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Attentional dysfunction serves as a candidate organizing mechanism for persistent postural-perceptual dizzinessAttentional Issues May Be a Key Factor in Dizziness
Frontiers in MedicinePublished September 10, 2026DOI ↗Editorial oversight: Dr. Ji-eun Park, MD · Brain, Mind & Pain
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Key Takeaway
Recognize attentional dysfunction as a candidate organizing mechanism and potential target for future PPPD research.
This narrative review synthesizes evidence regarding the role of attentional dysfunction as a candidate organizing mechanism for patients with persistent postural-perceptual dizziness (PPPD). The review integrates findings from neuroimaging, behavioral studies, and clinical observations to map the underlying pathophysiology of the condition.
Key findings include structural and functional alterations in the DLPFC, ACC, posterior insula, precuneus, visual cortex, and vestibular cortical regions. These changes involve large-scale networks including attention, salience, sensorimotor, visual, and default-mode networks. Behaviorally, postural control and self-motion perception may become excessively attention-dependent, leading to stiffened postural strategies and abnormal sensory-perceptual scaling. Clinical phenotypes identified include balance vigilance, attentional bias, and various intolerances related to visual, quiet standing, and motion.
The authors note that the proposed active-inference model is hypothesis-generating rather than definitive. Clinical relevance lies in identifying attentional dysfunction as a framework for future research using ERP, computational modeling, and dual-task paradigms. These findings may eventually support phenotype-stratified trials to improve targeted management of PPPD.
How this fits prior evidence
This narrative review addresses a gap in the underlying mechanisms of persistent postural-perceptual dizziness. It builds upon the established framework of five anchor clinical phenotypes used to guide individualized management. While previous evidence established these phenotypes for treatment sequencing, this review explores the underlying attentional dysfunction and neuroimaging findings that may explain these clinical presentations.
Researchers are looking into why some people experience persistent postural-perceptual dizziness (PPPD). This condition involves a feeling of dizziness that lasts for months. A review of current evidence suggests that problems with attention, rather than just inner ear issues, may be a main reason why these symptoms continue.
Studies show that people with PPPD may have changes in specific brain regions involved in attention and sensory processing. These individuals might also show different behaviors, such as becoming overly focused on their balance or having difficulty performing two tasks at once. These findings suggest that the brain may be over-relying on attention to manage balance.
Because this is a narrative review of various studies, the findings are currently used to form new theories rather than provide a definitive diagnosis. The research highlights that attention is a key area for future study. Patients should speak with their doctor to discuss how these findings might relate to their specific symptoms.
What this means for you:
Attentional issues may play a major role in persistent dizziness, offering a new way to understand the condition.
Common questions
What is the link between attention and dizziness?
The review suggests that attentional dysfunction may be a main way the body organizes the experience of persistent postural-perceptual dizziness. This means the brain's way of processing information and focusing on balance might be affected in people with this condition.
How does this affect daily behavior?
People with this condition may show specific behaviors, such as becoming overly dependent on attention for balance, having trouble with dual-tasking, or showing stiffened postural strategies. These findings help identify how the brain handles movement and sensory information.
Is this a proven cause of dizziness?
The current evidence is a narrative review, which means it is used to generate new theories rather than provide a definitive proof. The model is currently considered hypothesis-generating, so it is not yet a confirmed medical rule.
Study Details
Study typeSystematic review
EvidenceLevel 1
PublishedSep 2026
View Original Abstract ↓
Persistent postural-perceptual dizziness (PPPD) is a common chronic functional neuro-otological disorder characterized by persistent non-spinning dizziness, unsteadiness, and heightened sensitivity to upright posture, motion, and visually complex environments. Several conceptual models have been proposed to explain its persistence, including failure of readaptation after a destabilizing event, maladaptive multisensory integration with excessive visual or somatosensory weighting, and prediction-actual sensory mismatch with amplified prediction errors. This narrative review synthesizes neuroimaging, behavioral, psychophysical, and clinical evidence to examine attentional dysfunction as a candidate organizing mechanism that may link these partly overlapping pathways. Structural and functional alterations involving the dorsolateral prefrontal cortex (DLPFC), anterior cingulate cortex (ACC), posterior insula, precuneus, visual cortex, vestibular cortical regions, and large-scale attention, salience, sensorimotor, visual, and default-mode networks suggest distributed functional reorganization rather than a single lesional substrate. Behavioral studies indicate that postural control and self-motion perception may become excessively attention-dependent in subsets of patients, with dual-task effects, altered visual exploration, stiffened postural strategies, and abnormal sensory-perceptual scaling. Clinical studies further show balance vigilance, attentional bias, and heterogeneous symptom phenotypes, including visual intolerance, quiet standing or sitting intolerance, passive motion intolerance, and active motion intolerance. We propose a revised active-inference model in which attention contributes to dysregulated precision weighting across visual, vestibular, somatosensory, interoceptive, and postural prediction-error signals. This model is hypothesis-generating rather than definitive. It accommodates patients with or without a clear preceding vestibular disorder and patients whose symptoms occur without overt body motion. The framework highlights testable targets for future studies using event-related potentials, computational modeling, dual-task paradigms, and phenotype-stratified treatment trials.
