Original Study
The Component Structure of the Dizziness Handicap Inventory
(DHI): A Reappraisal
Kelly M. Van De Wyngaerde, yMinji K. Lee, Gary P. Jacobson, zKalyan Pasupathy,
ySantiago Romero-Brufau, and §Devin L. McCaslin
Division of Vestibular Sciences, Vanderbilt University Medical Center, Nashville, Tennessee; yKern Center for the Science
of Healthcare Delivery; zDepartment of Health Sciences Research, Kern Center for the Science of Healthcare Delivery; and
§Department of Otolaryngology, Mayo Clinic, Rochester, Minnesota
Objective.: The Dizziness Handicap Inventory (DHI) is a
25-item self-report questionnaire developed to measure the
disabling and handicapping impact of dizziness. The present
investigation was conducted in an effort to re-assess the
factor structure of the DHI.
Study Design.: Retrospective study.
Setting.: Tertiary care center.
Patients.: Subjects were 1,991 patients who were evaluated
in the Mayo Clinic-Rochester Vestibular and Balance
Laboratory.
Main Outcome Measures.: Exploratory factor analysis: an
exploratory bifactor analysis (EFA) with bifactor rotation
was used to analyze a random sample of 999 patients.
Analyses were used to determine the dominance of the
general factor (i.e., total score) relative to the group factor
(i.e., subscales). Confirmatory factor analysis: a confirmatory
bifactor graded response model was fit with appropriate
item-to-group relationships that was discovered by our
exploratory analyses. To validate the bifactor model that was
identified with the exploratory analyses, a bifactor model
The presence and magnitude of peripheral and central
vestibular system impairments may be measured using
several conventional vestibular system electroneurodiag-
nostic tests (e.g., videonystagmography and rotary chair
testing). Despite their usefulness for the diagnosis and
management of the dizzy patient these tests are insuffi-
cient for describing the impact a patient’s dizziness has
on their well-being and quality of life. In an attempt to
understand better the functional impact of disorders
causing dizziness in patients, several self-report ques-
tionnaires addressing dizziness disability/handicap have
been developed over the last three decades. Perhaps the
Address correspondence and reprint requests to Devin L. McCaslin,
Ph.D., Department of Otolaryngology, Mayo Clinic, Gonda 12-400
AUD, 200 1st Street SW, Rochester, MN; E-mail: mccaslin.devin@
mayo.edu
The authors disclose no conflicts of interest.
DOI: 10.1097/MAO.0000000000002365
ß 2019, Otology & Neurotology, Inc.
Copyright © 2019 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
with three grouping factors (i.e., Physical manifestations,
Catastrophic impact of dizziness, and the Emotional impact
of dizziness) were fit to a different random sample of 992
patients using the new item-to-group factor specifications.
Results.: In the confirmatory analyses, all items had a
positive factor loading on the general factor. There were 14
items that loaded on the general factor only. The rest of the
items (n ¼ 11) loaded on both the general factor and one of
three group factors.
Conclusions.: Conclusions of the study revealed several
findings: 1) reporting the result as a total score (i.e., a single
general factor) is warranted, and, 2) there is statistical
support for the existence of three subscales representing: the
Physical manifestations, Catastrophic impact, and Emotional
impact of dizziness and vertigo. Key Words: Dizziness—
Dizziness Handicap Inventory—Self-report dizziness
handicap.
Otol Neurotol 40:1217–1223, 2019.
most widely-used self-report measure of dizziness dis-
ability/handicap is the Dizziness Handicap Inventory (1).
The DHI was originally developed to evaluate the
precipitating physical factors associated with dizziness
as well as the functional and emotional consequences of
vestibular impairment. Since its publication in 1990, the
DHI has been referenced more than 1500 times in the
scientific literature and has been translated into more than
17 languages (2–18). Due to its strong validity and test/
retest reliability (1) the DHI has become the ‘‘gold stan-
dard’’ against which similar scales have been compared.
An a priori assumption by Jacobson and Newman (1)
was that items in the DHI could be subgrouped into
content domains (i.e., subscales). To this end, the inves-
tigators created subscales that were designed to assess the
Physical manifestations (nine items) of dizziness, ver-
tigo, and unsteadiness as well as the Functional (seven
items) and Emotional (9 items) consequences of vestib-
ular impairment. The investigators did not evaluate the
validity of the empirically-created subscale structure.
1218 K. M. VAN DE WYNGAERDE ET AL.
Accordingly, it should be no surprise that the subscale
structure developed by Jacobson and Newman (1) has
been challenged.
Asmundson et al. (19) administered the DHI to
95 individuals in their vestibular disorders clinic and
performed a principal components analysis (PCA) to
assess the validity of the subscales reported by Jacobson
and Newman (1). The results of their analysis supported
using either a 2-factor or 3-factor solution (i.e., using 2 or
3 different subscales). Similarly, Perez et al. (16) evalu-
ated responses drawn from 337 subjects using the Span-
ish language version of the DHI and identified a 3-factor
solution that differed from the original subscales pro-
posed in 1990 and what was proposed by Asmundson
et al. (19)
Subsequent to the publication of these reports, statis-
tical techniques (i.e., either factor analysis or principal
components analysis) have been performed on several
other translations of the DHI (e.g., Dutch, German,
Japanese, Norwegian, and Persian versions) with sample
sizes ranging from 92 to 194 subjects (7,13–15,20–22).
Results of these studies have supported the contentions
that: 1) the DHI consists of at least two to three factors
and, 2) one of the factors addresses the ‘‘physical
impact’’ of dizziness on physical functioning in everyday
life.
Most recently, Ardic et al. (23) examined a sample of
2,111 patients. They conducted a factor analysis on the
data set and, in agreement with past investigations, the
results revealed a factor structure that differed from what
was empirically created in the original investigation (1).
Their final recommendation was to abandon the original
subscale structure of the DHI and report only the total
score from all 25 items.
Researchers interested in assessing the subscale struc-
ture of a measurement device often hypothesize that
several highly-related domains comprise the general
construct of interest (24). Factor analytic evaluations
of such measures often reveal both the evidence of a
general factor running through the items and some evi-
dence of multidimensionality arising from groups of
items that assess similar content (25). Bifactor models
can assess whether each item loads directly on a general
factor and additionally on another residual group factor.
The general factor reflects what is common among the
items and the individual differences of a trait (e.g.,
dizziness) in which the users of the measures are most
interested. The additional orthogonal group factors rep-
resent common residual variance not accounted for by the
general factor. We hypothesized that the DHI has a
general factor as well as possibly several group factors
not accounted for by the general factor. This is because
the DHI was developed using a Rasch model with
unidimensional assumptions, but with several content
areas. In this study we investigated whether the score
of the full DHI reflects the variability of a single con-
struct, or, multiple sources of variance (i.e., a result that
would suggest the presence of several content domains
that would support the development of subscales).
Otology & Neurotology, Vol. 40, No. 9, 2019
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METHODS
Design
This investigation received ethical approval from the Mayo
Clinic Institutional Review Board in Rochester, MN (ID: 18–
000088). A retrospective analysis with exempt status was
completed for 999 patients (mean age 57.60 yr, sd 17.70 yr,
585 men) who were evaluated between April 3, 2007 and
November 29, 2007 in our Vestibular and Balance Laboratory
at Mayo Clinic in Rochester, MN. All subjects included in this
investigation were evaluated for a history of dizziness, vertigo,
and/or imbalance. Table 1 describes the proportions of diagno-
ses observed in our neurotology clinic from 2000 to 2010. The
reader will note that for 14% of patients there was no diagnosis.
Each patient completed a DHI using a paper-pencil admin-
istration technique before their vestibular function assessments.
The DHI is a 25-item measure of dizziness disability/handicap.
The patient must answer each item with the following
responses: ‘‘yes’’ which is awarded four points, ‘‘sometimes’’
which is awarded two points, or ‘‘no’’ which is awarded zero
points. A maximum score is 100 points (i.e., representing the
maximum dizziness disability/handicap). The individual DHI
scores for items 1 to 25 were entered into a database after the
patient’s assessment was completed.
Exploratory Factor Analysis
Without assuming any relationships between items and
factors, we refined our definitions of the latent subdomains
using exploratory bifactor analysis (EFA) with Jenrich and
Bentler’s (26) bifactor rotation using the 999 random sample.
The number of extracted factors was determined by inspection
of the screeplot and the eigenvalues that exceeded 1.0. We used
the explained common variance (ECV), coefficient omega
hierarchical (vH), and standardized loadings on the general
factor greater than 0.30 to determine the dominance of a general
factor for fitting the bifactor model (27). If data are consistent
with a bifactor structure, one can obtain a higher ECV index,
which indicates a stronger general factor (i.e., total score from
all 25 items) relative to the group factors (i.e., subscales). In
addition, coefficient omega hierarchical (vH) indicates the
general factor saturation of a test or survey (i.e., how well data
captures one concept) (28). Values of 0.70 or higher for vH
suggest that the scale is sufficiently unidimensional for most
analytic procedures that assume unidimensionality (29,30).
Lastly, standardized loadings on the general factor greater than
0.30 could indicate a well-defined general factor despite the
presence of the group factors (31,32).
Confirmatory Factor Analysis
A confirmatory bifactor graded response model was fitted
with appropriate item-to-group relationships that was discov-
ered by our exploratory analyses. To validate the bifactor model
TABLE 1. Proportions of diagnoses observed in our
neurotology clinic from 2000 to 2010
Persistent postural-perceptual dizziness 38%
Vestibular migraine 17%
Menière’s disease 15%
Benign paroxysmal positional vertigo 7%
Vestibular neuritis 7%
Unspecified dizziness 7%
Other 7%
Superior canal dehiscence 2%
 THE COMPONENT STRUCTURE OF THE DIZZINESS HANDICAP INVENTORY
that was identified with the exploratory analyses, a bifactor
model with three grouping factors (i.e., Physical manifestations,
Catastrophic impact of dizziness, and the Emotional impact of
dizziness) were fit to a different random sample of 992 patients
using the new item-to-group factor specifications.
To this end, for Investigation 2, subjects were 992 patients
(mean age 56 yrs, sd 18.05 yrs, 599 men) who were evaluated
between November 21, 2016 and August 29, 2017 in our
Vestibular and Balance Laboratory at Mayo Clinic in Roches-
ter, MN. An excellent model fit and large item-to-group factor
loadings would indicate that the current bifactor model would
be favored over the original three factor models.
RESULTS
Exploratory Factor Analysis
Before fitting the exploratory bifactor model, we
searched for evidence of sufficient unidimensionality.
Assuming three factors (i.e., physical, emotional, and func-
tional) that were originally proposed for scoring, we found
the ECV value was 0.80. Note that ECV is the ratio of
variance explained by the general factor divided by the
variance explained by the general plus the group factors.
With the same assumption, we also found that the vH value
was 0.92. This evidence supported the essential unidimen-
sionality necessary for fitting the bifactor models.
To decide the number of factors to extract for explor-
atory bifactor analyses, we searched for the eigenvalues
exceeding the criterion of 1.0. There were five factors
with eigenvalues greater than 1.0. Therefore, we con-
ducted EFA extracting one general factor and four group
factors. These factor loadings from the resulting model
are shown in Table 2.
The first factor that we are referring to as the General
factor, accounted for 70% of the total variance. All item
loadings on the general factor exceeded 0.30 except for
one item, ‘‘Does turning over in bed increase your
problem?’’ that had a marginal loading of 0.13. Accord-
ingly, one possible solution was to delete item 13 from
the questionnaire completely. However, because this
item had a strong factor loading of 0.62 on the first
group factor, the item was retained for further analysis.
Next, we investigated whether generating subscales
from the residual data (after extracting the general factor)
was warranted (i.e., based on the content of the items and
salient factor loadings >0.30 and the content). The first
group factor explained 12.9% of the variance and con-
sisted of five items that assessed the Physical manifes-
tations of vestibular impairment. These items and their
factor loadings are shown in Table 2 in the ‘‘Group factor
1’’ column. The content of these items was related to
whether head movements such as looking up, bending
over, turning over in bed, or getting in and out of bed
increased the patient’s dizziness.
The second group factor explained 5.9% of the vari-
ance and consisted of three items that assessed the
patient’s fear of Catastrophic impact (i.e., a catastrophic
event) associated with their vestibular impairment. These
items with their factor loadings can be found on Table 2
in the ‘‘Group factor 2’’ column. The content of these
Copyright © 2019 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.
1219
items were associated with difficulty or fear of leaving
home, going for a walk, staying home by oneself.
The third group factor explained 6.4% of the vari-
ance and consisted of three items that assessed the
Emotional impact associated with a vestibular
impairment. They are the items with factor loadings
found on Table 2 in the ‘‘Group factor 3’’ column.
The content of these items focused on the effect that
dizziness-related frustration, depression, and stress
that affected interpersonal relationships.
Factor 4 explained 4.7% of the variance and consisted
of two items, the content of which centered on activity
restrictions. These items may be found in Table 2 in the
‘‘Group factor 4’’ column. These items included the
words ‘‘restrict,’’ which appeared to be a linguistic
feature rather than a specific subdomain of dizziness.
And because a factor with only two items is generally
considered weak or unstable, we limited our group
factors to the first three individual factors.
Confirmatory Factor Analysis
In the confirmatory analyses, all items had a positive
factor loading on the general factor. There were 14 items
that loaded on the general factor only (see Table 3). The
rest of the items (n ¼ 11) loaded on both the general
factor and one of three group factors. The fit of the new
model was excellent (M2 [239] ¼ 1395.09, p < 0.001,
root mean square error of approximation ¼ 0.070 [90%
confidence interval, 0.066–0.073], Tucker Lewis
Index ¼ 0.96, comparative fit index ¼ 0.96). In the cur-
rent model, all general factor loadings were greater than
0.30 except item P13 that demonstrated a general factor
loading of 0.27. The fact that all group factor loadings
were at least 0.25 enabled a clear interpretation of the
internal structure of the dizziness construct. Items in each
of the grouping factors had a positive factor loading for
their respective group only. That is, there were no cross-
loadings for any of the items. These results are shown in
Table 3.
Factor communality estimates (i.e., the proportion of
the variance in an item explained by the model) ranged
from 0.32 to 0.89. The percentage of variance in the data
explained by the general factor was 46%. The proportion
of variance explained by the physical manifestations factor
was 6%. The amount explained by the Emotional impact
factor of was 3%. The percentage of variance explained
by the Catastrophic impact of vertigo was 2%. The
dominance of the general factor persisted with vH ¼ 0.93.
In this EFA we identified three group factors. We
investigated whether the three group factors added value
beyond the total score (i.e., whether it was worthwhile to
report subscale scores for the three content areas in
addition to the total score). Subscale scores can be of
interest to clinicians due to their potential benefits in
providing more detailed information about their patients.
A general dizziness score provides an overall assessment
of dizziness, while subscale scores have the potential to
allow clinicians to monitor and address specific aspects
of dizziness. Thus, it can be determined whether subscale
Otology & Neurotology, Vol. 40, No. 9, 2019
1220 K. M. VAN DE WYNGAERDE ET AL.
TABLE 2. Exploratory bifactor analyses and their factor loadings on the general factor and on each of the four subscales
Factor 1 Factor 2 Factor 3 Factor 4
General Physical Emotional Catastrophic Participation
Factor Manifestations Impact Impact Restriction

P1. Does looking up increase your problem? 0.38 0.45

E2. Because of your problem, do you feel frustrated? 0.51 0.30
F3. Because of your problem, do you restrict your travel for 0.71 –0.38
business or pleasure?
P4. Does walking down the aisle of a supermarket increase your 0.66
problem?
F5. Because of your problem, do you have difficulty getting into 0.32 0.50
or out of bed?
F6. Does your problem significantly restrict your participation in 0.78 –0.39
social activities, such as going out to dinner, going to movies,
dancing or to parties?
F7. Because of your problem, do you have difficulty reading? 0.48
F8. Does performing more ambitious activities like sports, 0.67
dancing, and household chores, such as sweeping or putting
dishes away, increase your problem?
E9. Because of your problem, are you afraid to leave your home 0.63 –0.49
without having someone accompany you?
E10. Because of your problem, have you been embarrassed in 0.52
front of others?
P11. Do quick movements of your head increase your problem? 0.43 0.49
F12 Because of your problem, do you avoid heights? 0.51
P13 Does turning over in bed increase your problem? 0.13 0.62
F14 Because of your problem, is it difficult for you to do 0.74
strenuous housework or yard work?
E15 Because of your problem, are you afraid people may think 0.53
that you are intoxicated?
F16 Because of your problem, is it difficult for you to go for a 0.73 –0.33
walk by yourself?
P17 Does walking down a sidewalk increase your problem? 0.70
E18 Because of your problem, is it difficult for you to 0.58
concentrate?
F19 Because of your problem, is it difficult for you to walk 0.57
around your house in the dark?
E20 Because of your problem, are you afraid to stay home 0.42 –0.46
alone?
E21 Because of your problem, do you feel handicapped? 0.68
E22 Has your problem placed stress on your relationship with 0.56 0.43
members of your family or friends?
E23 Because of your problem, are you depressed? 0.57 0.40
F24 Does your problem interfere with your job or household 0.68
responsibilities?
P25 Does bending over increase your problem? 0.48 0.47

Only non-trivial group factor loadings (>0.30) are printed. The group factor loadings 0.30 are not presented in this table.

scores from the group factors add value over the total score
alone (i.e., general dizziness score) using the concept,
‘‘proportional reduction in mean squared error’’ (PRMSE).
Here the true subscale score is estimated based on the
observed subscale score and the observed total score. If
the PRMSE of the subscale score (PRMSEs), which is equal
to the reliability of the subscale score is greater than the
PRMSE of the total score (PRMSEx), then there is a positive
added value of reporting the subscale score. Using this
method, it appeared that all three subscales contributed
added value. Specifically, the PRMSEs values were 0.75,
0.75, and 0.71 while the corresponding PRMSEx values
were 0.50, 0.69, 0.63 for physical manifestations of
dizziness, catastrophic impacts of vertigo, and emotional
effect of vertigo and dizziness subscales.
DISCUSSION
Since the publication of the DHI in 1990, results of
several investigations employing either FA or PCA have
supported the contention that related items in the DHI can
be grouped statistically to provide additional information
beyond the general factor (i.e., effect of dizziness on the
emotional impact of dizziness on the patient). Results of
these investigations generally have supported a two or
three factor solution.

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 THE COMPONENT STRUCTURE OF THE DIZZINESS HANDICAP INVENTORY 1221
TABLE 3. Factor loadings from the confirmatory bifactor model with three group factors (n ¼ 992)
Factor
General Physical Emotional Catastrophic Communality
Factor Manifestations Impact Impact Estimatesa

P1. does looking up increase your problem 0.39 0.51 0 0 0.41

E2. Because of your problem, do you feel frustrated? 0.65 0 0.35 0 0.54
F3. Because of your problem, do you restrict your travel for 0.76 0 0 0 0.57
business or pleasure?
P4. Does walking down the aisle of a supermarket increase your 0.69 0 0 0 0.48
problem?
F5. Because of your problem, do you have difficulty getting into 0.44 0.50 0 0 0.44
or out of bed?
F6. Does your problem significantly restrict your participation in 0.86 0 0 0 0.73
social activities, such as going out to dinner, going to movies,
dancing or to parties?
F7. Because of your problem, do you have difficulty reading? 0.66 0 0 0 0.43
F8. Does performing more ambitious activities like sports, 0.78 0 0 0 0.61
dancing, and household chores, such as sweeping or putting
dishes away; increase your problem?
E9. Because of your problem, are you afraid to leave your home 0.75 0 0 0.57 0.89
without having someone accompany you?
E10. Because of your problem, have you been embarrassed in 0.61 0 0 0 0.37
front of others?
P11. Do quick movements of your head increase your problem? 0.47 0.62 0 0 0.60
F12 Because of your problem, do you avoid heights? 0.59 0 0 0 0.35
P13 Does turning over in bed increase your problem? 0.27 0.66 0 0 0.51
F14 Because of your problem, is it difficult for you to do 0.86 0 0 0 0.74
strenuous housework or yard work?
E15 Because of your problem, are you afraid people may think 0.57 0 0 0 0.32
that you are intoxicated?
F16 Because of your problem, is it difficult for you to go for a 0.80 0 0 0.27 0.72
walk by yourself?
P17 Does walking down a sidewalk increase your problem? 0.70 0 0 0 0.49
E18 Because of your problem, is it difficult for you to 0.72 0 0 0 0.52
concentrate?
F19 Because of your problem, is it difficult for you to walk 0.68 0 0 0 0.46
around your house in the dark?
E20 Because of your problem, are you afraid to stay home 0.67 0 0 0.39 0.60
alone?
E21 Because of your problem, do you feel handicapped? 0.81 0 0 0 0.66
E22 Has your problem placed stress on your relationship with .68 0 0.34 0 .57
members of your family or friends?
E23 Because of your problem, are you depressed? 0.65 0 0.66 0 0.85
F24 Does your problem interfere with your job or household 0.84 0 0 0 0.70
responsibilities?
P25 Does bending over increase your problem? 0.59 0.52 0 0 0.61
a
Factor communality indicates the proportion of variance the factors explain in the item response.

For example, Asmundson et al. (19) performed a PCA
on 95 DHI questionnaires obtained in their vestibular
disorders clinic. The results of their analysis supported
either a 2-factor solution consisting of ‘‘general functional
limitations’’ and ‘‘postural difficulties’’ or a 3-factor
solution of ‘‘disability in activities of daily living,’’
‘‘phobic avoidance,’’ and ‘‘postural difficulties.’’
Perez et al. (16) conducted a PCA on responses
obtained from 337 subjects using the Spanish version
of the DHI. They identified a 3-factor solution consisting
of ‘‘vestibular handicap,’’ ‘‘vestibular disability,’’ and
‘‘visuo-vestibular disability.’’ The third factor, ‘‘visuo-
vestibular disability,’’ described the self-perceived
postural instability in relation to contextual factors such
as integrating visual stimuli. This factor was maintained
in the Dutch version of the DHI (7) and was similar in the
German (20) and Japanese (13) versions. The Japanese
version also contained four other subscales, two of which
related to the vestibular disability and handicap subscales
suggested by Perez et al. (16).
Kurre et al. (20) conducted an investigation of the
German translation of the DHI. The investigators evalu-
ated 94 subjects. Results of their efforts supported a
3-factor solution ‘‘effect of dizziness and unsteadiness
on emotion and participation,’’ ‘‘specific activities/
movements provoking dizziness and unsteadiness,’’

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1222 K. M. VAN DE WYNGAERDE ET AL.
and ‘‘self-perceived walking ability/feeling of postural
stability in relation to contextual factors.’’ Emulating the
data extracted in the Spanish, Dutch, and English ver-
sions, these subscales were comparable in their content
domains of ‘‘participation restrictions,’’ ‘‘limitations
in activities due to motion sensitivity,’’ and ‘‘visuo-
vestibular dysfunction (7,16,19).’’
Most recently, a factor analytic investigation of the
DHI was reported by Ardic et al. (23). The investigators
reported their findings drawn from a sample of 2,111
patients. Two subscales were proposed. The first factor
was similar in content to the original functional and
physical subscales. The second correlated with the emo-
tional subscale. The analysis also confirmed the strong
internal consistency reliability of the total score (i.e., the
general factor). These findings, and the recommendation
to abandon any subscale structure, have been supported
by several authors (14,16,19).
In the present investigation we have demonstrated
validity for the creation of subscales that are designed
to predict the presence of benign paroxysmal positional
vertigo (BPPV). This contention was first reported by
Whitney et al. (33) who extracted from the original 25-
item DHI both five-item (P1, F5, P11, P13, and P25) and
two-item (F5 and P13) subscales. The investigators
examined the predictive accuracy of responses of the
subscales to the presence of BPPV. Using the hypothe-
sized subscales, a diagnosis of BPPV for these patients
could be predicted successfully. That is, their results
showed the probability of having BPPV increased sig-
nificantly as the patients endorsed a greater number of
items for both subscales.
Similar to the a priori grouping of the items in the
original DHI, the items chosen by Whitney et al. (33)
were selected empirically and without statistical confir-
mation. Interestingly, analyses of several translated ver-
sions of the DHI were later revealed to contain subscales
that are identical to the proposed BPPV subscales. Both
our confirmatory analysis in the present investigation and
the PCA of the Dutch (7) and German (20) versions
contain subscales with items identical to those in our
five-item Physical Manifestations subscale. Likewise,
the analysis of the Japanese (13) version of the DHI
revealed five factors, one of which contained the same
items found in the 2-item subscale proposed by Whitney
et al. (33).
Chen et al. (34) conducted an investigation to explore
the validity and screening potential of the proposed
BPPV subscales in a Chinese population. Results of their
analyses revealed acceptable internal consistency reli-
ability with good predictive accuracy. Both the subscale
scores as well as the total score significantly increased in
individuals diagnosed with BPPV. Previous research (35)
has suggested the total DHI score is useful in predicting
BPP, a finding that is at odds with the data reported by
Whitney et al. (33). The work conducted by Whitney
et al. (33) and Chen et al. (34) both support the contention
that the ‘‘new’’ DHI subscales offered an accurate
screening tool to predict the presence of BPPV.
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The results of the two investigations reported herein
have suggested that: 1) if desired, the existing 25-item
total score can remain, ‘‘as is.’’ Additionally, the results
suggest that it is possible to create three subscales, from
the original 25-item device that address the effects of:
changing head and body position on dizziness (physical
manifestations), the Emotional Impact of dizziness
on everyday life and the effect of dizziness on the
Catastrophic impact of dizziness and vertigo.
The dominance of the general factor means that
clinicians and researchers need only compute and
interpret one dizziness score. The three subscales
(i.e., the physical, emotional, and functional sub-
scales) developed empirically by Jacobson and New-
man (1) were not supported in our analyses. Instead,
we found that 11 items measured three group factors
as well as a general factor, and 14 items measured
only the general factor. Our results do not indicate that
the subscales must be reported to reliably assess
dizziness. However, our results on the value added
by the group factor scores (i.e., PRMSE) do support
reporting separate scores. That is, should clinicians
and researchers prefer a more detailed analysis of the
data then calculating responses for the Physical man-
ifestations of dizziness and vertigo, Catastrophic
impact of dizziness and vertigo, and the Emotional
impact of dizziness and vertigo is recommended.
CONCLUSION
The results of the current investigation support two
methods of analyzing data from the DHI: 1) continue
with the current practice of calculating a total score as the
simple sum of the values for the 25 items (i.e., the total
DHI score that ranges from 0 to 100%), or, 2) calculate a
total score and, then calculate subscale scores to assess
the Physical manifestations (i.e., sum of the items scores
for 1, 5,11, 13, and 25), Catastrophic impact (i.e., sum of
the item scores for 9, 16, and 20), and Emotional Impact
(i.e., sum of the items scores for 2, 22, and 23) of
dizziness on the dizzy patient.
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Otology & Neurotology, Vol. 40, No. 9, 2019