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

Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the committee for the Classification of Vestibular Disorders of the Barany Society Jeffrey P. Staab Annegret Eckhardt‐Henn Arata Horii Rolf G. Jacob Michael Strupp Thomas Brandt Adolfo M. Bronstein

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Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the committee for the Classification of Vestibular Disorders of the Barany Society 2017 Journal of Vestibular Research 10.3233/ves-170622 staab2017-diagnostic-criteria-for-persistent staab2017-diagnostic-criteria-for-persistent.txt, the project's staged copy 09f5ee0406e62fb7274c6541ea712dfbaa8476bd cc-by-nc medicine

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0 spans located by searching the stored text for the quote's exact words, allowing any whitespace between them A DIAGNOSIS CREATED BY MERGING FOUR OLDER TERMS RATHER THAN BY SPLITTING ONE - persistent postural-perceptual dizziness, assembled by the Barany Society from 30 years of research on phobic postural vertigo, space-motion discomfort, visual vertigo and chronic subjective dizziness, and written into the ICD-11 beta draft Quotation withheld because this record is not cleared for redistribution. what a clinician must find before calling chronic dizziness PPPD, when no examination, laboratory test or image is pathognomonic and the diagnosis is nonetheless not one of exclusion Quotation withheld because this record is not cleared for redistribution. five diagnostic criteria A-E with seven explanatory notes, a differential diagnosis against nine named conditions, and a published account of where the committee's own consensus standard was not met Quotation withheld because this record is not cleared for redistribution. method Quotation withheld because this record is not cleared for redistribution. four terms coined in four clinical settings over three decades, describing overlapping patients, consolidated into one name whose precursors are kept as index terms in the classification that supersedes them Quotation withheld because this record is not cleared for redistribution. expert-consensus expert-consensus Quotation withheld because this record is not cleared for redistribution. A DIAGNOSIS MADE BY CONSOLIDATION, WHICH IS A SHAPE THIS CORPUS DID NOT HAVE: `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.` Every other naming event we hold splits, renames, retires or revises. This one MERGES four terms from four clinical settings into one Quotation withheld because this record is not cleared for redistribution. AND THE BODY PUBLISHES ITS OWN DECISION RULE BEFORE REPORTING ANY DECISION: `The consensus process for decision-making seeks a result that has broad support. It does not require unanimity, but demands more than a simple majority. Were the latter sufficient for developing diagnostic criteria or writing treatment guidelines, then informative aspects of the minority opinion could be lost to practicing clinicians, the scientific community, and general public.` The threshold is stated, and the reason for it is that a bare majority DISCARDS INFORMATION Quotation withheld because this record is not cleared for redistribution. AND THEN IT NAMES THE SUB-QUESTION THAT FAILED THAT RULE: `Members of the Behavioral Subcommittee and their advisors reached consensus about the diagnostic criteria for PPPD and its relationship to SMD, VV, and CSD, but not PPV.` The boundary of the agreement is published with the agreement - and the corpus has nothing else that draws it this precisely Quotation withheld because this record is not cleared for redistribution. AND THE VOTE ON THAT QUESTION IS RECORDED, AT A MAJORITY THE COMMITTEE'S OWN RULE CALLS INSUFFICIENT: `In the end, a simple majority of subcommittee members voted against including PPV as a subtype of PPPD` - after two paragraphs printing the arguments in favour (30 years of research, personality and phobic factors that `affect clinical presentation`) and against (`difficult to operationalize`, `may have to be updated`, `could perplex clinicians and investigators`). A body that says a simple majority is not enough, and then reports one Quotation withheld because this record is not cleared for redistribution. AND ONE AUTHOR'S OWN EARLIER DEFINITION IS RETIRED BY NAME IN THE SAME PARAGRAPH: `However, the definition of PPPD is better supported; hence, PPPD now fully supplants CSD.` Staab defined chronic subjective dizziness in 2004, defined it `more explicitly in 2007`, and is the first author here Quotation withheld because this record is not cleared for redistribution. AND THE SUPERSEDED TERMS SURVIVE AS MACHINE-READABLE POINTERS: `The World Health Organization permits related terms to be listed in the ICD-11. Therefore, PPV, SMD, VV, and CSD were retained as index terms for cross-referencing in the ICD-11 beta draft definition of PPPD.` Our `alternatives` layer, in a real classification, decided by a committee - a retired name kept precisely so that the old literature still resolves Quotation withheld because this record is not cleared for redistribution. AND A CRITERION SET BY CONSENSUS IN THE ADMITTED ABSENCE OF ANY MEASUREMENT: `There are no data to identify one of these factors as being consistently more troublesome than the others or to determine the sensitivities and specificities of requiring the presence of one, two, or all three factors to make a diagnosis of PPPD. Therefore, the consensus definition of Criterion B requires that affected individuals report at least some difficulty with all three factors.` The strictest of the three options, chosen BECAUSE none of them has been measured Quotation withheld because this record is not cleared for redistribution. AND A WORD TAKEN BACK FROM ITS OWN TWENTIETH-CENTURY SENSE: `Here functional conditions are considered as they were in the early 19th century as disorders `arising from a change in the mode of action of an organ`, unrelated to structural or cellular deficits ... Quotation withheld.` A definition reverting a term to an older sense and naming the sense it rejects Quotation withheld because this record is not cleared for redistribution. AND THE SOCIETY'S OWN CURRENT TERM IS SET ASIDE, DELIBERATELY AND WITH A REASON: `In 2009, the Barany Society adopted the term visually induced dizziness or VID to replace VV in the ICVD nomenclature ... Herein, the historical moniker VV is used to refer to Bronstein's original description and the subsequent body of research on that symptom.` A paper knowingly using a superseded term, because the LITERATURE it is summarising is indexed under the old one Quotation withheld because this record is not cleared for redistribution. AND A PRECEDENT FOR WHAT HAPPENS WHEN NOBODY DOES THIS: `As otology, neurology, and psychiatry matured into separate specialties in the early 20th century, Platzschwindel and Platzangst faded from use and agoraphobia became a psychiatric disorder, losing its space and motion context.` Two terms died and a third survived with part of its meaning removed - not by decision, by disciplinary drift. The 1870s syndromes and PPPD describe the same patients Quotation withheld because this record is not cleared for redistribution. AND THE DEFINERS WARN AGAINST READING THEIR OWN CRITERIA AS A CHECKLIST: `Clinicians who apply Criteria A and B as simple checklists of symptoms without capturing the dynamic features of their patients' histories (Criterion C) assume a reductionist view of the diagnosis ... Scientists who fail to consider the dynamics of PPPD risk muddling rather than illuminating the nature of the disorder.` The instrument comes with an instruction not to use it as an instrument Quotation withheld because this record is not cleared for redistribution. NO POSITIVE TEST, AND NOT A DIAGNOSIS OF EXCLUSION EITHER: `There are no findings on physical examination, laboratory testing, or diagnostic imaging that are pathognomonic of PPPD ... an abnormal finding on physical examination or laboratory testing does not exclude a diagnosis of PPPD ... Furthermore, PPPD is not a diagnosis of exclusion.` Both doors are shut: nothing confirms it and nothing rules it out, and it may not be given by elimination either Quotation withheld because this record is not cleared for redistribution. AND WHETHER IT IS ONE DISORDER AT ALL IS PRINTED AS AN OPEN QUESTION: `(a) Is PPPD a single disorder with one principal pathophysiologic process or is it the common manifestation of multiple conditions that produce similar symptoms from different pathophysiologic mechanisms? (b) If PPPD is a single disorder, does it have clinically meaningful and validly distinguishable subtypes?` Two analogies are offered for the two answers - PTSD for one syndrome from many precipitants, hypertension for one number from many diseases Quotation withheld because this record is not cleared for redistribution. AND A SUBTHRESHOLD CATEGORY WAS REFUSED FOR WANT OF DATA: `Members of the subcommittee concluded that there were not enough published data to define a clinically meaningful probable or subthreshold version of PPPD.` The Barany Society's own vestibular migraine and Meniere criteria carry `probable` tiers; this one declines to, and says why Quotation withheld because this record is not cleared for redistribution. AND THE EPIDEMIOLOGY IS BORROWED FROM THE FOUR PRECURSORS, NOT MEASURED ON PPPD: `No epidemiologic studies are available for PPPD, but its prevalence and incidence may be estimated from research done on patients with PPV, VV, CSD` - so every frequency in this paper describes populations defined by the terms PPPD replaces Quotation withheld because this record is not cleared for redistribution. requiring ALL FIVE criteria A-E, and declining to publish a 'probable' or subthreshold tier for patients who meet only some eliminates: applying the label to non-specific chronic dizziness - which the paper warns against in the same breath as saying PPPD is NOT a diagnosis of exclusion · outcome: held Quotation withheld because this record is not cleared for redistribution. requiring at least some difficulty with ALL THREE exacerbating factors of Criterion B, rather than one or two eliminates: nothing that has been measured - the paper states outright that the sensitivities and specificities of the one-, two- and three-factor rules are unknown · outcome: partial Quotation withheld because this record is not cleared for redistribution. a period of prospective monitoring with a symptom log and serial examinations when no precipitant can be identified or symptoms worsen gradually eliminates: mistaking a slowly emerging degenerative disorder for PPPD · outcome: held Quotation withheld because this record is not cleared for redistribution. PPPD PPPD Quotation withheld because this record is not cleared for redistribution. chronic vestibular disorder chronic vestibular disorder Quotation withheld because this record is not cleared for redistribution. persistent postural-perceptual dizziness persistent postural-perceptual dizziness Quotation withheld because this record is not cleared for redistribution. chronic subjective dizziness chronic subjective dizziness Quotation withheld because this record is not cleared for redistribution. VID VID Quotation withheld because this record is not cleared for redistribution. VV VV Quotation withheld because this record is not cleared for redistribution. functional functional Quotation withheld because this record is not cleared for redistribution. psychogenic psychogenic Quotation withheld because this record is not cleared for redistribution. anxiety disorders anxiety disorders Quotation withheld because this record is not cleared for redistribution. MdDS MdDS Quotation withheld because this record is not cleared for redistribution. `PPPD` - a chronic FUNCTIONAL vestibular disorder, `not a structural or psychiatric condition`, defined by five criteria all of which must be fulfilled Quotation withheld because this record is not cleared for redistribution. `functional` (this paper's sense) - the EARLY 19TH CENTURY sense, `arising from a change in the mode of action of an organ`, explicitly NOT the 20th-century synonym for psychogenic or psychosomatic Quotation withheld because this record is not cleared for redistribution. `VV` (visual vertigo) - used here in Bronstein's 1995 sense, in preference to the Barany Society's own 2009 replacement `VID`, because the body of research is indexed under the older name Quotation withheld because this record is not cleared for redistribution. `agoraphobia` - Westphal's 1870s sense included space and motion; the modern psychiatric sense LOST that context when the specialties separated Quotation withheld because this record is not cleared for redistribution. extends → thirty years of research on phobic postural vertigo (Brandt & Dieterich 1986), space-motion discomfort (Jacob 1989), visual vertigo (Bronstein 1995) and chronic subjective dizziness (Staab 2004, 2007) - four terms whose common core becomes the criteria Quotation withheld because this record is not cleared for redistribution. supersedes → the author's own definition of chronic subjective dizziness, which 'PPPD now fully supplants' because 'the definition of PPPD is better supported' Quotation withheld because this record is not cleared for redistribution. critiques → reading diagnostic criteria as checklists - 'Clinicians who apply Criteria A and B as simple checklists ... assume a reductionist view of the diagnosis' Quotation withheld because this record is not cleared for redistribution. PPPD —is-a→ chronic vestibular disorder PPPD chronic vestibular disorder the relation itself is separately evidenced · strength of the relation: 0.95 · note: 'PPPD IS A CHRONIC…' The ICVD divides by DURATION (acute / episodic / chronic) and by PRESUMED MECHANISM (structural / functional / psychiatric), and PPPD is chronic-functional on both · the relation stated: PPPD is placed in the ICVD's CHRONIC class, and the classification's other axis makes it FUNCTIONAL rather than structural or psychiatric Quotation withheld because this record is not cleared for redistribution. chronic subjective dizziness —renamed-across-fields→ persistent postural-perceptual dizziness chronic subjective dizziness persistent postural-perceptual dizziness the relation itself is separately evidenced · strength of the relation: 0.95 · note: 'THE TERM PPPD…' CALLED HONESTLY: THIS IS A CONSOLIDATION, NOT A ONE-FOR-ONE RENAMING. Four terms from otoneurology, psychiatry and balance medicine become one, and the corpus has no edge type for many-into-one. 'renamed-across-fields' is the closest the vocabulary offers and the fields really are different - the subcommittee was constituted with an otologist, a neurologist and two psychosomatic/psychiatric members precisely because the four terms came from four clinics · the relation stated: CSD is one of four precursor terms consolidated into PPPD - and the paper says later, in its own words, that 'PPPD now fully supplants CSD' Audit 2026-09-28: DOUBTFUL - read against its full span and kept, but the span lists chronic subjective dizziness as one of four research strands from which PPPD's criteria were derived; renamed-across-fields is loose. Quotation withheld because this record is not cleared for redistribution. VV —renamed-across-fields→ VID VV VID the relation itself is separately evidenced · strength of the relation: 0.95 · note: 'IN 2009, THE…' The rename is real and eight years old; the authors set it aside because THE EVIDENCE THEY ARE SUMMARISING IS INDEXED UNDER THE OLD NAME. A retired term still doing work, in the same paper that retires CSD · the relation stated: the Barany Society replaced VV with VID in its own ICVD symptom nomenclature in 2009 - and this paper, published by that society, goes on using VV Quotation withheld because this record is not cleared for redistribution. functional —distinct-from→ psychogenic functional psychogenic the relation itself is separately evidenced · strength of the relation: 0.95 · note: 'IN THIS CONNOTATION…' The edge records a term being pulled back from a sense it held for eighty years - and the paper dates both senses and cites the field (gastroenterology) that revived the older one · the relation stated: in this paper's sense 'functional' denotes a change in the MODE OF ACTION of an organ and carries NO presumption of psychopathology Quotation withheld because this record is not cleared for redistribution. PPPD —distinct-from→ anxiety disorders PPPD anxiety disorders the relation itself is separately evidenced · strength of the relation: 0.95 · note: 'Patients with PPPD may express…' The two conditions are separated by WHAT THE PATIENT IS AFRAID OF - a distinction with no test behind it, in a paper that says no test exists · the relation stated: both produce avoidance; the CONTENT of the concern differs - noxious symptoms versus fear of incapacity, injury or attention Quotation withheld because this record is not cleared for redistribution. MdDS —distinct-from→ PPPD MdDS PPPD the relation itself is separately evidenced · strength of the relation: 0.95 · note: 'A MAJOR DIFFERENCE…' A boundary drawn by what the patients do after treatment, in a corpus where boundaries are usually drawn by a marker or a cut-off · the relation stated: distinguished by response to treatment and by the direction of the motion effect - MdDS improves during passive motion, PPPD worsens Quotation withheld because this record is not cleared for redistribution. A DIAGNOSIS MADE BY CONSOLIDATING FOUR OLDER TERMS: `The term PPPD is new, but the disorder is not ... derived ... from an exhaustive review of 30 years of research on phobic postural vertigo, space-motion discomfort, visual vertigo, and chronic subjective dizziness` A DIAGNOSIS MADE BY CONSOLIDATING FOUR OLDER TERMS: `The term PPPD is new, but the disorder is not ... derived ... from an exhaustive review of 30 years of research on phobic postural vertigo, space-motion discomfort, visual vertigo, and chronic subjective dizziness` Quotation withheld because this record is not cleared for redistribution. AND A COMMITTEE THAT PUBLISHES ITS OWN DECISION RULE: `It does not require unanimity, but demands more than a simple majority` - because otherwise `informative aspects of the minority opinion could be lost` AND A COMMITTEE THAT PUBLISHES ITS OWN DECISION RULE: `It does not require unanimity, but demands more than a simple majority` - because otherwise `informative aspects of the minority opinion could be lost` Quotation withheld because this record is not cleared for redistribution. AND THEN REPORTS A DECISION TAKEN AT EXACTLY THE MAJORITY IT CALLS INSUFFICIENT: `In the end, a simple majority of subcommittee members voted against including PPV as a subtype of PPPD` - and `reached consensus ... BUT NOT PPV` AND THEN REPORTS A DECISION TAKEN AT EXACTLY THE MAJORITY IT CALLS INSUFFICIENT: `In the end, a simple majority of subcommittee members voted against including PPV as a subtype of PPPD` - and `reached consensus ... BUT NOT PPV` Quotation withheld because this record is not cleared for redistribution. AND THE RETIRED TERMS ARE KEPT AS MACHINE-READABLE POINTERS: `PPV, SMD, VV, and CSD were retained as index terms for cross-referencing in the ICD-11 beta draft definition of PPPD` AND THE RETIRED TERMS ARE KEPT AS MACHINE-READABLE POINTERS: `PPV, SMD, VV, and CSD were retained as index terms for cross-referencing in the ICD-11 beta draft definition of PPPD` Quotation withheld because this record is not cleared for redistribution. AND A CRITERION SET IN THE ADMITTED ABSENCE OF MEASUREMENT: `There are no data ... to determine the sensitivities and specificities of requiring the presence of one, two, or all three factors ... Therefore, the consensus definition of Criterion B requires ... all three` AND A CRITERION SET IN THE ADMITTED ABSENCE OF MEASUREMENT: `There are no data ... to determine the sensitivities and specificities of requiring the presence of one, two, or all three factors ... Therefore, the consensus definition of Criterion B requires ... all three` Quotation withheld because this record is not cleared for redistribution. AND A WORD PULLED BACK FROM ITS OWN 20TH-CENTURY SENSE: `functional is not a synonym for psychogenic or psychosomatic as it was throughout most of the 20th century` AND A WORD PULLED BACK FROM ITS OWN 20TH-CENTURY SENSE: `functional is not a synonym for psychogenic or psychosomatic as it was throughout most of the 20th century` Quotation withheld because this record is not cleared for redistribution. AND A TERM THAT SURVIVED BY LOSING PART OF ITS MEANING: `Platzschwindel and Platzangst faded from use and agoraphobia became a psychiatric disorder, losing its space and motion context` - drift, not decision AND A TERM THAT SURVIVED BY LOSING PART OF ITS MEANING: `Platzschwindel and Platzangst faded from use and agoraphobia became a psychiatric disorder, losing its space and motion context` - drift, not decision Quotation withheld because this record is not cleared for redistribution. `a chronic vestibular disorder defined by criteria A-E ... All five criteria must be fulfilled` - one or more of dizziness, unsteadiness or non-spinning vertigo on most days for 3 months or more, exacerbated by upright posture, active or passive motion, and moving or complex visual stimuli PPPD Quotation withheld because this record is not cleared for redistribution. `disorders ARISING FROM A change in the mode of action of an organ, unrelated to structural or cellular deficits` - the early-19th-century sense, revived in gastroenterology, explicitly NOT the 20th-century psychogenic sense functional Quotation withheld because this record is not cleared for redistribution. `Symptoms must be present for more than 15 of every 30 days. Most affected individuals experience symptoms every day or nearly every day` - the threshold is far below where the patients actually sit duration threshold in Criterion A Quotation withheld because this record is not cleared for redistribution. `making them the most common diagnoses among young adults and the second most common among all adults, trailing only BPPV` prevalence of the precursor diagnoses in tertiary vestibular clinics Quotation withheld because this record is not cleared for redistribution. `These results indicate that PPPD is likely to develop in a significant proportion of patients afflicted with acute or episodic vestibular syndromes` incidence after an acute or episodic vestibular disorder Quotation withheld because this record is not cleared for redistribution. the precipitant is part of Criterion C, and this is the only place its distribution is given precipitating conditions, by share of cases Quotation withheld because this record is not cleared for redistribution. `Staab, et al. found that this diagnostic definition was highly sensitive (>85%) and specific (>90%) for detecting CSD` - CSD, not PPPD. The new definition supplants the old one on the strength of numbers measured on the old one, and the paper says elsewhere that the sensitivities of its own Criterion B are unknown the only sensitivity and specificity in the paper belong to the SUPPLANTED term Quotation withheld because this record is not cleared for redistribution. upright posture, active or passive motion, and moving or complex visual stimuli - all three required, with no evidence about requiring one or two instead the three exacerbating factors Quotation withheld because this record is not cleared for redistribution.

The full text of this article is not redistributable, so it is not included here. The evidence sentences are withheld with it; the tag layer and its grounding status remain. The article itself is at https://doi.org/10.3233/ves-170622.