Mal de Debarquement (MDD)

Timothy C. Hain, MD, Last updated 5/2002.

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We recently published a survey study on MDD (Hain et al, 1999). This page is mainly based on that article, with additions as we learn more about the disorder. Mal de Debarquement or "MDD" is a type of vertigo and imbalance that occurs after getting off of a boat. The usual situation is that of a person who has gone on a cruise. Most individuals with this diagnosis are women between the ages of 40 and 50 who go on a 7-day cruise. After getting off the boat, or "debarking" (debarquement), they develop a rocking sensation, as if they are still on the boat. The rocking sensation may persist for months or even years ! Most people seem to have it for a month or less though -- our study largely recruited people with longer duration symptoms (3.5 years was the mean).

Duration of MDD

What Causes Mal de Debarquement ?

Little is known about this rare disorder. It is clear, however, that MDD is not caused by an injury to the ear or brain. At this writing (5/2002), the predominant opinion is that MDD is a variant motion sickness. While this theory doesn't explain why MDD seems to mainly affect women in their 40's it does seem to account for observations of naval personnel who have a similar land-sickness experience. Some dizziness experts believe that MDD is caused by a variant of migraine. Because the condition largely occurs in females, it may also have something to do with sex hormones, such as estrogen or progesterone. It could also be genetic, related to two copies of the 'X' chromosome perhaps combined with other susceptibility factors. It seems unlikely to be a psychological disturbance -- although it is always difficult to entirely exclude psychological problems, the male:female ratio and other aspects of this disorder would make this unlikely.

Diagnosis of Mal de DebarquementAge distribution of MDD

The diagnosis is made by a combination of the history (rocking after prolonged exposure to a boat), and exclusion of reasonable alternatives. Tests to exclude Menieres disease should be done, and if there is a history of plane flight, perilymph fistula should also be considered. A typical patient is a woman of appropriate age (see figure to the side), who has gone on a cruise and who is now rocking.

In my practice, I get the following tests:

Rotatory chair and video-ENG  . The result is usually normal, occasionally may find unusually strong or prolonged optokinetic or vestibular responses, and there is also sometimes direction-changing positional nystagmus as has been reported by Brown and Baloh in 1987.
Audiogram (expect normal, abnormal suggests other disorders)
Blood tests for autoimmune disorders involving the ear (ANA, TSH, anti-microsomal antibodies, in some cases the anti-cochlear antibodies test and HLA-DR testing)

Treatment for Mal de Debarquement

After the MDD has started, most medications that work for other forms of dizziness or motion sickness are ineffective. Specifically, antivert, bonine, meclizine, dramamine, scopolamine seem to be of little use. Valium and related medications such as Klonapin are helpful in some persons. There is some worry that these medications may prolong the duration of symptoms (although this worry has not yet been tested by a research study). An antidepressant called amitriptyline may also be helpful. Occasionally persons with rocking due to other causes respond to one of the SSRI type antidepressants, and this may also be worth considering. Hormonal medications such as estrogen or progesterone might be problematic -- it might be worth a trial of stopping them if this is practical. Recently (11/2001) we have been told that non-steroidal anti-inflammatory medications such as "Celebrex" or "Vioxx" have helped two patients. Also anecdotally, phenytoin and carbamazepine (or oxy-carbamazepine) may be useful in reducing symptoms. A controlled trial of these medications may be in order if more evidence accumulates.

Prevention: It is possible that medications taken prior and during boat travel might prevent development of MDD. Anecdotal evidence suggests that while antivert and scopolamine are ineffective, some people can prevent MDD by taking Valium, Klonapin, or Ativan prior to getting on the boat or airplane. Again, this possibility has not been tested by a research study and a trial, perhaps controlled with one of the medications known not to prevent MDD might be helpful. Nevertheless, medications which suppress the inner ear or block adaptation to inner ear signals might be useful.

Physical therapy: Physical therapy may be helpful in MDD, although the evidence is not very strong. In our study, 10/15 persons who had vestibular rehabilitation reported improvement, but the natural history of MDD is to improve, and one wonders what would have happened had they not undergone rehabilitation. Zimbelman (see below) has written a review of rehabilitation in MDD. A controlled trial of vestibular rehabilitation in MDD would be helpful.

Avoidance of motion is clearly helpful. If you get dizzy from riding on boats, don't do it !

 

References on Mal de Debarquement

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