Handbook of Clinical Neurology, Vol.

137 (3rd series)

Neuro-Otology
J.M. Furman and T. Lempert, Editors
http://dx.doi.org/10.1016/B978-0-444-63437-5.00028-5
© 2016 Elsevier B.V. All rights reserved

Chapter 28

Mal de debarquement syndrome

T.C. HAIN1* AND M. CHERCHI2
1
Chicago Dizziness and Hearing and Department of Physical therapy and Human Movement Sciences,
Northwestern University, Chicago, IL, USA
2
Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA

Abstract
Mal de debarquement syndrome (MdDS) is typified by a prolonged rocking sensation – for a month or
longer – that begins immediately following a lengthy exposure to motion. The provoking motion is usually
a sea voyage. About 80% of MdDS sufferers are women, and most of them are middle-aged. MdDS
patients are troubled by more migraine headaches than controls. Unlike dizziness caused by vestibular
disorders or motion sickness, the symptoms of MdDS usually improve with re-exposure to motion.
The long duration of symptoms – a month or more – distinguishes MdDS from land-sickness. Treatment
of MdDS with common vestibular suppressants is nearly always ineffective. Benzodiazepines can be help-
ful, but their usefulness is limited by the potential for addiction. Studies are ongoing regarding treatment
with visual habituation and transcranial magnetic stimulation.

Mal de debarquement syndrome (MdDS), literally, “bad
disembarkment,” refers to prolonged and inappropriate
sensations of movement after exposure to motion. The
syndrome typically follows a lengthy sea voyage
(Brown and Baloh, 1987), but it has also been observed
following extended airplane travel, train travel, and space
flight (Stott, 1990). Symptoms include rocking, swaying,
and imbalance. MdDS is distinguished from ordinary
motion sickness, seasickness (mal de mer), and some-
times from “land-sickness” by persistence of symptoms
for a month or longer. Also, unlike disorders of the inner
ear and seasickness, most individuals with MdDS report
that their symptoms improve with re-exposure to motion,
such as driving a motor vehicle (Hain et al., 1999; Cha
et al., 2008).
A typical case history is as follows: a 50-year-old
woman went on an ocean cruise. She developed motion
sickness on the cruise, which responded to transdermal
scopolamine. Immediately after returning from the cruise
and getting on to solid ground, she developed imbalance
and a rocking sensation, accompanied by fatigue and dif-
ficulty concentrating. Her description was: “Imagine
feeling like you are on rough seas 24 hours a day, 7 days
a week.” This sensation persisted for several months.
A meta-analysis of MdDS was recently published by
Van Ombergen and associates (2015). MdDS is a disor-
der that mainly affects middle-aged women. The propor-
tion of males affected by MdDS varies between 0 and
25% (Van Ombergen et al., 2015). Symptoms last at least
1 month (in most studies) and usually abate before
6 months have elapsed. However, symptoms can persist
for years, as well as recur after periods of remission.
MdDS patients are often very distressed by their symp-
toms (Arroll et al., 2014) and also are troubled by more
migraine headaches than controls (Cha and Cui, 2013).
Between 41% and 73% of persons disembarking from
seagoing voyages experience unsteadiness (Gordon
et al., 1995, 2000; Cohen, 1996). This is commonly
called land-sickness. Land-sickness typically persists
for 2 days or less. Some authors use an alternative term
for land-sickness – “transient mal de debarquement,”
defining the transient syndrome as symptoms lasting less
than 48 hours (Van Ombergen et al., 2015). We prefer the
more common term.

*Correspondence to: Timothy C. Hain, M.D., Professor (Emeritus), Northwestern University Feinberg School of Medicine,
645 N. Michigan, Suite 410, Chicago IL 60611, USA. Tel: +1-312-274-0197, E-mail: t-hain@northwestern.edu
392 T.C. HAIN AND M. CHERCHI
Table 28.1
Features distinguishing mal de debarquement syndrome
from land-sickness
Mal de debarquement Land-
syndrome sickness
Duration 1 or more months, can 2 days
last for years maximum
Gender About 80% female Equal
distribution
Motion-sick on No Yes
boat
Relieved by Yes No
driving
Table 28.1 lists the features that distinguish MdDS
from land-sickness. Persons with land-sickness are
also likely to have seasickness (Gordon et al., 1995),
while persons with MdDS generally are untroubled by
seasickness. Males and females do not appear to differ
significantly in the incidence, intensity, or duration of
land-sickness symptoms (Cohen, 1996). Land-sickness,
confusingly, is also termed “mal de debarquement,”
without the transient qualifier, by some authors.
MdDS also has similarities to motion sickness or sea-
sickness (mal de mer). However, MdDS is easily distin-
guished from motion sickness, as motion sickness starts
during motion rather than after motion as does MdDS, by
the shorter duration of motion sickness, and because
motion sickness often provokes nausea and vomiting,
while MdDS generally does not. Most persons with
MdDS have relief of rocking symptoms when in motion,
such as driving a car, but experience recurrence of rock-
ing once motion has stopped (Hain et al., 1999; Cha et al.,
2008). In motion sickness, many persons find driving,
entailing more motion, very difficult. This is also often
true for persons with vestibular disorders.
MdDS also overlaps with a little-studied group of
patients with rocking sensations, who develop similar
symptoms to MdDS, without a preceding motion expo-
sure (Cha and Cui, 2013). Often these patients develop
head or trunk rocking. In our clinical experience, the
age, gender, and pattern of medication responsiveness
of this group are similar to those of MdDS.
CAUSE OF MdDS: PERSISTENT
ADAPTATION TO SWAYING
ENVIRONMENTS?
MdDS syndrome does not have the features of a
“pathologic” disease, in the sense that it does not follow
an injury and is not associated with structural damage to
the inner ear or a blood chemistry abnormality. Rather, it
is provoked by exposure to motion that does not trouble
most individuals. While on the boat, the brain must
adjust leg and body motion so that they counter the
rhythmic pattern of shipboard motion. Adaptation to
such movement is sometimes called “gaining sea legs.”
A common explanation for MdDS is that persons with
MdDS are good at adapting to unusual motion situations,
such as ocean travel, but slow to give up their adaptation
when they return to stable ground (Mair, 1996). This is a
reasonable general suggestion, but it lacks specifics.
Let us consider the visual, somatosensory, and
vestibular consequences of boat motion in the ante-
rior–posterior plane, and how the brain might develop
adaptive “rules” to handle them. Traveling on a boat
exposes a person to angular and linear movement, some
of which is predictable and some of which is not. For
small rotations of the boat under the person, there is no
vestibular consequence, as bodily inertia tends to keep
the person upright in space. Vision is accurate on the deck
but inaccurate inside. Although there is rotation around
the ankle joint, and thus somatosensory input, there
should be no “righting” response from the person
because the body is upright in space. As vision is unreli-
able, a “rule” about using visual cues cannot be made.
The rule then for pitch rotation of the boat is that
one should ignore somatosensory information signaling
rotation. Thus, for pitch of the boat, a selective “down-
weighting” of somatosensory information, or both
somatosensory and visual information, according to con-
text, would be reasonable.
For linear acceleration of the boat under the person, or
“surge,” as it is called in nautical contexts, inertia tends to
keep the person still in space, but because of shear force
at the feet, the person rotates at the ankles and becomes
destabilized. Then vision, vestibular and somatic senses
are activated by the bodily rotation with respect to the
boat, and an active response is needed to prevent a fall.
Thus, for surge of the boat, no relative sensory down-
weighting would be appropriate, but increased responses
to all types of input might be helpful.
As different weightings would be useful for different
types of boat motion, no single weighting rule would be
optimal. A potential solution that also explains persistent
symptoms is that in MdDS there is prediction of boat
motion through an internal model of boat motion – an
internal oscillator. By using prediction, one can deter-
mine the best rule to follow – one should ignore
(down-weight) ankle and visual inputs that are entrained
with boat rocking, but attend to or perhaps up-weight
sensory input that is uncorrelated with boat rocking.
With respect to the hypothesis that MdDS is caused by
persistent reweighting of visual, vestibular, or somato-
sensory input, the data so far are contradictory. Further-
more, the data are largely based on studies of the more
 
MAL DE DEBARQUEMENT SYNDROME
abundant subject groups having land-sickness (largely
sailors), but that have almost no overlap with the usual
demographic characteristics of the MdDS population
(i.e., middle-aged women).
Nachum and associates (2004) used posturography to
study young males aged 18–22 with motion sickness and
land-sickness (they considered land-sickness to be
equivalent to mal de debarquement). They reported that
these young men developed increased reliance on
somatosensory input after motion exposure, and reduced
weighting of vision and vestibular input. While the accu-
racy of visual input depends on whether one is inside the
boat or on the deck, semicircular canal input is accurate
on boats, and somatosensory input is intermittently accu-
rate. Accordingly, it is difficult to understand a rationale
for this adaptation. Another study, that of Stoffregen and
associates (2013), also miscategorized land-sickness as
MdDS and also studied a population with almost no over-
lap with the MdDS patients reported in the medical
literature.
A more reasonable possibility than increased reliance
on somatosensory input is that individuals with MdDS
may develop an increased reliance on visual and vestib-
ular information. This occurs in normal subjects who are
exposed to situations where somatosensory feedback is
distorted (Peterka, 2002), and would also be a reasonable
adaptation to boat pitch. Either adaptation might result in
inaccurate land sensorimotor integration. Nevertheless,
neither of these adaptations explains the rocking sensa-
tion of MdDS or the characteristic improvement when
driving a car.
In an attempt to explain the prolonged duration of
MdDS and the characteristic improvement with driving,
in 2007 we first proposed that MdDS might be explained
by internal model theory. In particular, an internal model
of periodic boat motion – an internal oscillator that is
entrained by boat motion – might allow one to select
out salient sensory input (boat surge) and ignore the non-
salient input (boat pitch) (Hain, 2007). Cha (2015)
recently offered a similar theory involving “intrinsic
brain networks driven by oscillatory motion exposure.”
In support of this idea, some animals exhibit persistent
oscillations in central neurons after periodic movement
ends (Barmack and Shojaku, 1992). Also, postmove-
ment illusions of rocking can be induced by sinusoidal
rotation in some individuals (Lewis, 2004). Such an
internal oscillator might be activated and produce a per-
sistent rocking sensation because of noise related to
activities of daily life, even when there is no ongoing
periodic motion.
Moeller and Lempert (2007) proposed that MdDS
might be due to “pseudo-hallucinations from vestibular
memory,” similar to the Charles Bonnet syndrome that
afflicts some persons with severe visual loss. They also
393
suggested that MdDS might be a secondary complication
involving anxiety and focused attention on symptoms.
While possible in some cases, these ideas do not provide
an explanation for the age and female gender distribution
of MdDS.
The most recent mechanistic proposition for MdDS is
that of Dai and associates (2014). They proposed that
MdDS was caused by maladaptation of the vestibulo-
ocular reflex (VOR) to roll of the head during rotation,
and reported that a 5-day-long protocol attempting to
readapt the VOR resulted in “substantial recovery on
average for approximately 1 year” of 17 of 24 subjects
(Dai et al., 2014). While these results are encouraging,
this theory does not explain why patients with MdDS
are better while driving. Furthermore, it is difficult to
see why ordinary movement through the environment
should not recalibrate the VOR over a few days – the
usual upper limit for the duration of land-sickness. At
the time of writing (2015), the roll adaptation theory
and treatment protocol need more study.
TREATMENT OF MdDS
The usual clinical treatment strategy for MdDS is to
attempt to make the patient comfortable, while waiting
for the MdDS to end by itself (typically within 6 months).
Conventional vestibular suppressants that affect anticho-
linergic pathways, such as meclizine and transdermal
scopolamine, are not helpful in MdDS (Hain et al.,
1999). Benzodiazepines, such as clonazepam, are of
the most benefit (Hain et al., 1999; Cha, 2012), but risk
of addiction limits their use. Selective serotonin reuptake
inhibitor-type antidepressants are also suggested as
being potentially helpful (Cha, 2012). There are also
reports of good responses to gabapentin, amitriptyline,
and venlafaxine – all medications that are also helpful
in migraine.
After 6 months have gone by, if the MdDS patient is
no better, there is more pressure to find another interven-
tion. While vestibular physical therapy would seem rea-
sonable, Cha (2012) commented that “only rare patients
seem to be cured by vestibular therapy.” In fact, the only
peer-reviewed literature describing physical therapy
treatment for MdDS are two case reports (Zimbelman
and Watson, 1992; Liphart, 2015). Of course, it is not
known how these cases would have done without inter-
vention. In general, while many individuals with MdDS
undergo vestibular rehabilitation, again because of a lack
of controls, it is not possible to determine whether they
did any better than persons who were not treated (Hain
et al., 1999). Thus the efficacy of vestibular rehabilitation
for MdDS is unknown.
Motion sickness has been treated successfully with
habituation (Dai et al., 2011) and one might reasonably
394 T.C. HAIN AND M. CHERCHI
argue that, if MdDS is a motion sickness variant, it might
also respond to a similar approach. Habituation entails a
down-weighting of motion input, and can reduce the
long-duration vestibular responses commonly associated
with motion sickness susceptibility (Dai et al., 2007). Dai
and associates (2014) reported that rolling the head from
side to side while watching a rotating full-field visual
stimulus was a successful treatment in 17 of 24 MdDS
subjects.
Although there are well-developed self-directed
motion habituation protocols such as the Puma exercises
(Puma, 2010), there are presently no reports of their effi-
cacy in MdDS. In as much as patients with MdDS ini-
tially became ill after repetitive motion exposure, it is
also reasonable to conjecture that more motion exposure,
as is required for habituation, might worsen MdDS.
Repetitive transcranial magnetic stimulation over the
dorsolateral prefrontal cortex was reported by Cha et al.
(2013) to be associated with short-term symptom
improvement in a pilot study, as well as helpful in more
recent studies (Guofa et al., 2014; Pearce et al., 2015).
More study is needed of this treatment modality for
MdDS. In particular, a treatment protocol that accom-
plishes long-term improvement in this disorder that lasts
months to years is crucial.
If MdDS is caused by an internal oscillator developed
to predict boat motion or psychologic mechanisms rather
than cross-axis VOR adaptation, as suggested by Dai and
associates (2014), or inappropriate sensory weighting, as
suggested by many others, one’s treatment strategy
should reasonably be aimed at manipulation of psycho-
logic variables. Patients need to ignore their aberrant
internal signal, in the same way that most persons with
tinnitus eventually develop an ability to ignore abnormal
internally generated sounds. Treatments that decrease
vigilance, obsessiveness, and anxiety, as well as
“tincture of time,” would be the optimum strategy. If this
conjecture is correct, as is the case with tinnitus, therapy
that focuses attention on the rocking sensation could
even be counterproductive.
To summarize, MdDS is an uncommon disorder in
which individuals, mainly middle-aged women, develop
a prolonged, inappropriate illusion of rocking motion,
paradoxically relieved by actual motion such as driving.
The rare entity of MdDS differs from the common entity
of land-sickness, primarily in that MdDS must last at
least a month to be diagnosed. Treatments of MdDS that
reduce anxiety (such as benzodiazepine medication) and
medications effective for migraine are currently the best
established treatments of MdDS. There are recent reports
of successful treatment of MdDS using transcranial mag-
netic stimulation and habituation. The visual stimulus-
based habituation treatment as developed by Dai and
associates (2014) is especially promising.
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