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

Abstract

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.

Persistent postural-perceptual dizziness (PPPD): a common, characteristic and treatable cause of chronic dizziness

“…Thus, making the diagnosis relies on the patient history (Box 1 1). Dizziness, unsteadiness and vertigo are notoriously difficult to describe and patients will offer various reports of symptoms, including non-spinning vertigo (“I feel a sense of motion – it’s not whirling – even though I’m still”; “I feel as if my body is swaying like I’m on a boat”), unsteadiness (“I feel I’m about to fall”), light-headedness (“I feel as if I might pass out”) and mild dissociation (“I feel spaced out/as if my legs are spongy/as if I’m floating”).…”

“…Symptoms are exacerbated by upright posture, moving about actively or being moved passively (eg, standing, walking or riding in a vehicle), or being immersed in environments with complex or moving visual stimuli (eg, a hallway with complex patterned carpet, a supermarket aisle, looking at traffic). This visual hypersensitivity, which can occur in isolation as the symptom of ‘visual vertigo’,10 is a characteristic feature of PPPD, and often one of its most impairing features, especially in the modern world with its ever-growing intensity of visual stimulation.

Bárány Society diagnostic criteria for persistent postural-perceptual dizziness1 One or more symptoms of dizziness, unsteadiness or non-spinning vertigo on most days for at least 3 months.Symptoms last for prolonged (hours-long) periods of time, but may wax and wane in severity.Symptoms need not be present continuously throughout the entire day.Persistent symptoms occur without specific provocation, but are exacerbated by three factors: upright posture, active or passive motion without regard to direction or position, and exposure to moving visual stimuli or complex visual patterns.The disorder is triggered by events that cause vertigo, unsteadiness, dizziness, or problems with balance, including acute, episodic or chronic vestibular syndromes, other neurological or medical illnesses, and psychological distress.When triggered by an acute or episodic precipitant, symptoms settle into the pattern of criterion A as the precipitant resolves, but may occur intermittently at first, and then consolidate into a persistent course.When triggered by a chronic precipitant, symptoms may develop slowly at first and worsen gradually.Symptoms cause significant distress or functional impairment.Symptoms are not better accounted for by another disease or disorder.

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“…Patients with Parkinson’s disease and other structural gait disorders can develop functional dizziness 22. In this situation, PPPD is suggested most strongly by the presence of sensitivity to visually challenging stimuli when patients are seated 1. Panic disorder and generalised anxiety disorder may be causes or sequelae of PPPD.…”

“…Persistent postural-perceptual dizziness (PPPD) is a chronic functional disorder of the nervous system, characterised by non-spinning vertigo and perceived unsteadiness (see box 1 for diagnostic criteria1). The symptoms are exacerbated when patients assume upright postures and in situations with complex or moving visual stimuli (figure 1).…”

“…In tertiary dizziness centres, either phobic postural vertigo or chronic subjective dizziness, two conceptual predecessors of PPPD, is the second most common diagnosis, accounting for about 15%–20% of all patient presentations 4. Prospective studies of patients who were followed for 3–12 months after acute or episodic vestibular ailments such as vestibular neuritis or BPPV suggest that persistent dizziness of the type seen in PPPD will develop in one out of four individuals,1 making the incidence of PPPD in this situation much higher than widely appreciated.…”