precipitants: psychological distress, vestibular, other medical
- Comorbidity: anxiety, phobia, depression
- Predisposing factors: neurotic temperament, preexisting anxiety
3
Q
Pathophysiologic processes in the development of PPPD
A
- Precipitants: vestibular crisis, medical event, acute anxiety
- Acute adaptation: visual-somatosensory dependence, high-risk postural control strategies, environmental vigilance
- Recovery: neurologic, medical, behavioral
- Failure of re-adaptation: provoking factors include -> upright posture, motion of self (active/passive), visual stimuli (complex/moving)
4
Q
Diagnostic criteria for 3PD
A
- Duration: 3 months
- Provoking factors: exposures to complex visual motion demands or environments, active/passive head motion w/o directional preponderance, postural relationship (most severe when walking/standing)
- Primary Sx: vague dizziness or non spinning vertigo “walking on ice”, vague unsteadiness
- Tempo: persistent, prolonged (h
- Examination: normal physical exam, normal vestibular testing, normal MRI
5
Q
Main clinical characteristics of 3PD
A
- Persisting subjective non-rotational vertigo or dizziness
- Hypersensitivity to motion stimuli: pt’s own movement or motion of objects in the visual surround
- Difficulties with precision visual tasks
- Typically have normal values in clinical balance tests
- Some pts may develop 2ndy functional gait disorder with slow or hesitant gait or “walking on ice”
- Objective tests to prove the diagnosis of 3PD do NOT exist
6
Q
Describe visual discomfort for 3PD patients
A
- Those with 3PD report higher visual discomfort to images that deviate from natural spectra (busy images)
- Images that produce high discomfort tend to share similarities with the types of challenging, highly cluttered environments that trigger 3PD symptoms
7
Q
What is the visual vertigo analogue scale
A
- Patient rates how severe their symptoms are for each stimuli
- Used to help decide treatment plan/strategy
8
Q
Outcomes for 3PD to guide treatment
A
- Visual vertigo analogue scale
- Situational vertigo questionnaire
- Patient specific functional scale + fear avoidance
9
Q
Slide 14
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10
Q
Slide 15
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11
Q
Presentation of symptoms for 3PD
A
- Typically pts don’t experience symptom-free intervals but rather transition from acute to chronic symptoms
- For episodic pts 3PD symptoms may remit & then return with recurrences of the triggering condition before settling into a persistent pattern
- 3PD often follows an acute vestibular disorder: ~3/4 of individuals w/ longstanding 3PD have co-existing anxiety or depressive symptoms
12
Q
Common clinical exam findings for 3PD
A
- Normal but symptomatic oculomotor testing
- Head impulse & postural vestibular testing normal but symptomatic
- Abnormal & usually severe motion sensitivity
- Overall integrity of postural control w/ weight shifts, single leg, & tandem balance, unless showing some co-morbid functional overlay
- Presence of safety behaviors: frequent touching walls, avoidance of unsupported standing/walking
13
Q
Red flags that are NOT 3PD
A
- Indistinct onset (possible but not common): early in the course of progressive neurotologic disease, generalized anxiety disorder & dyautonomias may present this way
- Progressive symptoms (slowly worsening over years): neurodegenerative disorder, peripheral neuropathy, progressive vestibular loss, cerebellar degeneration, Parkinson’s disease
- Falls (gait disturbance is not part of 3PD): peripheral/central neurotologic disorder, cardiovascular/autonomic disorder, functional gait disorder
- Constant symptoms (regardless or provocative factors): often with other physical complaints, somatic symptom disorder
14
Q
Treatment options for 3PD
A
- Medications from the classes of selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs)
- Habituation exercise: chronic hypersensitivity to motion stimuli & visual complexity that are core symptoms of 3PD indicate the need for a habituation/desensitization approach
15
Q
Habituation for 3PD
A
- Carried out in a graded fashion to motions that increase symptoms
- here motions may be head/body motions or movement of objects in the environment
- The effect of habituation tends to be specific to the motion executed so exercises are specific to motions that aggravate symptoms
