Follow Dr. Win Huang to Learn Clinical Diagnosis (Case 10)

Sometimes “Dizziness” Is Not Really Dizziness

Last week I saw a very interesting patient.

She was a 68-year-old woman of Chinese descent who came all the way from Tahiti. She was referred by one of my long-term patients. Her ancestors migrated to Tahiti many years ago, and she is already the third generation or even later, so she no longer speaks Chinese. However, she still has strong trust in Chinese medicine.

She came to see me because of a problem that had bothered her for many years — dizziness.

According to her description, this “dizziness” had been present for many years. She had seen many specialists and undergone numerous medical examinations, but no clear cause had ever been found.

Her description of the symptoms was very specific.

When lying down — no dizziness.
When sitting — no dizziness.
Turning in bed — no dizziness.

Even when sitting, moving her head up, down, or side to side did not trigger any dizziness.

However, once she stood up and started walking, she began to feel dizzy. Sometimes when she saw moving environments — such as crowds, traffic, or visually complex surroundings — the sensation became worse.

When I heard this description, my first thought was a relatively uncommon condition known as Persistent Postural-Perceptual Dizziness, or PPPD.

The characteristic feature of PPPD is that symptoms are usually mild when lying or sitting, but patients may experience persistent dizziness or unsteadiness when standing, walking, or in visually complex environments.

I shared this idea with her. She immediately took out her phone and looked up the condition. After comparing the symptoms, she said it sounded very similar to what she had been experiencing. She told me that although she had seen many doctors before, no one had ever given her a clear explanation, so hearing this possibility gave her a sense of direction.

Next, I performed several simple physical examinations.

First, I asked her to stand with both feet together. Whether her eyes were open or closed, she was able to maintain a stable posture. This suggested that her proprioceptive system was likely intact.

Then I asked her to stand on one leg. She could hardly maintain the position, regardless of whether her eyes were open or closed.

After that, I asked her to perform a tandem walking test, walking along a straight line. Normally, a person can walk along a straight line without difficulty. However, she swayed noticeably and had trouble maintaining balance.

These findings made me reconsider the case.

PPPD is usually considered a functional vestibular disorder. Patients often feel dizzy or unsteady, but objective neurological examination usually shows no clear abnormalities. In this patient, however, there was a measurable decline in balance ability.

So I returned to the most basic question:

Was the patient’s “dizziness” truly vertigo in the medical sense?

True vertigo usually presents as a spinning sensation, as if the environment is rotating, often accompanied by nausea or vomiting. But that was not what she described. What she actually felt was instability when standing and walking — a floating sensation, as if walking on soft ground.

In other words, what she called “dizziness” was actually closer to a balance disorder.

Once this distinction became clear, the clinical picture started to make sense.

Human balance depends on the integration of several systems, including the vestibular system, proprioception, the cerebellum, and the brain’s ability to integrate all this information. With aging, each of these systems can gradually decline, especially the brain’s ability to integrate balance information.

Under such circumstances, many older adults develop a typical pattern:
they can remain relatively stable while standing still, but become unstable during walking.

Looking again at this patient’s examination results:

She could stand steadily with both feet together, but had difficulty standing on one leg and could not walk steadily along a straight line. These findings clearly suggested a reduction in her balance capacity.

Therefore, this case was not PPPD and not classical vertigo. Instead, it was more consistent with age-related decline in balance integration, leading to a balance disorder.

This case reminded me of something important in clinical practice. Many patients say they feel “dizzy,” but that does not necessarily mean true vertigo. Sometimes the word “dizziness” simply reflects a subjective feeling of instability. If we fail to distinguish between vertigo and balance disorders, it is easy to take the wrong diagnostic direction, and any treatment aimed at “dizziness” may miss the real problem.

Very often, once we hear the word “dizziness,” we continue to focus only on dizziness. A series of tests may follow — MRI scans, blood tests, vestibular examinations — and when none of them reveal clear abnormalities, both the patient and the physician may feel lost.

But sometimes the simplest approach is the most useful: basic balance testing.

In this patient, the inability to stand on one leg and difficulty walking in a straight line made PPPD unlikely. The absence of dizziness while sitting and a normal finger-to-nose test helped exclude cerebellar dysfunction. Stable standing with eyes open and closed suggested that proprioception was intact. The absence of dizziness while lying down or turning the head also made vestibular disorders less likely.

Putting all these findings together, my final impression was decline in cerebral balance integration.

Once the problem was identified, the treatment strategy became clearer. The focus was no longer on treating “dizziness” itself, but on improving the brain’s balance integration function. Therefore, I mainly used scalp acupuncture and recommended that the patient perform regular balance training exercises at home.