Clinical picture. M., a woman in her late thirties, was referred eight months after an acute episode of BPPV that had resolved on repositioning. She reported near-constant rocking sensations, avoided supermarkets, and gripped her handbag or trolley whenever she walked on uneven ground. Her GP had repeated vestibular and neurological investigations, all unremarkable, yet she remained convinced something had been missed. In the first session, the clinician introduced the five-step loop from the PPPD psychoeducation sheet and walked through each box with M., naming her own examples at each stage: the original BPPV as the trigger, the recurrent thought "doctors must have missed something" as the threat appraisal, and trolley-gripping as the safety behaviour blocking recalibration. M. noted, with some surprise, that the diagram described her week accurately. By the end of the session she was able to articulate that her vestibular system had healed and that the alarm, rather than the ear, was the current problem, which reduced her urgency to seek further scanning.
CBT Model of PPPD: PDF Worksheet, Tools and Exercises
A visual PDF worksheet clinicians can use in session to map the dizziness maintenance loop, correct common misconceptions, and ground PPPD psychoeducation in a shared model.
Clinical vignettes
Psychoeducation Shifts the Threat Appraisal
Attention Loop Recognised in a Young Man
Clinical picture. T., a man in his mid-twenties with a history of health anxiety and one prior panic attack, presented following a vestibular migraine that had lasted three days. Four months on, he described a persistent low-level sway, worsened by scrolling on his phone, busy corridors, and any head movement at his desk. He had begun checking for wobble several times per minute, a habit he had not previously labelled as problematic. The clinician used the attention-trap section of the informational sheet to explain how repeated body-scanning amplifies the perception of normal postural sway and disrupts the automatic processing that balance ordinarily relies on. T. recognised his checking behaviour on the diagram and agreed to a brief between-session experiment: a ten-minute walk during which he directed attention outward rather than inward. He returned reporting that sway felt noticeably less pronounced during that period, which provided a concrete, experientially grounded rationale for the attention-retraining work that followed.
Patients with Persistent Postural-Perceptual Dizziness arrive in your consulting room having already seen neurology, ENT, and often cardiology. They know something is physically wrong; they have the symptom diary to prove it. Convincing them, verbally and in real time, that a perpetuating psychological loop is keeping the dizziness alive, without dismissing their very real somatic experience, is one of the harder psychoeducation tasks in a neuro-rehabilitative caseload. This fiche PDF gives you a visual model to do exactly that, in a single session moment.
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Why PPPD is so difficult to explain without a visual anchor
The central clinical challenge is not complexity but perceived contradiction. Patients hear "your ear has healed" as "this is all in your head", and they shut down before you can introduce the maintenance model. Without a shared diagram to point to, the loop concept stays abstract: threat appraisal, arousal, attentional hypervigilance, and safety behaviours feel like four separate ideas rather than one self-sustaining cycle.
There is also a real symptom-credibility issue. Unlike panic disorder, where patients often already suspect an anxiety component, PPPD patients typically do not. Dizziness in supermarkets, on escalators, or in front of patterned floors feels purely vestibular. Pointing to a CBT cognitive model that names those environments as attention traps rather than physical hazards requires a visual reference point that the patient can follow in real time, and take home afterwards.
The fiche also pre-empts the most common confusions, PPPD versus BPPV, "real" versus "psychological", before they derail the session. That saves significant time.
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Access all the toolsWhat the fiche contains: a visual loop for in-session use
The support visuel at the heart of the fiche is a five-box circular loop: Trigger → Threat → Arousal → Watch → Safety behaviour, each linked by a caption explaining the mechanism ("arousal itself adds dizziness", "gripping blocks recalibration"). You can trace each patient's presentation around that loop in real time, naming which boxes are most active for them before introducing any intervention rationale.
Beyond the loop, the fiche maps three trap categories in plain clinical language: threat thoughts (e.g. "I can't trust my body anymore"), attention traps (body checking, visual dependence, lost autopilot), and behaviour traps (gripping, stiffening, avoidance). This taxonomy maps directly onto the CBT maintaining processes framework and gives you a structured way to prioritise intervention targets with a patient who presents across all three domains simultaneously.
A section on what helps break the loop translates directly into graduated behavioural work: free head movement in small doses, progressive grip-release, deliberate return to busy visual environments. This connects naturally to graded exposure planning and can be used alongside a physiotherapist's vestibular rehabilitation programme. Three in-session discussion prompts appear at the foot of the fiche, grounding debriefing in specific behavioural targets rather than general insight.
> Key point: the fiche is a visual support that structures the psychoeducation conversation; it is not a self-completion questionnaire. The clinician uses it to point, annotate, and anchor, and the patient leaves with a concrete reference model, not a homework assignment.
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When and how to introduce the fiche
Timing matters here. The fiche works best after a preliminary anamnèse has established the original vestibular trigger, the duration of symptoms, and the patient's current avoidance pattern, typically from the second or third session onward. Introducing it too early, before the patient feels heard, risks the "all in your head" misread the fiche itself addresses.
A useful opening: "I'd like to show you something that's helped other people make sense of why dizziness can stick around even after the ear has healed, it maps out a loop, and I'd like us to work out together which parts feel most familiar to you." This framing positions the fiche as collaborative mapping, not didactic instruction.
Patients with prominent health anxiety or high reassurance-seeking behaviour may resist the loop model initially, particularly the "checking amplifies normal sway" panel, which can feel counterintuitive. Spending more time on the autonomic nervous system arousal pathway, and normalising physical anxiety sensations as a legitimate amplifier, often eases that resistance. For patients whose primary maintenance mechanism is avoidance, the fiche pairs well with a formal exposure hierarchy built around the environments listed in section two (supermarkets, screens, escalators, patterned floors).
The debrief question to prioritise is the one on safety behaviours: "If you find yourself gripping or stiffening, what would dropping one safety behaviour this week look like?" That single question, asked with the loop diagram still visible, converts psychoeducation into a concrete, adaptive coping commitment before the session ends.
The fiche does not replace the therapeutic formulation or the vestibular rehabilitation referral. It makes the explanation cleaner, the vocabulary shared, and the patient's first behavioural step easier to name.
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