Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the committee for the Classification of Vestibular Disorders of the Bárány Society

Abstract

This paper presents diagnostic criteria for persistent postural-perceptual dizziness (PPPD) to be included in the International Classification of Vestibular Disorders (ICVD). The term PPPD is new, but the disorder is not. Its diagnostic criteria were derived by expert consensus from an exhaustive review of 30 years of research on phobic postural vertigo, space-motion discomfort, visual vertigo, and chronic subjective dizziness. PPPD manifests with one or more symptoms of dizziness, unsteadiness, or non-spinning vertigo that are present on most days for three months or more and are exacerbated by upright posture, active or passive movement, and exposure to moving or complex visual stimuli. PPPD may be precipitated by conditions that disrupt balance or cause vertigo, unsteadiness, or dizziness, including peripheral or central vestibular disorders, other medical illnesses, or psychological distress. PPPD may be present alone or co-exist with other conditions. Possible subtypes await future identification and validation. The pathophysiologic processes underlying PPPD are not fully known. Emerging research suggests that it may arise from functional changes in postural control mechanisms, multi-sensory information processing, or cortical integration of spatial orientation and threat assessment. Thus, PPPD is classified as a chronic functional vestibular disorder. It is not a structural or psychiatric condition.

Keywords: Bárány Society; Chronic subjective dizziness; classification; phobic postural vertigo; space motion discomfort; visual vertigo.

Fig.1

Putative mechanisms of PPPD. PPPD is thought to develop via a dynamic process (arrow). In about 70% of patients, a structural vestibular syndrome (e.g., vestibular neuritis, BPPV) or other medical condition precipitates PPPD (black dot, a) [79]. Individuals who respond to the precipitating event with a high level of anxiety and body vigilance appear likely to progress to PPPD (i.e., to traverse the arrow from the initial structural event through this transient psychological stage to the chronic functional disorder) [23, 28, 30]. Anxiety-related personality traits or pre-existing anxiety disorders appear to increase the risk of developing PPPD [7, 76, 80]. In about 30% of patients, PPPD begins with acute psychological distress (black dot, b) and then progresses to the functional disorder [79]. PPPD may co-exist with structural or psychological illnesses [24], placing patients in the intersections of the functional and psychological or structural ellipses. Anxiety-related personality traits and psychological symptoms (check marks, ✓) are incorporated into PPV [12, 13], whereas they are considered predisposing factors and comorbid symptoms, respectively, in PPPD. PPPD = Persistent postural-perceptual dizziness. PPV = Phobic postural vertigo.