The environmental somatization syndrome

General diseases and medications in 687 patients reporting on adverse effects from dental materials

OBJECTIVES

Examination of patients claiming adverse effects from dental materials can be very challenging. Particularly, systemic aspects must be considered besides dental and orofacial diseases and allergies. Therefore, the aim of this study was to investigate a cohort of 687 patients reporting on adverse effects from dental materials focusing on findings related to known general diseases or conditions or medication-related findings with relevance to their subjective complaints.

METHODS

Six hundred eighty-seven patients visiting a specialized consultation on claimed adverse effects from dental materials were retrospectively investigated for their subjective complaints, findings related to known general diseases or conditions, medication-related findings, dental and orofacial findings, or allergies with relevance to their subjective complaints.

RESULTS

The most frequent subjective complaints were burning mouth (44.1%), taste disorders (28.5%), and dry mouth (23.7%). In 58.4% of the patients, dental and orofacial findings relevant to their complaints could be found. Findings related to known general diseases or conditions or medication-related findings were found in 28.7% or 21.0% of the patients, respectively. Regarding medications, findings related to antihypertensives (10.0%) and psychotropic drugs (5.7%) were found most frequently. Relevant diagnosed allergies toward dental materials were found in 11.9%, hyposalivation in 9.6% of the patients. In 15.1% of the patients, no objectifiable causes for the expressed complaints could be found.

CONCLUSIONS

For patients complaining of adverse effects from dental materials, findings related to known general diseases or conditions and medications should be given particular consideration, while still in some patients, no objectifiable causes for their complaints can be found.

CLINICAL RELEVANCE

For patients complaining about adverse effects from dental materials, specialized consultations and close collaboration with experts from other medical fields are eligible.

Multiple Chemical Sensitivity

Multiple Chemical Sensitivity (MCS), a condition also known as Chemical Sensitivity (CS), Chemical Intolerance (CI), Idiopathic Environmental Illness (IEI) and Toxicant Induced Loss of Tolerance (TILT), is an acquired multifactorial syndrome characterized by a recurrent set of debilitating symptoms. The symptoms of this controversial disorder are reported to be induced by environmental chemicals at doses far below those usually harmful to most persons. They involve a large spectrum of organ systems and typically disappear when the environmental chemicals are removed. However, no clear link has emerged among self-reported MCS symptoms and widely accepted objective measures of physiological dysfunction, and no clear dose-response relationship between exposure and symptom reactions has been observed. In addition, the underlying etiology and pathogenic processes of the disorder remain unknown and disputed, although biologic and psychologic hypotheses abound. It is currently debated whether MCS should be considered a clinical entity at all. Nevertheless, in the last few decades MCS has received considerable scientific and governmental attention in light of the many persons reporting this illness. In this review, we provide a general overview of the history, definition, demographics, prevalence, and etiologic challenges in defining and understanding MCS.

Metabolomics and psychological features in fibromyalgia and electromagnetic sensitivity

Fibromyalgia (FM) as Fibromyalgia and Electromagnetic Sensitivity (IEI-EMF) are a chronic and systemic syndrome. The main symptom is represented by strong and widespread pain in the musculoskeletal system. The exact causes that lead to the development of FM and IEI-EMF are still unknown. Interestingly, the proximity to electrical and electromagnetic devices seems to trigger and/or amplify the symptoms. We investigated the blood plasma metabolome in IEI-EMF and healthy subjects using ¹H NMR spectroscopy coupled with multivariate statistical analysis. All the individuals were subjected to tests for the evaluation of psychological and physical features. No significant differences between IEI-EMF and controls relative to personality aspects, Locus of Control, and anxiety were found. Multivariate statistical analysis on the metabolites identified by NMR analysis allowed the identification of a distinct metabolic profile between IEI-EMF and healthy subjects. IEI-EMF were characterized by higher levels of glycine and pyroglutamate, and lower levels of 2-hydroxyisocaproate, choline, glutamine, and isoleucine compared to healthy subjects. These metabolites are involved in several metabolic pathways mainly related to oxidative stress defense, pain mechanisms, and muscle metabolism. The results here obtained highlight possible physiopathological mechanisms in IEI-EMF patients to be better defined.

[Environmental medical syndromes]

Environmental medical syndromes comprise sick building syndrome (SBS), multiple chemical sensitivity (MCS)/idiopathic environmental intolerances (IEI), electromagnetic hypersensitivity, chronic fatigue syndrome (CFS), burnout, fibromyalgia, and the candida syndrome. There is also some overlap described in the literature. There is still no established knowledge of etiology, pathology, pathophysiology, diagnostics, therapy, prevention and prognosis. These syndromes are thought to result from a complex interaction of physical, chemical and/or (micro)biological environmental stresses, individual dispositions, psychological influencing factors, perceptual and processing processes, variants of somatization disorders, culturally or socially caused distress, or simply iatrogenic causation. Examination and treatment methods must be developed or existing ones scientifically validated. However, all uncertainties in the assessment of these syndromes do not absolve the physician from taking patients seriously and helping them as best as possible.

Mass fainting in garment factories in Cambodia

This paper reports an ethnographic study of mass fainting among garment factory workers in Cambodia. Research was undertaken in 2010-2015 in 48 factories in Phnom Penh and 8 provinces. Data were collected in Khmer using nonprobability sampling. In participant observation with monks, factory managers, health workers, and affected women, cultural understandings were explored. One or more episodes of mass fainting occurred at 34 factories, of which 9 were triggered by spirit possession. Informants viewed the causes in the domains of ill-health/toxins and supernatural activities. These included "haunting" ghosts at factory sites in the wake of Khmer Rouge atrocities or recent fatal accidents and retaliating guardian spirits at sites violated by foreign owners. Prefigurative dreams, industrial accidents, or possession of a coworker heralded the episodes. Workers witnessing a coworker fainting felt afraid and fainted. When taken to clinics, some showed signs of continued spirit influence. Afterwards, monks performed ritual ceremonies to appease spirits, extinguish bonds with ghosts, and prevent recurrence. Decoded through its cultural motifs of fear and protest, contagion, forebodings, the bloody Khmer Rouge legacy, and trespass, mass fainting in Cambodia becomes less enigmatic.

"Struggle to obtain redress": Women's experiences of living with symptoms attributed to dental restorative materials and/or electromagnetic fields

The aim of this study was to explore the experiences of illness and the encounters with health care professionals among women who attributed their symptoms and illness to either dental restorative materials and/or electromagnetic fields, despite the fact that research on health effects from dental fillings or electricity has failed to substantiate the reported symptoms. Thirteen women (aged 37-63 years) were invited to the study and a qualitative approach was chosen as the study design, and data were collected using semi-structured interviews. The analysis was conducted with a constant comparative method, according to Grounded Theory. The analysis of the results can be described with the core category, "Struggle to obtain redress," the two categories, "Stricken with illness" and "A blot in the protocol," and five subcategories. The core category represents the women's fight for approval and arose in the conflict between their experience of developing a severe illness and the doctors' or dentists' rejection of the symptoms as a disease, which made the women feel like malingerers. The informants experienced better support and confirmation from alternative medicine practitioners. However, sick-leave certificates from alternative medicine practitioners were not approved and this led to a continuous cycle of visits in the health care system. To avoid conflicting encounters, it is important for caregivers to listen to the patient's explanatory models and experience of illness, even if a medical answer cannot be given.

On the Recognition of Multiple Chemical Sensitivity in Medical Literature and Government Policy

The history of chemical sensitivity in America is reviewed from the first description published by Edgar Allan Poe in 1839, to its first medical definition as a symptom of neurasthenia in 1869, its rediscovery as allergic toxemia in 1945, its redefinition in 1987 as multiple chemical sensitivity (MCS), and its overlap in the 1990s with chronic fatigue syndrome, fibromyalgia syndrome, and Gulf War syndrome (GWS). More than half of the over 500 peer-reviewed articles on MCS support an organic basis for MCS, whereas less than one-quarter support a psychiatric basis. The same 2:1 difference is seen in the numbers of MCS researchers writing these articles and the number of journals publishing them. A psychogenic interpretation of MCS also is specifically rejected in the latest formal position statement on the subject, a 1994 consensus of the American Lung Association, American Medical Association (AMA), U.S. Environmental Protection Agency (US EPA), and U.S. Consumer Product Safety Commission (US CPSC) (U.S. Government Printing Office 1994–523–217/81322). This and other government recognition of MCS in policy, research, and scientific conferences are summarized. Dozens of federal, state, and local authorities accept MCS as a legitimate disease and/or disability that deserves reasonable accommodation in housing, employment, and public facilities. Official recognition is expected later in 1999 when the U.S. Centers for Disease Control and Prevention (CDC) announces a formal definition of MCS and the federal Interagency Workgroup on MCS releases its long-awaited final report, 4 years in the making. Given that epidemiological data from three states puts the prevalence of chemical sensitivity at 16 to 33% of the general population, 2 to 6% of whom have already been diagnosed with MCS, this truly is a hidden epidemic that deserves the priority attention of public health researchers and policy makers. Industrial toxicologists are encouraged to work on reducing and eliminating the use of synthetic fragrances, chemical sensitizers, and other irritants in consumer products and occupational settings.

Multiple Chemical Sensitivities: Psychogenic or Toxicodynamic Origins

The multiple chemical sensitivity (MCS) phenomenon can cause significant dysfunction and symptomatology and presents a difficult challenge for patient management. Central to the MCS debate is whether this phenomenon results from a primary emotional response to perceived chemical exposures or from pathological interactions between chemicals and biological systems. Those who believe the latter argue that toxic interactions result in physiological impairment and that subsequent emotional problems derive from such impairment. Distinguishing between psychogenic (emotional) or a toxicodynamic (chemical toxicity) origin is essential to the medical management of an MCS patient. A psychogenic basis requires treatment with appropriate behavioral therapies; in contrast, a belief in a strictly toxicodynamic etiology argues for avoidance and often precludes treatments that address the psychological responses. Current scientific evidence strongly suggests that behavioral or psychogenic explanations predominate for reported MCS symptoms. Acceptance of a purely toxic origination (i.e., pathological abnormalities result from a low level chemical exposure) defies known toxicological and medical principles; whereas psychogenic explanations are consistent with these principles. Because symptoms are the end points of many diseases with many causes, both physical and emotional, modern medicine is charged with and expected to consider both when treating MCS patients. The argument can be made that insufficient information exists about the causal nature of many diseases, and future research may provide support for a strict toxicodynamic cause. However, the practice of medicine must be based upon current knowledge, not future possibilities. Proper care of MCS patients requires identifying the existence of both psychological and organic pathological dysfunction. The rejection of a psychological aspect of the MCS phenomenon and appropriate behavioral treatments is both illogical and detrimental to MCS sufferers.

Idiopathic environmental intolerance attributed to electromagnetic fields (IEI-EMF) and electrosensibility (ES) - are they connected?

INTRODUCTION

The tendency of experiencing unpleasant symptoms in the proximity of working electric devices is called idiopathic environmental intolerance attributed to electromagnetic fields (IEI-EMF). Evidence about psychophysiological backgrounds of the phenomenon (i.e., detection ability and mechanisms of symptom generation) is not yet conclusive.

METHODS

Participants of the provocation experiment were 29 individuals with self-reported IEI-EMF and 42 control persons. Participants completed questionnaires (symptom expectations, somatosensory amplification - SSAS, modern health worries radiation subscale - MHW-R), and attempted to detect the presence of 50 Hz 0.5 mT magnetic field (MF) directed to their right arm in 20 subsequent 1-min sessions. Heart rate was also recorded and various indices of heart rate variability (HF, LF/HF, SDNN) were calculated.

RESULTS

Using the methodology of the signal detection theory, individuals with IEI-EMF as opposed to the control group showed a higher than random detection performance (d' differed slightly but statistically significantly from zero), and they used a significantly lower criterion (β value) when deciding about the presence of the MF. Detection sessions followed by correct decisions (hits or correct rejections) were characterized by higher HRV (SDNN and HF indices) than periods followed by errors (misses or false alarms). Previous expectations and affiliation to the IEI-EMF group were significant predictors of symptoms reported following exposure. IEI-EMF was closely related to MHW-R and SSAS scores.

CONCLUSION

Detection of MF might be possible for people with IEI-EMF to some extent. Although heightened sensibility to MFs may play a role in the development and/or in the perpetuance of the IEI-EMF phenomenon, symptoms attributed to the MF seem to be mainly of psychogenic origin.

The German Multicentre Study on Multiple Chemical Sensitivity (MCS)

In this multicentre study on multiple chemical sensitivity (MCS) 291 consecutive environmental medicine (EM) outpatients were examined in several environmental medicine outpatient centres/units throughout Germany in 2000/2003. Of the EM outpatients, 89 were male (30.6%) and 202 were female (69.4%), aged 22-80 (mean 48 years, S.D.=12 years). The sample was representative for university-based environmental outpatient departments and represented a cross-sectional study design with an integrated clinical-based case-control comparison (MCS vs. non-MCS). Three classifications of MCS were used: self-reported MCS (sMCS), clinically diagnosed MCS (cMCS), and formalised computer-assisted MCS with two variants (f1MCS, f2MCS). Data were collected by means of an environmental medicine questionnaire, psychosocial questionnaires, the German version of the Composite International Diagnostic Interview (CIDI), and a medical baseline documentation, as well as special examinations in partial projects on olfaction and genetic susceptibility markers. The hypothesis guided evaluation of the project showed that the patients' heterogenic health complaints did not indicate a characteristic set of symptoms for MCS. No systematic connection could be observed between complaints and the triggers implicated, nor was there any evidence for a genetic predisposition, or obvious disturbances of the olfactory system. The standardised psychiatric diagnostics applying CIDI demonstrated that the EM patients in general and the subgroup with MCS in particular suffered more often from mental disorders compared to an age and gender matched sample of the general population and that in most patients these disorders commenced many years before environment-related health complaints. Our results do not support the assumption of a toxicogenic-somatic basis of the MCS phenomenon. In contrast, numerous indicators for the relevance of behavioural accentuations, psychic alterations or psychosomatic impairments were found in the group of EM-outpatients with subjective "environmental illness".

Psychobiological personality dimensions in two environmental-illness patient groups

The aim of the present study was to investigate the psychobiological personality dimensions in two subgroups of patients with environmental illness (EI). Fifty-nine patients, 34 women and 25 men (aged 32-69 years), were referred for symptoms allegedly caused by abnormal sensitivity to either dental fillings (DF; n=26) or electromagnetic fields (EMF; n=33). For the evaluation of personality, the Swedish 238-item version of the Temperament and Character Inventory (TCI) was used. Compared with a control group, the EMF group scored higher on the temperament dimension Persistence. The DF group scored higher on the TCI subscales Harm Avoidance (fatigability and asthenia) and Self-Directedness (self-acceptance). Women scored higher than men did on the Novelty Seeking and Reward Dependence (RD) dimensions in the DF group and on RD in the control group, indicating an inherited gender difference. No differences were found between men and women in the EMF group. Our results indicate that the high level of persistence found in the EMF group and the high level of fatigability and asthenia in combination with high self-acceptance found in the DF group represent vulnerable personalities. No significant differences were found between the two patient groups, indicating that these groups are quite similar regarding personality. This vulnerability can be expressed as various mental and somatic symptoms, which can be interpreted as EI symptoms by the affected individual.

Unloading the trunk: neurasthenia, CFS and race

The aetiologies of both chronic fatigue syndrome (CFS) and its predecessor neurasthenia, have been linked to technological advances in 'developed' countries. This paper discusses how this has led to a form of race thinking within discussions about fatigue which has persisted for more than a century. We review the historical development of this race thinking from neurasthenia to CFS and describe how it is manifested in both the lay- and medical literature. We also review the epidemiological literature on CFS and ethnicity to better understand the relatively low percentage of non-white patients seen in tertiary referral clinics for CFS. The aim of this paper is to act as a starting point for a debate on race and CFS.

Are syndromes in environmental medicine variants of somatoform disorders?

To date, relatively little is known about the etiology, pathophysiology, diagnosis, therapy, prevention and prognosis of environment-related syndromes like multiple chemical sensitivity (MCS), idiopathic environmental intolerance (IEI), sick building syndrome (SBS), chronic fatigue syndrome (CFS), candida syndrome (CS) and burnout syndrome (BS). Part of the reason is that these syndromes have not been clearly defined and classified in scientific categories distinct from each other, and that they show clinical similarities to classified somatoform disorders. Furthermore, there are at least three possible explanations for the existence of these syndromes: (1) The syndromes may result from the interaction of environmental factors, individual susceptibility and psychological factors (i.e., how they are perceived and seen by the patient); (2) they may reflect socially and culturally accepted methods of expressing distress; and/or (3) they may be iatrogenic. Despite all the uncertainties in evaluation of environmental syndromes, physicians have the duty to take the affected person's problems seriously. A comprehensive systematic classification which better accounts for these complex clinical manifestations is long overdue. Until these syndromes are well defined, the terms used for them should definitely not be applied to connote a specific disease process.

Idiopathic Environmental Intolerance

Toxicogenic and psychogenic theories have been proposed to explain idiopathic environmental intolerance (IEI). Part 2 of this article is an evidence-based causality analysis of the psychogenic theory using an extended version of Bradford Hill's criteria. The psychogenic theory meets all of the criteria directly or indirectly and is characterised by a progressive research programme including double-blind, placebo-controlled provocation challenge studies. We conclude that IEI is a belief characterised by an overvalued idea of toxic attribution of symptoms and disability, fulfilling criteria for a somatoform disorder and a functional somatic syndrome. A neurobiological diathesis similar to anxiety, specifically panic disorder, is a neurobiologically plausible mechanism to explain triggered reactions to ambient doses of environmental agents, real or perceived. In addition, there is a cognitively mediated fear response mechanism characterised by vigilance for perceived exposures and bodily sensations that are subsequently amplified in the process of learned sensitivity. Implications for the assessment and treatment of patients are presented.

Psychiatric morbidity and low self-attentiveness in patients with environmental illness

Controversy surrounds the origin of symptoms attributed to environmental pollutants or widely used chemicals, and the authors believed that a psychiatric evaluation could advance understanding of this contentious condition. They assessed psychiatric morbidity, somatization, and self-attentiveness in patients seen in their Environmental Clinic. Two hundred ninety-five consecutive patients underwent SCID-I and -II interviews and were investigated with self-rating scales for self-attentiveness and somatization. The authors found a high prevalence of mental disorders (66% had a current SCID diagnosis, and 75% had a lifetime SCID diagnosis) and a low level of self-attentiveness, which was not necessarily associated with psychiatric disease. Among patients visiting an Environmental Clinic, mental disorders were common and needed to be diagnosed and treated by standard interventions. Patients who did not meet diagnostic criteria for a psychiatric disorder had relatively low somatization scores and low private self-attentiveness. These "externalizers" could benefit from an intervention that teaches them to focus on their internal and emotional lives. In these patients, the authors consider low self-attentiveness a major feature that may act as a pathogenic factor for environmental illness.

Neurophysiological study of patients with perceived 'electrical hypersensitivity'

The aim of the present study was to investigate baseline neurophysiological characteristics of the central and autonomous regulation and their reactivity to different tests in a group of persons with so-called 'electrical hypersensitivity', which is often considered as a form of psychosomatic disorders. Twenty patients with combinations of neuroasthenic symptoms (general fatigue, weakness, dizziness, headache) and facial skin (itching, tingling, redness) have been investigated. An equal number of symptom-free persons served as a control group. The examination comprised self-reported measures, testing of visual functions, measurements of blood pressure, heart rate and its variability, electrodermal activity, respiration, EEG and visual evoked potentials (VEP). Several variables were found to differ between the patient and the control groups. The mean value of heart rate in rest condition was higher in the patient group compared to the controls (mean value of inter-beat intervals were 0.80 and 0.90 s, respectively). Heart rate variability and response to standing test were decreased in the patient group compared to the controls. Patients had faster onset, higher amplitudes, and left-right hand asymmetry of the sympathetic skin responses. They had a higher critical fusion frequency (43 vs. 40 Hz), and a trend to increased amplitude of steady-state VEPs at stimulation frequencies of 30-70 Hz. The data indicated that the observed group of patients had a trend to hyper sympathotone, hyperresponsiveness to sensor stimulation and heightened arousal.

Idiopathic environmental intolerances (formerly multiple chemical sensitivity) psychiatric perspectives

Idiopathic environmental intolerances (IEI)/multiple chemical sensitivity (MCS) is characterized by various somatic symptoms which cannot be explained organically, but are attributed to the influences of toxic environmental chemicals in low, usually harmless doses. In the absence of a widely accepted definition of IEI, contradictory aetiological hypotheses and therapeutic suggestions are discussed. Some authors doubt the existence of IEI/MCS as a disease entity of its own. The label IEI does not implicate neither a diagnosis of somatic disease nor that it is caused by an avoidable exposure. Many IEI patients suffer from psychiatric diseases. A majority of them can be diagnosed as somatoform disorders. Consequently, psychiatric therapies could be effective. This review describes the current knowledge about IEI/MCS, outlines a diagnostic algorithm and a psychotherapeutic concept for variants of IEI understood as a somatoform disorder.

Idiopathic environmental intolerances (IEI): myth and reality

The psychogenic theory presupposes that idiopathic environmental intolerance (IEI) is an overvalued idea explained by psychological and psychosocial processes. The polysomatic symptoms are amplifications of complaints common to the general population, psychophysiological manifestations of stress and the stress-response, or symptoms of psychiatric clinical syndromes. The psychogenic theory is supported by provocation challenge studies which demonstrate that appraisals of 'reactions' are unreliable and cognitively mediated. Clinical studies of IEI cases consistently identify greater incidence of current and premorbid lifetime psychiatric disorders and co-morbidity with functional somatic syndromes that are fashionable 'diagnoses'. The toxicogenic theory presupposes low-level chemical sensitivity or intolerance without objective signs to a plethora of diverse chemical agents. Symptoms are synonymous with disease and attributions are synonymous with cause. Hypotheses about physiological processes and mechanisms are implausible and unsupported by evidence. Advocates claim this phenomenon is so ephemeral that the principles and methods of toxicology do not apply and that a scientific paradigm shift is in order.

Potential mechanisms in chemical intolerance and related conditions

The symptom of chemical intolerance may occur in isolation, but often occurs in conjunction with other chronic symptoms such as pain, fatigue, memory disturbances, etc. This frequent clustering of symptoms in individuals has led to the definition of several chronic multisymptom syndromes, such as multiple chemical sensitivity, fibromyalgia, chronic fatigue syndrome, and Gulf War illnesses. The aggregate research into these syndromes has suggested some unifying mechanisms that contribute to symptomatology. Multiple lines of evidence suggest that there is aberrant function of numerous efferent neural pathways, such as the autonomic nervous system and hypothalamic-pituitary axes, in subsets of individuals with these conditions. There is perhaps the greatest evidence for abnormal sensory processing in these syndromes, with a low "unpleasantness threshold" for multiple types of sensory stimuli. Psychological and behavioral factors are known to play a significant role in initiating or perpetuating symptoms in some persons with these illnesses. In the field of pain research, the interrelationship between physiologic and psychologic factors in symptom expression has been well studied. Using both established and novel methodologies, studies have suggested that psychologic factors such as hypervigilance and expectancy are playing a relatively minor role in most individuals with fibromyalgia and that clear evidence exists of physiologic amplification of sensory stimuli. These studies need to be extended to more sensory tasks and to larger numbers of subjects with related conditions. It is of note, though, that existing data on this spectrum of illnesses would suggest that there may be greater psychologic contributions to symptomatology if an illness is defined in part by behavior (e.g., avoidance of chemical exposures) rather than on the basis of symptoms alone.

Environmental illness: fatigue and cholinesterase activity in patients reporting hypersensitivity to electricity

The lack of a pathophysiological marker hinders studies on environmental illnesses of unknown origin. Hence, research focused on the identification of such a marker is a priority. This study investigated the nature and a possible etiology of fatigue in hypersensitivity to electricity (the most commonly reported environmental illness in Sweden). The aim was to test the hypothesis that perceived fatigue was due to alterations in cholinesterase activity. The study group consisted of 14 people who reported a hypersensitivity to electricity, including disabling fatigue. We assessed cholinesterase activity three times: twice based on current symptoms reported by the subjects (severe fatigue attributed to electromagnetic fields and absence of this symptom) and once at a randomly selected time. No significant reduction in acetylcholinesterase was identified in any subject. Examined on a group level, no significant reduction in activity was identified at the time of severe fatigue, and no correlation between reported degree of fatigue and cholinesterase activity was observed. Fatigue attributed to electromagnetic fields was nonphysical and showed a significant correlation to difficulties in concentrating. The results do not support the hypothesis that a change in cholinesterase activity mediates fatigue in people reporting hypersensitivity to electricity.

Anxiety and depressive states in multiple chemical sensitivity

Cases with multiple chemical sensitivity (MCS) frequently present mental symptoms. This study discusses the characteristics of the anxiety and depressive state of MCS by comparing patients of MCS with a gender and age-matched control group. In this investigation, MCS cases were selected among those satisfying the diagnostic criteria of Cullen after ruling out other physical diseases. Patients visiting ophthalmologists with other diseases were designated as the control. Evaluation of the anxiety and depressive state was performed in 48 cases of MCS and 48 controls using the Japanese version of the State-Trait Anxiety Inventory, the Self-rating Depression Scale (SDS), and the Hamilton Rating Scale for Depression. Significantly higher mean values of subjective anxiety and a depressive state were obtained in 18 MCS cases than in 18 controls for the follow-up patients, while no significant difference was observed between MCS and controls of 30 new patients for each group. Therefore, anxiety in MCS is characterized by the continuous high anxiety level. MCS is also characterized by a continuance of depressive state at a "neurotic level" category by SDS. The anxiety scores and depressive levels were highly correlated in MCS and controls at the first and subsequent appearances, except those in the follow-up control cases. In conclusion, both anxiety and a depressive state in MCS remained at high level until the subsequent examination, when those in controls decreased to a normal level.

Multiple chemical sensitivity: a review of the theoretical and research literature

Multiple chemical sensitivity (MCS) is a term used to describe a disorder characterized by a vast array of somatic, cognitive, and affective symptoms, the cause of which is attributed to exposure to extremely low levels of a variety of chemicals. Upon examination of the patient with a diagnosis of MCS, objective physical findings and consistent laboratory abnormalities are typically nonexistent. The concept of MCS has ignited considerable controversy in the fields of toxicology, immunology, allergy, psychology, and neuropsychology. Central to the controversy is the disagreement over the extent to which the manifestation of MCS is mediated by psychological factors. Because of the large number of neuropsychological symptoms associated with a diagnosis of MCS, neuropsychologists are increasingly receiving referrats for the assessment of these patients. It is important, therefore, that neuropsychologists become aware of the variety of clinical issues that must be taken into account when assessing an individual with a diagnosis of MCS. The theoretical and research literature on individuals with a diagnosis of MCS is reviewed here.

Conversion disorder and multiple chemical sensitivity: a comparative study of psychological defense strategies

This study compared psychological defensive strategies in two groups of patients with multiple chemical sensitivity (n = 10) and conversion disorder (n = 10) by means of the projective perceptual Defense Mechanism Test. We attempted to create a model for personality assessment based on the test data of prior patients, in which new patients could successively be tested. The overall results indicated that it was possible to separate the clinical groups significantly from a control group and from each other. In comparison to the controls, the clinical groups were characterized by patterns that were more nonemotionally adapted as well by a lateness of perception, but the ways in which the clinical groups maintained this difference were not the same. The multiple chemical sensitivity group was characterized above all by blocking maneuvers, while the main defensive strategy of the conversion disorder group was distortion of content.

Chemical sensitivity and fatigue syndromes from hypoxia/hypercapnia

The multiple chemical sensitivities syndrome (MCS) and other chronic syndromes causing fatigue, headache and other protean CNS symptoms without observable signs, are proposed to result from hypoxia/hypercapnia (H/H) due to disturbed breathing. The concept is explained in terms of sleep apnea (SA), although H/H could result from causes other than SA. Reasons for considering this etiologic linkage are as follows: 1. MCS symptoms resemble those of SA. 2. The only physical signs associated with MCS (upper airway inflammation and obstruction) can aggravate SA. 3. The only neuropsychiatric finding common among MCS symptomatics, reduced verbal recall, is associated with SA. 4. Many MCS symptomatics attribute onset of their condition to a pesticide or solvent exposure. Solvent neurotoxicity may cause cacosmia, a symptom of MCS and SA. 5. Improved upper airway patency, a first-line therapy in SA, may improve symptoms in some MCS-like conditions. Implications for diagnosis and treatment of MCS are discussed.

Olfaction and symptoms in the multiple chemical sensitivities syndrome

Whereas most idiosyncratic environmental sensitivity complaints do not fit known diagnoses, the multiple chemical sensitivities syndrome (MCS) is an extreme presentation that has defined diagnostic criteria. MCS symptomatics claim that they acquired a sensitized state as the result of a chemical exposure, usually to a solvent or pesticide, but not to a fragrance. Before this exposure, they did not experience symptoms. Following sensitization, symptoms increasing in number and severity with time are attributed by the MCS symptomatic to various exposures that are innocuous to most individuals. Although phenomenological studies have provided no evidence that particular odors elicit MCS symptoms, low levels of fragrances and perfumes are frequently associated with the reporting of MCS symptoms. This evaluation examines proposed mechanisms by which odorants and fragrances might cause either sensitization or elicitation of MCS symptoms, including altered odor sensitivity, primary irritancy or irritancy-induced upper airway reactivity, neurogenic switching of trigeminal irritancy signals, time-dependent sensitization and limbic kindling, CNS toxicity, and various psychiatric conditions. In no case was there persuasive evidence that any olfactory mechanism involving fragrance underlies either induction of a sensitized state or the triggering of MCS symptoms. Fragrances and other odorants could, however, be associated with symptoms as claimed by MCS symptomatics, because they are recognizable stimuli, but fragrance has not been demonstrated to be causal in the usual sense.

Multiple chemical sensitivities: the social construction of an illness

Multiple chemical sensitivities (MCS) has emerged as an important and highly controversial issue in occupational health. Debate centers on whether the illness is "physical" or "psychological." A strong corporate-backed campaign has framed the debate and has pushed MCS advocates into a strategy of "proving the physical" nature of MCS. Proponents of both positions, however, share key assumptions that impede long-term efforts to benefit MCS sufferers, including acceptance of the physical/psychological dichotomy as a paradigm for the illness, a desire to rid the debate of "politics" to allow "objective scientific" data to be amassed, and a view of MCS as unique without links to other occupational illnesses. While a grassroots movement has benefited MCS sufferers in a number of important ways, the shared assumptions have impeded development of a more complex model for the illness that is reflective of a complex reality, reproduced mainstream expert/non-expert relationships, and failed to connect with the broader occupational health and safety movement. The author outlines an alternative theory and practice to begin addressing these issues, beginning with a recognition of MCS as a problem of developing knowledge within a context of class power.

Quantitative EEG patterns during nose versus mouth inhalation of filtered room air in young adults with and without self-reported chemical odor intolerances

Individuals who report illness (e.g. nausea, headache) from common chemical odors tend to report CNS symptoms suggestive of olfactory-limbic system involvement. This study compared the resting quantitative electroencephalographic (qEEG) patterns of young adult college students reporting subjectively elevated chemical odor intolerance ratings (HICI) with those of controls reporting little or no odor intolerance (LOCI). Each group was subdivided into those with higher (HIDEP) vs. lower (LODEP) ratings of concomitant depression. Nineteen channels of EEG were recorded during a single session over four separate rest periods, respectively, following baseline, cognitive, chemical exposure and olfactory identification tests. Each recording involved two 30-s, eyes-closed, filtered room air breathing conditions: (1) nose inhalation followed by mouth exhalation and (2) mouth inhalation followed by mouth exhalation. HICI showed significantly less beta 1 (beta 1) over the temporal-central region during nose than during mouth inhalation. Over some temporal and central leads, task, DEP and CI interacted to influence beta 1 as well. For theta (theta), CI differences emerged during nose inhalation after the cognitive task at Cz, after chemical exposures at C3, Cz and C4 and after the olfactory ID task at C4. CI differences emerged during mouth breathing after the olfactory ID task at Cz, C4 and T4. The T5-T6 coronal array showed significant CI differences after chemical exposures during nose breathing and during mouth breathing after the cognitive and olfactory ID tasks. The theta findings in the HICI may be related to reports of disturbed attention in CI.

Pearls, pitfalls, and updates in toxicology

Pearls and pitfalls learned from our practical experiences caring for poisoned patients are presented. Clinical pearls include the following: using diagnostic tests to detect end-organ toxicity, applying physiologic principles to the management of hemodynamically unstable poisoned patients, and dealing with psychologic injuries from hazardous materials incidents. Recognizing serious complications from poisoning and adverse drug effects, including the serotonin syndrome, are offered as pitfalls. Pharmaceutical companies are rapidly developing and marketing new therapies. Therefore, updates on the evolving role of NAC as an antidote for acetaminophen poisoning, new psychotropic medications, and new antidotes were included in this article. These pearls, pitfalls, and updates are intended to provide practical information that is readily applicable to the clinical practice of emergency medicine.

Physical and mental problems attributed to dental amalgam fillings: a descriptive study of 99 self-referred patients compared with 272 controls

OBJECTIVE

The physical and mental symptomatology of 99 self-referred patients complaining of multiple somatic and mental symptoms attributed to dental amalgam fillings were compared with patients with known chronic medical disorders seen in alternative (N = 93) and ordinary (N = 99) medical family practices and patients with dental amalgam fillings (N = 80) seen in an ordinary dental practice.

METHOD

The assessments included written self-reports, a 131-item somatic symptom checklist; Eysenck Personality Questionnaire, the General Health Questionnaire, and Toronto Alexithymia Scale.

RESULTS

The dental amalgam sample reported significantly more physical symptoms from all body regions. Self-reports suggested that 62% suffered from a chronic anxiety disorder (generalized anxiety disorder or panic). Forty-seven percent suffered from a major depression compared with 14% in the two clinical-comparison samples and none in the dental control sample. Symptoms suggesting somatization disorder were found in 29% of the dental amalgam sample compared with only one subject in the 272 comparison subjects. One third of the dental amalgam patients reported symptoms of chronic fatigue syndrome compared with none in the dental control sample and only 2 and 6%, respectively, in the two clinical comparison samples. The dental amalgam group reported higher mean neuroticism and lower lie scores than the comparison groups.

CONCLUSION

Self-referred patients with health complaints attributed to dental amalgam are a heterogeneous group of patients who suffer multiple symptoms and frequently have mental disorders. There is a striking similarity with the multiple chemical sensitivity syndrome.