Associations between symptoms, modern health worries, and somatosensory amplification in patients with building-related symptoms

OBJECTIVE

The objective of the present study was to investigate the associations between somatosensory amplification, modern health worries (MHWs), and symptoms among patients with building-related symptoms (BRS).

METHODS

Patients with self-reported and medically confirmed BRS (n = 83) were included in this cross-sectional study. The Somatosensory Amplification Scale (SSAS) was used to quantify the tendency to amplify somatic sensations and perceive them as unpleasant and dangerous. Concerns about harmful effects of modern technologies were assessed with the Modern Health Worries Scale (MHWS). Symptoms commonly found in different forms of environmental intolerance were assessed with the Environmental Hypersensitivity Symptom Inventory (EHSI).

RESULTS

Patients with BRS were characterized by more frequent and more severe environmental hypersensitivity symptoms compared to a reference population. Females and those with co-morbid self-reported chemical intolerance reported even more symptoms. MHWS and SSAS scores showed weak to moderate associations with symptoms, even after adjusting for socio-economic variables. However, neither the mean MHWS score or the SSAS score of our sample differed from normative scores.

CONCLUSION

Patients with BRS are not characterized by elevated levels of MHWs and somatosensory amplification, thus other, psychosocial and/or environmental, factors may have contributed to the development of the condition. However, the associations between severity of symptoms and MHWs and somatosensory amplification suggest that psychosocial characteristics may substantially influence symptom experience in this group.

A heartbeat away from a valid tracking task. An empirical comparison of the mental and the motor tracking task

Individuals' ability to perceive their heartbeats, called cardioceptive accuracy, is assessed with various paradigms. Performance in the mental and a novel motor tracking task that eliminates disturbing tactile sensations was assessed at rest and during walking with the participation of 45 young people. Significantly higher scores in the mental tracking task than in the motor tracking task were found. Scores obtained at rest were consistently higher than their walking counterparts. Motor responses showed no temporal association with heartbeats for 84% of participants at rest and 95% during walking. Overall, participants' cardioceptive accuracy at rest and under slight physical activity was poor. Even if people rely on their heartbeat-related sensations during their daily activity, it is either not the ability that is assessed by the tracking tasks, or it is a relatively poor source of information about the actual state of the body.

Psychological models of development of idiopathic environmental intolerances: Evidence from longitudinal population-based data

The origin of idiopathic environmental intolerances (IEIs) is an open question. According to the psychological approaches, various top-down factors play a dominant role in the development of IEIs. The general psychopathology model assumes a propensity towards mental ill-health (negative affectivity) increases the probability of developing IEIs. The attribution model emphasizes the importance of mistaken attribution of experienced somatic symptoms; thus, more symptoms should lead to more IEIs. Finally, the nocebo model highlights the role of expectations in the development of IEIs. In this case, worries about the harmful effects of environmental factors are assumed to evoke IEIs. We estimated cross-lagged panel models with latent variables based on longitudinal data obtained at two time points (six years apart) from a large near-representative community sample to test the hypothesized associations. Indicators of chemical intolerance, electromagnetic hypersensitivity, and sound sensitivity fit well under a common latent factor of IEIs. This factor, in turn, showed considerable temporal stability. However, whereas a positive association was found between IEIs and increased somatic symptoms and modern health worries six years later, the changes therein could not be predicted as hypothesized by the three psychological models. We discuss the implications of these results, as well as methodological aspects in the measurement and prediction of change in IEIs.

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.

The role of cognitive impairment in psychosocial functioning in remitted depression

BACKGROUND

Cognitive dysfunction is a prevalent and disabling symptom of Major Depressive Disorder (MDD), and is often retained in the remitted stage of illness. Emerging evidence suggests that cognitive impairment may be associated with dysfunction in a number of psychosocial domains (e.g., workplace productivity, social relationships). The current study explored the relationship between cognition and psychosocial functioning in remitted MDD and in healthy controls.

METHODS

Data were obtained from 182 participants of the Cognitive Function and Mood Study (CoFaM-S), a cross-sectional study of cognition, mood, and social cognition in mood disorders. Participants' (Remitted MDD n = 72, Healthy n = 110) cognition was assessed with a battery of cognitive tests including the Repeatable Battery for the Assessment of Neuropsychological Function (RBANS) and other standard measures of cognition (e.g., The Tower of London task). Psychosocial functioning was clinically evaluated with the Functioning Assessment Short Test (FAST).

RESULTS

The results indicated that executive functioning was the strongest independent predictor of functioning in remitted MDD patients, whereas various cognitive domains predicted psychosocial functioning in healthy individuals.

LIMITATIONS

Psychosocial functioning was measured with a clinical interview, and was therefore reliant on clinicians' judgement of impairment, as opposed to more objective measures of functioning.

CONCLUSIONS

These findings suggest that executive cognition plays an important role in functional recovery in remitted depression, and may be a crucial target in adjunctive treatment.

Attribution-Based Nocebo Effects. Perceived Effects of a Placebo Pill and a Sham Magnetic Field on Cognitive Performance and Somatic Symptoms

BACKGROUND

Negative non-specific (nocebo-like) effects of medications and electromagnetic fields are often described as results of mistaken attribution.

PURPOSE

The current study aimed to find empirical evidence supporting this theory.

METHOD

Participants completed questionnaires assessing modern health worries, health anxiety, and somatosensory amplification, were assigned to one of three conditions (placebo pill with sedative information, sham magnetic field, or control), and completed a 14-min vigilance task. Changes in physiological arousal (heart rate, heart rate variability, and skin conductance) and reported symptoms were also measured. Finally, causal attributions concerning cognitive performance and reported symptoms were assessed.

RESULTS

No increase in symptom reports and physiological arousal was measured in the two intervention groups. A perceived negative effect on cognitive performance was attributed to both sham conditions, and attributions were connected to modern health worries. A proportion of reported symptoms was ascribed to the placebo pill but not to the sham magnetic field. Symptom attributions were not related to any assessed psychological variables.

CONCLUSIONS

An aroused physiological state is not necessary for the automatic causal attribution process. Negative effects attributed to medication and environmental factors can be regarded as unavoidable side effects of human cognitive-emotional functioning; they might be alleviated, but cannot be completely eradicated.

Health complaints and wind turbines: The efficacy of explaining the nocebo response to reduce symptom reporting

BACKGROUND

A number of people are reporting an environmental sensitivity to sub-audible windfarm sound (infrasound), characterised by the experience of recurrent non-specific symptoms. A causal link between exposure and symptoms is not indicated by empirical evidence. Research indicates symptoms may be explained by the nocebo response, whereby health concerns and negative expectations, created from social discourse and media reports, trigger symptom reporting.

OBJECTIVE

The experimental aim was to test whether providing a nocebo explanation for symptoms, to individuals reporting symptomatic experiences during infrasound exposure, would ameliorate symptoms during further exposure.

METHOD

Sixty-six volunteers were randomly assigned to nocebo explanation or biological explanation groups. Participants were concurrently exposed to infrasound and audible windfarm sound, while reporting on current symptoms and mood, during two exposure sessions. Preceding session one, participants watched a presentation integrating media warnings about purported health risks posed by windfarm infrasound. Before session two, nocebo explanation participants viewed material outlining how nocebo responding could explain symptom reporting. Instead biological explanation participants watched material presenting pathophysiological theories for symptoms.

RESULTS

During session one, participants reported increased symptoms and mood deterioration from baseline assessment. During session two symptom reporting and mood deterioration was maintained by biological explanation participants, while mood and symptoms reported by nocebo explanation participants returned to baseline levels.

CONCLUSION

Results indicate that providing an explanation of the nocebo response, followed by exposure to infrasound, has the potential to operate as an intervention to reduce symptomatic experiences in people reporting symptoms attributed to windfarm generated infrasound.

The Link between Health Complaints and Wind Turbines: Support for the Nocebo Expectations Hypothesis

The worldwide expansion of wind energy has met with opposition based on concerns that the infrasound generated by wind turbines causes health problems in nearby residents. In this paper, we argue that health complaints are more likely to be explained by the nocebo response, whereby adverse effects are generated by negative expectations. When individuals expect a feature of their environment or medical treatment to produce illness or symptoms, then this may start a process where the individual looks for symptoms or signs of illness to confirm these negative expectations. As physical symptoms are common in healthy people, there is considerable scope for people to match symptoms with their negative expectations. To support this hypothesis, we draw an evidence from experimental studies that show that, during exposure to wind farm sound, expectations about infrasound can influence symptoms and mood in both positive and negative directions, depending on how expectations are framed. We also consider epidemiological work showing that health complaints have primarily been located in areas that have received the most negative publicity about the harmful effects of turbines. The social aspect of symptom complaints in a community is also discussed as an important process in increasing symptom reports. Media stories, publicity, or social discourse about the reported health effects of wind turbines are likely to trigger reports of similar symptoms, regardless of exposure. Finally, we present evidence to show that the same pattern of health complaints following negative information about wind turbines has also been found in other types of environmental concerns and scares.

[Study of self-reported health of people living near point sources of environmental pollution: a review. Second part: analysis of results and perspectives]

BACKGROUND

Epidemiological studies have investigated the health impacts of local sources of environmental pollution using as an outcome variable self-reported health, reflecting the overall perception interviewed people have of their own health. This work aims at analyzing the advantages and the results of this approach. This second part presents the results of the studies.

METHODS

Based on a literature review (51 papers), this article presents an analysis of the contribution of self-reported health to epidemiological studies investigating local sources of environmental pollution. It discusses the associations between self-reported health and exposure variables, and other risk factors that can influence health reporting.

RESULTS

Studies using self-reported health showed that local sources can be associated with a wide range of health outcomes, including an impact on mental health and well-being. The perception of pollution, especially sensory information such as odors, affects self-reported health. Attitudes referring to beliefs, worries and personal behaviors concerning the source of pollution have a striking influence on reported health. Attitudes can be used to estimate the reporting bias in a biomedical approach, and also constitute the main explanatory factors in biopsychosocial studies taking into account not only the biological, physical, and chemical factors but also the psychological and social factors at stake in a situation of environmental exposure.

CONCLUSION

Studying self-reported health enables a multifactorial approach to health in a context of environmental exposure. This approach is most relevant when conducted within a multidisciplinary framework involving human and social sciences to better understand psychosocial factors. The relevance of this type of approach used as an epidemiological surveillance tool to monitor local situations should be assessed with regard to needs for public health management of these situations.

Medical causation and expert testimony: allergists at this intersection of medicine and law

Clinical practice always necessitates proper diagnosis and correct treatment. For most clinical fields, determining the cause of the illness is irrelevant to the intervention. An oncologist, for example, has no need to explore the "cause" of the patient's lymphoma. Allergists, by contrast, have tools and the need to examine the relevant allergen which is the putative "cause" of the patient's allergic symptomatology. In the context of a legal claim, the "cause" of the symptoms or disorder is central, because it determines financial responsibility. However, in the case of an allergic disorder and identified allergen, a claim requires more. Whose allergen? Where did it come from? These are crucial questions that must be answered. This paper explores the approaches to causal assessment which are important for the clinical allergist as he/she navigates the interface between clinical practice and legal proceedings. Its purpose is to help the allergist understand that interface, and to be prepared to enter an unfamiliar legal arena.

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.

Does past pain influence current pain: biological and psychosocial models of sex differences

Previous studies have generally indicated sizeable sex differences for both laboratory pain reactivity and clinical pain reports. Numerous biological and psychosocial models have been invoked to account for these findings, but the laboratory and clinical findings have generally been examined in isolation. This paper reviews data which show a relationship between past clinical pain experiences and current responses to experimentally induced pain. Individuals with a greater pain history tend to show lower pain tolerance. Since women often have high pain experience levels and lower pain tolerance, one might ask whether the two factors are related. We review several models, based upon concepts of neonatal differences in pain reactivity, hypervigilance following early pain experiences, and concepts of peripheral and central sensitization or plasticity which might help to bridge the gap between clinical and experimental findings.

Repressive coping and alexithymia in idiopathic environmental intolerance

OBJECTIVE

To examine if the non-expression of negative emotions (i.e., repressive coping) and differences in the ability to process and regulate emotions (i.e., alexithymia) is associated with idiopathic environmental intolerance (IEI).

METHODS

The study included participants who had previously participated in a general population-based study and reported symptoms of environmental intolerance (n = 787) and patients with IEI (n = 237). The participants completed questionnaires assessing IEI, namely, a measure of repressive coping combining scores on the Marlowe-Crowne Social Desirability Scale (MCSDS) and the Taylor Manifest Anxiety Scale (TMAS), the Toronto Alexithymia Scale (TAS-20), and a negative affectivity scale (NAS). Multiple, hierarchical linear regression analyses were conducted using IEI variables as the dependent variables.

RESULTS

The TMAS and MCSDS scores were independently associated with the IEI variables, but there was no evidence of a role of the repressive coping construct. While the total alexithymia score was unrelated to IEI, the TAS-20 subscale of difficulties identifying feelings (DIF) was independently associated with symptoms attributed to IEI. Negative affectivity was a strong independent predictor of the IEI variables and a mediator of the association between DIF and IEI.

CONCLUSION

Our results provide no evidence for a role of repressive coping in IEI, and our hypothesis of an association with alexithymia was only partly supported. In contrast, strong associations between IEI and negative emotional reactions, defensiveness and difficulties identifying feelings were found, suggesting a need for exploring the influence of these emotional reactions in IEI.

An investigation of victimization and the clinical course of chronic fatigue syndrome

Medically unexplained syndromes, including chronic fatigue syndrome (CFS), have been associated with victimization in childhood and adulthood. The purpose of this study was to examine the associations of victimization experiences in childhood and adulthood with functional status and illness severity in a sample of patients with CFS using longitudinal data. In the sample of 93 patients with CFS, childhood abuse and neglect had greater impact than adulthood victimization. Overall, victimization experiences in childhood demonstrated modest associations with clinical outcomes in CFS, although several victimization experiences were in the opposite direction of expectations. Victimization predicted worse outcomes, but not worsening outcomes over time.

Fixed belief in cognitive dysfunction despite normal neuropsychological scores: neurocognitive hypochondriasis?

A subset of patients who present for neuropsychological testing report dysfunction in daily life activities secondary to cognitive deficits, but are found on formal testing to have no objective abnormalities, raising the possibility of "neurocognitive hypochondriasis." Such a case is presented, and the factors that appear to give rise to this presentation are explored. Cases of hypochondriacal overconcern regarding cognitive function are likely not rare, particularly given research showing there is little correlation between objective report of cognitive dysfunction and actual test scores in such conditions as mild traumatic brain injury, chronic fatigue syndrome, fibromyalgia, toxic mold exposure, and post-polio syndrome.

Assessment of Upper Respiratory Tract and Ocular Irritative Effects of Volatile Chemicals in Humans

Accurate assessment of upper respiratory tract and ocular irritation is critical for identifying and remedying problems related to overexposure to volatile chemicals, as well as for establishing parameters of irritation useful for regulatory purposes. This article (a) describes the basic anatomy and physiology of the human upper respiratory tract and ocular mucosae, (b) discusses how airborne chemicals induce irritative sensations, and (c) reviews practical means employed for assessing such phenomena, including psychophysical (e.g., threshold and suprathreshold perceptual measures), physiological (e.g., cardiovascular responses), electrophysiological (e.g., event-related potentials), and imaging (e.g., magnetic resonance imaging) techniques. Although traditionally animal models have been used as the first step in assessing such irritation, they are not addressed here since (a) there are numerous reviews available on this topic and (b) many rodents and rabbits are obligate nose breathers whose nasal passages differ considerably from those of humans, potentially limiting generalization of animal-based data to humans. A major goal of this compendium is to inform the reader of procedures for assessing irritation in humans and to provide information of value in the continued interpretation and development of empirical databases upon which future reasoned regulatory health decisions can be made.

Toward a medical anthropology of sensations: definitions and research agenda

In this article, we outline the importance of a medical anthropology of sensations for theories of psychopathology and psychological healing. We define what is meant by ;sensation' (differentiating monomodal and polymodal sensations) and describe some of the mechanisms that generate and amplify sensations. We propose the heuristic use of the concepts of sensation schemas, sensation interpretants, and sensation scripts. We argue against the naive assumption that sensation experience is the same across cultures. Finally, we consider how healing may occur through 'sensation semiosis.'

Psychological predictors of short- and medium term outcome in individuals with idiopathic environmental intolerance (IEI) and individuals with somatoform disorders

Idiopathic environmental intolerance (IEI), also known as multiple chemical sensitivity (MCS), is defined as a chronic polysymptomatic condition that cannot be explained by an organic disease. Previous studies suggest that IEI may be a variant of somatoform disorders (SFD), because both disorders overlap with respect to symptoms and psychological features of somatization. However, little is known about the short- and medium-term outcome of IEI and psychological outcome predictors. Two clinical groups (IEI and SFD) and a comparison group (CG) were followed through 32 mo to assess both the outcome, and the extent to which trait anxiety and somatic symptom attribution (assessed at first examination) predict outcome presented 12 and 32 mo later. Outcome measures were the number of self-reported IEI symptoms, IEI triggers, IEI-associated functional impairments, and the number of somatoform symptoms. In addition, the course of the 2 syndromes over the 32-mo follow-up period was investigated with standardized screening scales. The 3 diagnostic groups consisted of 46 subjects with IEI, 38 subjects with SFD but without IEI, and 46 subjects (CG) with neither IEI nor SFD. Syndrome stability was high over the 32-mo follow-up period, and at both follow-ups IEI and non-IEI subjects differed on all IEI outcome measures (symptoms, triggers, functional impairments). Both trait anxiety and somatic attribution (the tendency to attribute common somatic complaints to an illness) predicted outcome. In addition, somatic attribution was found to partially mediate the effect of trait anxiety on outcome in the IEI group. In conclusion, these results suggest that IEI is a chronic and disabling condition and that trait anxiety contributes to the maintenance of the disorder via somatic attributions.

Rated salience of internal and external cues in cases of self-reported hunger and illness

An event contingent diary method compared the rated salience of ambient external and internal cues reported in association with instances of feeling hungry and ill, to test whether environmental and psychological factors might be differentially identified in conjunction with these states. In cases of hunger but not illness, external and internal events were equally salient cues. However, within the general category of external cues, for those feeling hungry, smells were rated more salient than sounds. Within the category of internal cues, in both cases of hunger and illness, cognitions were rated as more salient than moods. We consider Pavlovian conditioning as a mechanism for these effects.

Psychologische Korrelate des Multiple Chemical Sensitivity (MCS)

Zusammenfassung. Theoretischer Hintergrund: Multiple Chemische Sensitivität (MCS) ist ein Syndrom mit organisch unerklärbaren Beschwerden, die von den Betroffenen auf niedrig dosierte Umweltschadstoffe attribuiert werden. Eine Risikogruppe für MCS stellen Probanden (Pbn) mit selbstberichteter Chemischer Sensitivität (CS) dar. Fragestellung: Sind eher toxikogene oder eher psychogene Faktoren für den Bericht von MCS-Beschwerden entscheidend? Methode: Fragebogenuntersuchung an 309 Studierenden, die sich in einem mit Polychlorierten Biphenylen (PCB) belasteten Universitätsgebäude aufhielten; Querschnittstudie. Ergebnisse: Während Expositionsdauer und MCS-Syndrom nicht korrelierten, lieferten psychologische Variablen (umweltbezogene Gefährdungskognitionen, Krankheitsangst, habituelle Sorgen und Absorption) hingegen einen signifikanten Beitrag zur Vorhersage des MCS-Syndroms. Nur Pbn mit CS, aber nicht jene ohne CS, berichteten nach Aktivierung eines “Schadstoffbelastungs-Schemas“ vermehrt MCS-Beschwerden. Schlussfolgerungen: Nach den Ergebnissen dieser Querschnittsuntersuchung und anderer Studien scheinen kognitive und andere psychologische Faktoren eine bedeutsame Rolle bei der Entstehung und Aufrechtung dieses Syndroms zu spielen.

Dysfunctional cognitions in idiopathic environmental intolerances (IEI)—An integrative psychiatric perspective

Idiopathic environmental intolerances (IEI) - formerly multiple chemical sensitivities (MCS) - are characterized by diffuse symptoms reported after exposure to low doses of everyday chemicals. Previous theories about the origin of IEI have emphasized either biological or psychological factors, neglecting a probable interplay. Many have suggested classifying IEI as a somatoform or an anxiety disorder, irrespective of some incongruities. By focusing on dysfunctional cognitions we discuss obvious parallels of IEI with somatoform disorders, and also indicate overlaps with anxiety and delusional disorders. To propose a hypothetical psycho-neurobiological basis of IEI, recent evidence about cortically represented symptoms in the absence of peripheral stimuli is briefly summarized. We conclude that IEI can serve as an illustrative example for the impact of cognitive, representational processes in symptom generation.

US-inflation in a differential odor-conditioning paradigm is not robust: relevance for medically unexplained symptoms

Reported somatic symptoms without clear relation to physiological processes are studied. A learning paradigm was used with two odors (CSs) and the inhalation of CO(2)-enriched air (US), while measuring symptom levels and respiratory behavior. After paring one odor with the CO(2)-enriched air and the other odor with air, half of the participants received a US-inflation manipulation (information manipulation and enhanced US). Subsequently, all participants received both odors with air (test). A difference between the odor previously paired with CO(2)-enriched air and the odor previously paired with air was found for the symptom measure, US-expectancy ratings, and, to a lesser extent, for respiratory volume. No differences, however, were found between the group receiving the US-inflation manipulation and a group not receiving this manipulation. The results indicate that, despite a successful learning of reported symptoms, US-inflation does not seem to be robust.

Selective attention, memory bias, and symptom perception in idiopathic environmental intolerance and somatoform disorders

Idiopathic environmental intolerance (IEI) refers to a polysymptomatic condition, similar to somatoform disorders. Various processes seem to contribute to its yet unknown etiology. Attention and memory for somatic symptom and IEI-trigger words was compared among participants with IEI (n = 54), somatoform disorders (SFD; n = 44) and control participants (n = 54). Groups did not differ in a dot-probe task. However, in an emotional Stroop task, attention was biased in IEI and SFD groups toward symptom words but not toward IEI-trigger words. Only the IEI group rated trigger words as more unpleasant and more arousing, and participants remembered them better in a recognition task. These implicit and explicit cognitive abnormalities in IEI and SFD may maintain processes of somatosensory amplification.

Effects of information and 50 Hz magnetic fields on cognitive performance and reported symptoms

The aim of this study was to explore the role of expectancies and beliefs about the potential effects of electromagnetic fields (EMFs) (what the subject thought the effect was going to be) and the effects of 50 Hz magnetic fields (400 microT(rms)) acute exposure on cognitive performance, the reporting of physical symptoms and some psychological and physiological parameters. Seventy-four healthy male volunteers aged between 40 and 60 years of age were randomly assigned to one of five groups, which differed in (1) the type of information they were given concerning the expected magnetic field effect on performance in cognitive tests (positive = enhancement of the performance; negative = impairment of the performance; neutral) and (2) the type of exposure (real or sham). Three groups were sham exposed with positive (group+), negative (group-) and neutral information (group+/-); one group was really exposed with neutral information (group expo) and one group was not exposed, though they wore the helmet, and did not receive any field-related information (control group). All the volunteers, except the control group, were led to believe that they would be exposed to a magnetic field of 400 microT(rms). The experimental design respected a double blind procedure and the experimental session involved three steps (pre-testing, exposure, and post-testing). Various measurements were taken, including cognitive performance, psychological parameters such as mood, vigilance, and reporting of symptoms. Physiological parameters such as blood pressure and pulse rate were also recorded. The information given did not significantly modify beliefs. No significant difference was found among the five groups depending on the type of information and the type of exposure in cognitive performance, psychological and physiological parameters. In the context of the study, with our population, the type of information given failed to induce expected changes in parameters measured. Our results do not support the hypothesis that an acute exposure to extremely low frequency magnetic fields (50 Hz, 400 microT(rms)) affects the parameters measured.

Evidence for overlap between idiopathic environmental intolerance and somatoform disorders

OBJECTIVE

Idiopathic environmental intolerance (IEI), also known as multiple chemical sensitivity, is a chronic, polysymptomatic condition that cannot be explained by an organic disease. Physical and psychological complaints are believed to be sustained by low levels of chemically unrelated substances in the environment. At present, it is unclear whether IEI is an environmental illness or a variant of somatoform disorders (SFD). This study examined whether IEI can be distinguished from SFD with respect to self-reported symptoms, trait anxiety, body-related cognitions, and symptom attributions.

METHODS

We compared 54 subjects with IEI, 54 subjects with SFD but without IEI, and 44 subjects with neither IEI nor SFD on symptom scales, psychological questionnaires, and structured interviews for IEI, depression, anxiety, and SFD.

RESULTS

More than half of the IEI subjects met Diagnostic and Statistical Manual of Mental Disorders, fourth edition criteria of SFD. This group shared both symptoms and psychological features of somatization with the SFD group. IEI subjects who did not fulfill criteria for a specific SFD were less impaired by their chemical sensitivity but differed nevertheless from nonsomatoform controls by significantly higher symptom scores, higher trait anxiety, a focus on autonomic sensations, and more pronounced somatic symptom attributions. These psychological features were significantly associated with the burden of somatic symptoms in both SFD and IEI. Furthermore, self-reported allergy but not total immunoglobulin E correlated with symptom burden in the total sample.

CONCLUSIONS

The similarity of IEI and SFD regarding symptoms and psychological features of somatization support the hypothesis that IEI is a variant of SFD.

Temperament and satisfaction with health status among persons with rheumatoid arthritis

PURPOSE

Health-related quality of life is a subjective phenomenon shaped by personal attributes. Research has demonstrated links between temperament and health outcomes. Because temperament is relatively stable, it could function as a moderator of quality of life. This study examined relationships among temperament disposition and satisfaction with health status.

DESIGN

The model developed by Sprangers and Schwartz was used to develop a secondary analysis of data collected in a cross-sectional, correlational study with stepwise linear regression analysis. Instruments used were MPQ (dispositions) and AMIS2 (health satisfactions).

SETTING

Two rheumatology private practices and 3 rheumatology clinics.

SAMPLE

One hundred fifty-three persons diagnosed with rheumatoid arthritis (mean age = 55.4).

FINDINGS

Scores reflecting Negative Affectivity (intrapersonal orientation and perception) demonstrated significant positive correlation (r = .26-.58) with all health domain satisfaction scores (P < .001). Negative Affectivity and Positive Affectivity (interpersonal orientation) jointly predicted 8.2%-37.8% of score variance.

CONCLUSION

Temperament dispositions are associated with health-related satisfaction.

IMPLICATION

Assessment of temperament can facilitate early identification of potential problems in the 3 quality of life domains (meaningfulness, manageability), and comprehensibility, and is useful for selecting or designing tailored interventions.

Illness perceptions in people with acute bacterial gastro-enteritis

Functional gastro-intestinal disorders (FGID) like irritable bowel syndrome (IBS) are common and can develop after gastro-enteritis. Illness representations may be important influences on the development of post-infectious FGIDs. Here, we studied both the relationship between prior chronic symptoms (FGIDs) and illness perception during an acute illness (bacterial gastro-enteritis) as well as the relationship between illness perception during an acute illness (bacterial gastro-enteritis) and the subsequent development of chronic abdominal symptoms. Two hundred and seventeen people with recent gastro-enteritis completed a questionnaire asking about gut symptoms consistent with a diagnosis of IBS, functional dyspepsia or functional diarrhoea and the Illness Perception Questionnaire. Those without a prior FGID were followed up and completed a similar gut questionnaire at six months. People with a prior FGID had significantly more symptoms and scored significantly higher on the timeline and consequence scores than those without. People who developed a FGID had a non-significantly higher number of symptoms and higher consequence and timeline scores than those who did not. Neither comparative group differed in the control/cure scores or causation scores. The implications of the findings are discussed.

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.

The dysphonic voice heard by me, you and it: differential associations with personality and psychological distress

Voice production is subject to and indicative of psychological status. The precise relationships of voice disorders and psychological variables remain unclear. We compared the correlations of self-reported and more objective measures of voice quality in dysphonic patients with personality, coping, affect and somatization. Two hundred and four subjects participating in a randomized, controlled trial of speech therapy underwent self-report, observer rating and computer acoustic analysis of voice quality. These three indices of voice quality were compared with regard to their correlations with individual differences in neuroticism, alexithymia, negative emotion coping, anxiety, depression, neurotic symptoms, medically unexplained symptoms and quality of life. Significant correlations were observed between self-reported voice problems and all of the personality/coping and clinical psychological distress measures. People who reported more voice problems had: higher neuroticism and alexithymia; a tendency to use emotion-oriented coping; more psychological distress; poorer quality of life; and more past medically unexplained symptoms. Expert voice rating correlated weakly with neurotic disturbance, quality of life and previous medically unexplained symptoms. Objective voice assessment (amplitude perturbation) showed no significant associations with any psychological measure. The strongest associations of psychological variables and voice measures are with self-report measures. This suggests that it is in part the patients' perception of their own voice quality which accounts for the association of voice production and psychological factors in subjects presenting to voice clinics.

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.

Anxiety sensitivity and depression in multiple chemical sensitivities and asthma

Patients with sensitivities to multiple chemicals report symptoms of cognitive dysfunction, respiratory distress, and mood disturbance. Lifetime and current psychiatric disorders, personality traits associated with symptom reporting, and tests of cognitive function were compared between 30 subjects with Multiple Chemical Sensitivities (MCS), 19 asthmatics, and 31 healthy controls. Relative to asthmatics and controls, more MCS subjects met criteria for current depression and somatization disorder. MCS subjects and asthmatics scored significantly higher than controls on scales of chemical odor intolerance and anxiety sensitivity, both of which were significant predictors of physical symptoms. Few differences on objective neuropsychological tests were noted. However, MCS subjects with comorbid depression performed significantly worse on a verbal memory test relative to asthmatics but not to controls. Anxiety and depression are significant contributors to the physical and cognitive symptoms of MCS subjects.

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.

Acquiring symptoms in response to odors: a learning perspective on multiple chemical sensitivity

In this chapter, a learning account is discussed as a potential explanation for the symptoms in multiple chemical sensitivity. Clinical evidence is scarce and anecdotal. A laboratory model provides more convincing results. After a few breathing trials containing CO2-enriched air as an unconditioned stimulus in a compound with harmless odor substances as conditioned stimuli, subjective symptoms are elicited and respiratory behavior is altered by the odors only. Also, mental images can become conditioned stimuli to trigger subjective symptoms. The learning effects cannot be explained by a response bias or by conditioned arousal, and they appear to involve basic associative processes that do not overlap with aware cognition of the relationship between the odors and the CO2 inhalation. Learned symptoms generalize to new odors and they can be eliminated in a Pavlovian extinction procedure. In accordance with clinical findings, neurotic subjects and psychiatric cases are more vulnerable to learning subjective symptoms in response to odors. Consistent with a learning account, cognitive-behavioral treatment techniques appear to produce beneficial results in clinical cases. Several criticisms and unresolved questions regarding the potential role of learning mechanisms are discussed.

Generalization of acquired somatic symptoms in response to odors: a pavlovian perspective on multiple chemical sensitivity

OBJECTIVE

Somatic symptoms that occur in response to odors can be acquired in a pavlovian conditioning paradigm. The present study investigated 1) whether learned symptoms can generalize to new odors, 2) whether the generalization gradient is linked to the affective or irritant quality of the new odors, and 3) whether the delay between acquisition and testing modulates generalization.

METHODS

Conditional odor stimuli (CS) were (diluted) ammonia and niaouli. One odor was mixed with 7.4% CO2-enriched air (unconditional stimulus) during 2-minute breathing trials (CS+ trial), and the other odor was presented with air (CS- trial). Three CS+ and three CS- trials were conducted in a semirandomized order (acquisition phase). The test phase involved one CS+-only (CS+ without CO2) and one CS- test trial, followed by three trials using new odors (butyric acid, acetic acid, and citric aroma). Half of the subjects (N = 28) were tested immediately, and the other half were tested after 1 week. Ventilatory responses were measured during and somatic symptoms were measured after each trial.

RESULTS

Participants had more symptoms in response to CS+-only exposures, but only when ammonia was used as the CS+. Also, generalization occurred: More symptoms were reported in response to butyric and acetic acid than to citric aroma and only in participants who had been conditioned. Both the selective conditioning and the generalization effect were mediated by negative affectivity of the participants. The delay between the acquisition and test phases had no effect.

CONCLUSIONS

Symptoms that occur in response to odorous substances can be learned and generalize to new substances, especially in persons with high negative affectivity. The findings further support the plausibility of a pavlovian perspective of multiple chemical sensitivity.

Symptomatology and health care utilization of women primary care patients who experienced childhood sexual abuse

OBJECTIVE

The purpose of this study was to (1) determine the symptomatology of women primary care patients who experienced childhood sexual abuse (CSA), using both a self-report survey and a chart review, and (2) determine their health care utilization patterns, using chart and information system reviews.

METHOD

An ex post facto research design was used. Women primary care patients who experienced CSA were compared with those who reported no CSA. Participants were recruited from a random sample of women patients from a large primary care clinic. They were mailed the survey; chart and information system reviews were conducted on those who returned surveys.

RESULTS

Of the 395 participants, 23% reported past CSA on the survey. Women who experienced CSA reported 44 out of 51 physical and psychosocial symptoms more frequently than their counterparts who reported no past CSA. Further, they experienced these symptoms more intensely and in greater number. In their charts, however, far fewer differences in symptoms between groups were found. Nonetheless, women who experienced CSA visited the primary care clinic an average of 1.33 more times than women with no CSA, and they incurred an average of $150 more in primary care charges over a 2-year period.

CONCLUSIONS

The findings indicate that many women primary care patients who experienced CSA suffer multiple symptoms that are not reflected in their charts. In addition, the findings demonstrate that not only is CSA associated with increased primary care visits, but also increased primary care costs, as measured by charges.

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 sensitivity as a conditional response

Pavlovian conditioning may contribute to some cases of multiple chemical sensitivity (MCS). On the basis of the conditioning analysis, environmental stimuli (especially olfactory cues) present at the time of a toxicant overdose become associated with the toxicant and elicit aversive conditional responses. Similar associations have been reported in patients receiving chemotherapy, and the literature on such 'pretreatment nausea' in cancer patients is relevant to understanding the role of conditioning in MCS. Evaluation of the contribution of conditioning to MCS has been complicated by confounding interpretations that emphasize conditional responses with interpretations which emphasize the psychiatric status of the patient. Appreciation of the contribution of Pavlovian conditioning to MCS will lead to a better understanding of this complex disorder.

Evolutionary game theory and multiple chemical sensitivity

Newlin's [Newlin D.B. Evolutionary game theory of tolerance and sensitization in substance abuse. Paper presented to the Research Society on Alcoholism, Hilton Head, SC, 1998] evolutionary game theory of addictive behavior specifies how evolutionarily stable strategies for survival and reproduction may lead to addiction. The game theory of multiple chemical sensitivity (MCS) assumes that: (1) the MCS patient responds to low-level toxicants as stressors or as direct threats to their survival and reproductive fitness, (2) this activates the cortico-mesolimbic dopamine system, (3) this system is a survival motivation center--not a 'reward center', (4) the subject emits a counter-response that is in the same direction as the naive response to the chemicals, (5) previously neutral stimuli associated with chemicals also trigger conditioned responses that mimic those to the chemicals, (6) these counter-responses further activate the dopaminergic survival motivation system, and (7) this produces a positive feedback loop that leads to strong neural sensitization in these structures and in behavior controlled by this system, despite a small initial response. Psychologically, the MCS patient with a sensitized cortico-mesolimbic dopamine system is behaving as though his/her survival is directly threatened by these chemicals. Non-MCS subjects have counter-responses opposite in direction to those of the chemicals and show tolerance. An autoshaping/sign-tracking model of this game is discussed. This evolutionary game makes several specific, testable predictions about differences between MCS subjects, non-MCS controls, and substance abusers in laboratory experiments, and between sensitized and nonsensitized animals.