A 2026 narrative review by Yang et al. proposes that overactive, misdirected attention may help keep persistent postural-perceptual dizziness (PPPD) going after an original balance problem has settled. The authors present this as a hypothesis-generating model, not proof that attention causes PPPD.
PPPD is a chronic functional dizziness disorder involving the way the nervous system processes balance and motion. It is not defined by visible structural damage, and routine balance tests and brain scans are often normal. The disorder was defined by the Bárány Society in 2017 and is listed by the World Health Organization in ICD-11 as a functional neuro-otologic disorder.
How PPPD can appear
The condition includes dizziness, unsteadiness or non-spinning vertigo on most days for at least three months. Symptoms typically worsen with upright posture, motion or complex visual scenes and must cause significant distress or functional difficulty. A precipitating condition is part of the definition, while another explanation must be ruled out.
The review describes four symptom patterns: intolerance of visual scenes, intolerance of sitting or standing quietly, intolerance of passive motion and intolerance of active motion. In a prospective study used to develop the Athens-Lubeck Questionnaire, about two-thirds of patients had one predominant pattern, with active motion intolerance the most common.
PPPD often begins after an acute balance problem such as benign paroxysmal positional vertigo, vestibular neuritis or vestibular migraine. It can also follow medical illness, psychological distress or a feeling of instability without a clear ear problem.
What attention may be doing
The review proposes that attention affects how much weight the brain gives to visual, inner-ear, body and balance signals. One proposed explanation is that a protective, high-alert balance mode remains active after the initial problem has improved. This could make ordinary movement or visual information feel more threatening or unreliable.
This model is known as multisensory reweighting, with amplified prediction errors also proposed as a mechanism. The review describes attention as a possible bridge between these processes: close monitoring may magnify small sensations, draw more attention to them and create a self-reinforcing loop of balance vigilance.
In one cited laboratory study, people with PPPD overestimated their own body sway compared with objectively measured sway. Other cited studies found lower thresholds for detecting inner-ear stimulation, higher thresholds for detecting visual motion and reports of motion during sham trials when no motion was present.
The review also discusses conscious management of balance, including a stiff stance, cautious walking and a narrower gaze during complex walking scenes. A light mental task appeared to steady some patients by diverting attention from balance monitoring, while a heavier task could worsen balance when mental resources were depleted.
What brain imaging can—and cannot—show
Imaging studies described in the review found altered communication among attention, salience, vestibular, visual and movement networks rather than one single damaged brain area. Reported findings included changes involving the dorsolateral prefrontal cortex, anterior cingulate cortex, cerebellum, vestibular regions, the default mode network and the precuneus.
These findings describe associations or differences between patients and comparison groups. They do not show that attention is the primary problem or that attention produces the imaging changes. The review also emphasizes that PPPD is not simply anxiety, although anxiety and threat-focused attention are common and may remain linked to balance and motion cues after inner-ear recovery.
Why the findings matter
Studies cited in the review estimate that PPPD accounts for about 15% to 20% of dizziness cases in specialist referral clinics and up to 40% in dedicated vestibular centers. The source states that it mostly affects adults aged 30 to 50 and affects women about four times as often as men.
Understanding different symptom patterns may eventually help researchers study whether people with visual intolerance, motion intolerance or quiet-standing intolerance respond differently to interventions. However, the review’s proposed treatment matching has not been tested in trials. Attention-bias modification, graded virtual-reality exposure and stimulation of the dorsolateral prefrontal cortex are described as ideas for future research, not established treatments.
A meta-analysis of six randomized trials found that adding cognitive behavioral therapy to conventional treatment improved Dizziness Handicap Inventory scores by an average of 8.17 points more than conventional treatment alone. The source notes that more randomized trials are needed. This finding does not establish that attention is the cause of PPPD; it adds to evidence that psychological and behavioral approaches may be relevant to some aspects of the disorder.
The bottom line
The attention account offers a way to connect visual sensitivity, balance monitoring and altered processing of motion signals in PPPD. But it remains one proposed mechanism within a broader, multisensory disorder. Attention alone is not considered a sufficient cause, and a full medical and vestibular evaluation is needed when dizziness lasts three months or more because other conditions must be excluded before PPPD can be diagnosed.
AI tools were used to assist with the preparation of this article under our editorial standards.
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