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

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.