Criteria for the diagnosis of Persistent Postural‐Perceptual Dizziness (PPPD)

Criteria A‐E must be satisfied to make a diagnosis of PPPD. A. One or more symptoms of dizziness, unsteadiness, or non‐spinning vertigo are present on most days for 3 months or more.1‐3 1. Symptoms are persistent, but wax and wane. 2. Symptoms tend to increase as the day progresses, but may not be active throughout the entire day. 3. Momentary flares may occur spontaneously or with sudden movements. B. Symptoms are present without specific provocation, but are exacerbated by: 1. Upright posture, 2. Active or passive motion without regard to direction or position, and 3. Exposure to moving visual stimuli or complex visual patterns, although these three factors may not be equally provocative.4 C. The disorder usually begins shortly after an event that causes acute vestibular symptoms or problems with balance, though less commonly, it develops slowly.5 1. Precipitating events include acute, episodic, or chronic vestibular syndromes, other neurologic or medical illnesses, and psychological distress. a) When triggered by an acute or episodic precipitant, symptoms typically settle into the pattern of criterion A as the precipitant resolves, but may occur intermittently at first, and then consolidate into a persistent course. b) When triggered by a chronic precipitant, symptoms may develop slowly and worsen gradually. D. Symptoms cause significant distress or functional impairment. E. Symptoms are not better attributed to another disease or disorder.6 Notes (1) The primary symptoms of PPPD include non‐motion sensations of disturbed or impaired spatial orientation (dizziness), feelings of being unstable while standing or walking (unsteadiness), and false or distorted sensations of swaying, rocking, bobbing, or bouncing of oneself (internal non‐spinning vertigo) or the surroundings (external non‐spinning vertigo) [45]. (2) Symptoms must be present for more than 15 of every 30 days. Most affected individuals experience symptoms every day or nearly every day. (3) Symptoms need not be continuous, but must be present for prolonged (hours‐long) periods throughout the day. Momentary symptoms alone do not fulfill this criterion. (4) All three provocative factors of criterion B must be discernable in the clinical history, but do not have to be equally troublesome. a. Upright posture means standing or walking. b. Active motion refers to a person’s self‐generated movements. Passive motion refers to a person being moved by conveyances or other individuals (e.g., riding in a vehicle or elevator/lift, being jostled in a crowd). c. Visual stimuli may encompass large or small portions of the visual field. Full field stimuli (e.g., passing traffic, rooms filled with busy décor, graphics displayed on large screens) are the most provocative, but smaller stimuli (e.g., books, computers, mobile electronic devices) may be troublesome when they are the focus of sustained visual attention. (5) The most common precipitating events are peripheral or central vestibular conditions (25‐30% of cases), attacks of vestibular migraine (15‐20%), panic attacks or generalized anxiety that manifest prominent dizziness (15% each), concussion or whiplash injuries (10‐15%), and autonomic disorders (7%). Other events that are capable of producing vertigo, unsteadiness or dizziness, or altering balance function (e.g., cardiac dysrhythmias, adverse drug reactions) trigger the disorder less commonly (collectively ~3%) [29,30]. The majority of conditions that trigger PPPD are acute or episodic in nature. Patients report the onset of chronic symptoms of PPPD following their acute illnesses. However, precipitants such as generalized anxiety disorder, autonomic disorders, and peripheral or central degenerative conditions may develop insidiously. In these cases, patients are less likely to report a distinct onset. When a specific precipitant cannot be identified, particularly when symptoms slowly worsen, re‐evaluation of the diagnosis is indicated and a period of prospective monitoring may be needed to confirm it. (6) PPPD may co‐exist with other diseases or disorders. Evidence of another active illness does not necessarily exclude a diagnosis of PPPD. Rather, clinical judgment must be exercised to determine the best attribution of the patient’s vestibular symptoms to all identified illnesses [44,51].