Peer Reviewed

Comments on PPPD as a psychosomatic disorder

Review by Kaitlin Ryan, AuD

In 2017, a consensus document of the committee for the Classification of Vestibular Disorders (ICVD) of the Bárány Society was published officially outlining the diagnostic criteria for Persistent-Postural Perceptual Dizziness (PPPD). Official diagnostic criteria include elements of several previously described perceptual phenomena dating back to the 19th century. In the late 1800’s, German physicians documented descriptions of spatial disorientation in busy environments (Platzschwindel – vertigo in a plaza/square)1, and others focused on the psychological consequences of this disorientation (Platzangst – fear of the plaza/square)1.

Drs. Katherina Hüfner and Barbara Sperner-Unterweger produced a commentary in 2023 outlining the diagnostic criteria for PPPD in a psychosomatic context compared to other conditions that manifest similarly. Dr. Jeffrey Staab, the chair of the classification committee of the Barany Society and one of the first to define PPPD, responded to their commentary. Hüfner and Sperner-Unterweger primarily take issue with the overly specific criteria, as in their clinical setting of psychosomatic vertigo syndromes they feel that it becomes restrictive and excludes a significant patient base. Specifically, the ICVD diagnostic criteria document for PPPD states that “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”1.  Given that all three must be present, Hüfner and Sperner-Unterweger assert that PPPD and disorders such as somatic symptom disorder (SSD) or bodily distress disorder (BDD) are comparative by definition and useful to use in combination if a patient with a psychosomatic vertigo syndrome is not able to meet criteria for PPPD. Per Staab, the main goal of the diagnostic criteria was to identify a specific clinical condition and not to cast a wide net for unexplained vestibular symptoms regardless of psychiatric status. He notes that often PPPD co-exists with other conditions and the goal of the diagnostic criteria is to guide a provider into considering all symptoms presented by the patient and all diagnostic possibilities prior to landing on a diagnosis.

Staab lastly notes the key differentiation between SSD, BDD and PPPD and why the mingling of these three disorders may confuse patients/providers. If you look closely at the comparisons of diagnostic criteria, you will notice that PPPD “must be precipitated by a condition that cause vertigo, mental illness or psychological distress”1, i.e., the diagnosis of PPPD depends on preexisting symptoms. SSD and BDD do not; their diagnostic criteria only include that the symptoms are persistent and cause distress, not that they were preexisting.

Overall, the diagnostic criterion for any psychosomatic disorder is there to differentiate one from another and are not intended to be interchangeable. While PPPD is a disorder based in a physical manifestation of a psychologic response to what the body identifies as a traumatic instance, the diagnosis of other psychosomatic disorders may not require this. The purpose of the publication of the diagnostic criteria of PPPD was to help differentiate this specific condition from one that may sound similar to providers when presented with a patient’s symptoms and offer a direct avenue to help correctly identify the appropriate diagnosis.

  1. Staab JP, Eckhardt-Henn A, Horii A, Jacob R, Strupp M, Brandt T, Bronstein A. Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the committee for the Classification of Vestibular Disorders of the Bárány Society
  2. Hüfner, Katharina and Sperner-Unterweger, Barbara. ‘Persistent-postural Perceptual Dizziness (PPPD): Yes, It Is a Psychosomatic Condition!’ 14 Aug. 2023 : 279 – 281.
  3. Comment on: “Persistent-postural Perceptual Dizziness (PPPD): Yes, It Is a Psychosomatic Condition!”’ 14 Aug. 2023 : 283 – 285.