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Overview of idiopathic environmental intolerance (multiple chemical sensitivity)

Authors
Donald W Black, MD
Scott Temple, PhD
Section Editor
Joel Dimsdale, MD
Deputy Editor
David Solomon, MD

INTRODUCTION

Idiopathic environmental intolerance (IEI), formerly called multiple chemical sensitivity, is a subjective illness marked by recurrent, nonspecific symptoms attributed to low levels of chemical, biologic, or physical agents. These symptoms occur in the absence of consistent objective diagnostic physical findings or laboratory tests that define an illness [1,2]. Many experiments and observational studies consistently identify psychopathology in patients with IEI, and implicate behavioral or psychiatric causes for this illness [3]. This indicates that the underlying illness in many cases of IEI is actually a psychiatric disorder, such as a somatoform, depressive, or anxiety disorder [4].

This topic provides an overview of IEI, including clinical management of this condition. Related topics are discussed separately. (See "Somatization: Epidemiology, pathogenesis, clinical features, medical evaluation, and diagnosis" and "Unipolar depression in adults: Assessment and diagnosis" and "Unipolar major depression in adults: Choosing initial treatment" and "Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis" and "Pharmacotherapy for panic disorder in adults".)

DEFINITION AND BACKGROUND

Patients with idiopathic environmental intolerance (IEI) typically report sensitivity to multiple, chemically unrelated substances and becoming ill with heterogeneous, nonspecific symptoms when exposed to low concentrations of chemicals [5-7]. Patients attempt to minimize exposure by modifying their lives, sometimes in far reaching ways.

These "chemically sensitive" people are sometimes treated by "clinical ecologists" or "environmental clinicians" who believe the disorder is acquired, highly prevalent in the general population, and goes unrecognized by most other clinicians.

The most frequently used term for this condition is "multiple chemical sensitivity," but many other terms have also been used, including "environmental illness." The World Health Organization in 1996 proposed the term "idiopathic environmental intolerance" (IEI) be used instead, because it avoids unsubstantiated assumptions of etiology, and many people attribute symptoms to environmental agents other than chemicals, such as food or electromagnetic forces [8].

                                     

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Literature review current through: Nov 2016. | This topic last updated: Tue Nov 24 00:00:00 GMT+00:00 2015.
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References
Top
  1. ACOEM position statement. Multiple chemical sensitivities: idiopathic environmental intolerance. College of Occupational and Environmental Medicine. J Occup Environ Med 1999; 41:940.
  2. Idiopathic environmental intolerances. American Academy of Allergy, Asthma and Immunology (AAAAI) Board of Directors. J Allergy Clin Immunol 1999; 103:36.
  3. Das-Munshi J, Rubin GJ, Wessely S. Multiple chemical sensitivities: review. Curr Opin Otolaryngol Head Neck Surg 2007; 15:274.
  4. Bornschein S, Hausteiner C, Zilker T, Förstl H. Psychiatric and somatic disorders and multiple chemical sensitivity (MCS) in 264 'environmental patients'. Psychol Med 2002; 32:1387.
  5. Levin AS, Byers VS. Environmental illness: a disorder of immune regulation. Occup Med 1987; 2:669.
  6. Meggs WJ, Dunn KA, Bloch RM, et al. Prevalence and nature of allergy and chemical sensitivity in a general population. Arch Environ Health 1996; 51:275.
  7. Miller CS. White paper: Chemical sensitivity: history and phenomenology. Toxicol Ind Health 1994; 10:253.
  8. International Programme on Chemical Safety (IPCS). Conclusions and recommendations of a workshop on "multiple chemical sensitivities (MCS)". Regul Toxicol Pharmacol 1996; 24:S188.
  9. Black DW. Environmental illness and misdiagnosis--a growing problem. Regul Toxicol Pharmacol 1993; 18:23.
  10. American Academy of Allergy: position statements--controversial techniques. J Allergy Clin Immunol 1981; 67:333.
  11. Clinical ecology. Executive Committee of the American Academy of Allergy and Immunology. J Allergy Clin Immunol 1986; 78:269.
  12. Clinical ecology. American College of Physicians. Ann Intern Med 1989; 111:168.
  13. Clinical ecology. Council on Scientific Affairs, American Medical Association. JAMA 1992; 268:3465.
  14. Bornschein S, Förstl H, Zilker T. Idiopathic environmental intolerances (formerly multiple chemical sensitivity) psychiatric perspectives. J Intern Med 2001; 250:309.
  15. Hausteiner C, Bornschein S, Hansen J, et al. Self-reported chemical sensitivity in Germany: a population-based survey. Int J Hyg Environ Health 2005; 208:271.
  16. Kreutzer R, Neutra RR, Lashuay N. Prevalence of people reporting sensitivities to chemicals in a population-based survey. Am J Epidemiol 1999; 150:1.
  17. Caress SM, Steinemann AC. Prevalence of multiple chemical sensitivities: a population-based study in the southeastern United States. Am J Public Health 2004; 94:746.
  18. Lax MB, Henneberger PK. Patients with multiple chemical sensitivities in an occupational health clinic: presentation and follow-up. Arch Environ Health 1995; 50:425.
  19. Bell IR, Peterson JM, Schwartz GE. Medical histories and psychological profiles of middle-aged women with and without self-reported illness from environmental chemicals. J Clin Psychiatry 1995; 56:151.
  20. Brodsky CM. 'Allergic to everything': a medical subculture. Psychosomatics 1983; 24:731.
  21. Stewart DE, Raskin J. Psychiatric assessment of patients with "20th-century disease" ("total allergy syndrome"). CMAJ 1985; 133:1001.
  22. Terr AI. Environmental illness. A clinical review of 50 cases. Arch Intern Med 1986; 146:145.
  23. Terr, AI. Multiple chemical sensitivity syndrome. Occup Asthma Allergies 1992;12:897.
  24. Simon GE, Katon WJ, Sparks PJ. Allergic to life: psychological factors in environmental illness. Am J Psychiatry 1990; 147:901.
  25. Black DW, Rathe A, Goldstein RB. Environmental illness. A controlled study of 26 subjects with '20th century disease'. JAMA 1990; 264:3166.
  26. Black DW, Rathe A, Goldstein RB. Measures of distress in 26 "environmentally ill" subjects. Psychosomatics 1993; 34:131.
  27. Simon GE, Daniell W, Stockbridge H, et al. Immunologic, psychological, and neuropsychological factors in multiple chemical sensitivity. A controlled study. Ann Intern Med 1993; 119:97.
  28. Fiedler N, Maccia C, Kipen H. Evaluation of chemically sensitive patients. J Occup Med 1992; 34:529.
  29. Fiedler N, Kipen HM, DeLuca J, et al. A controlled comparison of multiple chemical sensitivities and chronic fatigue syndrome. Psychosom Med 1996; 58:38.
  30. Black DW. Iatrogenic (physician-induced) hypochondriasis. Four patient examples of "chemical sensitivity". Psychosomatics 1996; 37:390.
  31. Bailer J, Witthöft M, Paul C, et al. Evidence for overlap between idiopathic environmental intolerance and somatoform disorders. Psychosom Med 2005; 67:921.
  32. Bailer J, Witthöft M, Rist F. Modern health worries and idiopathic environmental intolerance. J Psychosom Res 2008; 65:425.
  33. Eis D, Helm D, Mühlinghaus T, et al. The German Multicentre Study on Multiple Chemical Sensitivity (MCS). Int J Hyg Environ Health 2008; 211:658.
  34. Hausteiner C, Bornschein S, Bickel H, et al. Psychiatric morbidity and low self-attentiveness in patients with environmental illness. J Nerv Ment Dis 2003; 191:50.
  35. Hausteiner C, Mergeay A, Bornschein S, et al. New aspects of psychiatric morbidity in idiopathic environmental intolerances. J Occup Environ Med 2006; 48:76.
  36. Poonai N, Antony MM, Binkley KE, et al. Carbon dioxide inhalation challenges in idiopathic environmental intolerance. J Allergy Clin Immunol 2000; 105:358.
  37. Black DW, Doebbeling BN, Voelker MD, et al. Multiple chemical sensitivity syndrome: symptom prevalence and risk factors in a military population. Arch Intern Med 2000; 160:1169.
  38. Gibson PR, Elms AN, Ruding LA. Perceived treatment efficacy for conventional and alternative therapies reported by persons with multiple chemical sensitivity. Environ Health Perspect 2003; 111:1498.
  39. Staudenmayer H, Phillips S. MMPI-2 validity, clinical and content scales, and the Fake Bad Scale for personal injury litigants claiming idiopathic environmental intolerance. J Psychosom Res 2007; 62:61.
  40. Gots RE. Multiple chemical sensitivities: distinguishing between psychogenic and toxicodynamic. Regul Toxicol Pharmacol 1996; 24:S8.
  41. Journal of Toxicology and Environmental Health, Part A 2008; 71:766.
  42. Staudenmayer H. Psychological treatment of psychogenic idiopathic environmental intolerance. Occup Med 2000; 15:627.
  43. Black DW. The relationship of mental disorders and idiopathic environmental intolerance. Occup Med 2000; 15:557.
  44. Staudenmayer H, Binkley KE, Leznoff A, Phillips S. Idiopathic environmental intolerance: Part 1: A causation analysis applying Bradford Hill's criteria to the toxicogenic theory. Toxicol Rev 2003; 22:235.
  45. Staudenmayer H, Binkley KE, Leznoff A, Phillips S. Idiopathic environmental intolerance: Part 2: A causation analysis applying Bradford Hill's criteria to the psychogenic theory. Toxicol Rev 2003; 22:247.
  46. Staudenmayer H. Idiopathic environmental intolerances (IEI): myth and reality. Toxicol Lett 2001; 120:333.
  47. Bell, IR. Neuropsychiatric and biopsychosocial mechanisms in multiple chemical sensitivity: an olfactory-limbic system model. In: Multiple Chemical Sensitivities, National Academy Press, Washington DC 1992. p.89.
  48. Das-Munshi J, Rubin GJ, Wessely S. Multiple chemical sensitivities: A systematic review of provocation studies. J Allergy Clin Immunol 2006; 118:1257.
  49. Bornschein S, Hausteiner C, Römmelt H, et al. Double-blind placebo-controlled provocation study in patients with subjective Multiple Chemical Sensitivity (MCS) and matched control subjects. Clin Toxicol (Phila) 2008; 46:443.
  50. Heuser G, Mena I, Alamos F. NeuroSPECT findings in patients exposed to neurotoxic chemicals. Toxicol Ind Health 1994; 10:561.
  51. Bell IR, Schwartz GE, Hardin EE, et al. Differential resting quantitative electroencephalographic alpha patterns in women with environmental chemical intolerance, depressives, and normals. Biol Psychiatry 1998; 43:376.
  52. Black DW, Okiishi C, Gabel J, Schlosser S. Psychiatric illness in the first-degree relatives of persons reporting multiple chemical sensitivities. Toxicol Ind Health 1999; 15:410.
  53. Bornschein S, Hausteiner C, Konrad F, et al. Psychiatric morbidity and toxic burden in patients with environmental illness: a controlled study. Psychosom Med 2006; 68:104.
  54. Leznoff A. Provocative challenges in patients with multiple chemical sensitivity. J Allergy Clin Immunol 1997; 99:438.
  55. Binkley KE, Kutcher S. Panic response to sodium lactate infusion in patients with multiple chemical sensitivity syndrome. J Allergy Clin Immunol 1997; 99:570.
  56. Amundsen MA, Hanson NP, Bruce BK, et al. Odor aversion of multiple chemical sensitivities: recommendation for a name change and description of successful behavioral medicine treatment. Regul Toxicol Pharmacol 1996; 24:S116.
  57. Binkley K, King N, Poonai N, et al. Idiopathic environmental intolerance: increased prevalence of panic disorder-associated cholecystokinin B receptor allele 7. J Allergy Clin Immunol 2001; 107:887.
  58. Bolla-Wilson K, Wilson RJ, Bleecker ML. Conditioning of physical symptoms after neurotoxic exposure. J Occup Med 1988; 30:684.
  59. Andersson L, Claeson AS, Dantoft TM, et al. Chemosensory perception, symptoms and autonomic responses during chemical exposure in multiple chemical sensitivity. Int Arch Occup Environ Health 2016; 89:79.
  60. Barsky AJ, Borus JF. Functional somatic syndromes. Ann Intern Med 1999; 130:910.
  61. Lorber W, Mazzoni G, Kirsch I. Illness by suggestion: expectancy, modeling, and gender in the production of psychosomatic symptoms. Ann Behav Med 2007; 33:112.
  62. Dalton P. Cognitive influences on health symptoms from acute chemical exposure. Health Psychol 1999; 18:579.
  63. Hausteiner C, Bornschein S, Zilker T, et al. Dysfunctional cognitions in idiopathic environmental intolerances (IEI)--an integrative psychiatric perspective. Toxicol Lett 2007; 171:1.
  64. Witthöft M, Gerlach AL, Bailer J. Selective attention, memory bias, and symptom perception in idiopathic environmental intolerance and somatoform disorders. J Abnorm Psychol 2006; 115:397.
  65. Witthöft M, Rist F, Bailer J. Abnormalities in cognitive-emotional information processing in idiopathic environmental intolerance and somatoform disorders. J Behav Ther Exp Psychiatry 2009; 40:70.
  66. Staudenmayer H, Selner ME, Selner JC. Adult sequelae of childhood abuse presenting as environmental illness. Ann Allergy 1993; 71:538.
  67. Bailer J, Witthöft M, Bayerl C, Rist F. Trauma experience in individuals with idiopathic environmental intolerance and individuals with somatoform disorders. J Psychosom Res 2007; 63:657.
  68. Ford CV. Somatization and fashionable diagnoses: illness as a way of life. Scand J Work Environ Health 1997; 23 Suppl 3:7.
  69. Bornschein S, Hausteiner C, Drzezga A, et al. Neuropsychological and positron emission tomography correlates in idiopathic environmental intolerances. Scand J Work Environ Health 2007; 33:447.
  70. Rea, WJ, Johnson, AR, Ross, GH , et al. Considerations for the diagnosis of chemical sensitivity. In: Multiple Chemical Sensitivities, National Academy Press, Washington DC1992. p.169.
  71. Cullen MR. The worker with multiple chemical sensitivities: an overview. Occup Med 1987; 2:655.
  72. Jewett DL, Fein G, Greenberg MH. A double-blind study of symptom provocation to determine food sensitivity. N Engl J Med 1990; 323:429.
  73. Heuser, G, Wojdani, A, Heuser, S. Diagnostic markers of multiple chemical sensitivity. In: Multiple Chemical Sensitivities, National Academy Press, Washington DC 1992. p.117.
  74. Poonai NP, Antony MM, Binkley KE, et al. Psychological features of subjects with idiopathic environmental intolerance. J Psychosom Res 2001; 51:537.
  75. Tohen M, Bromet E, Murphy JM, Tsuang MT. Psychiatric epidemiology. Harv Rev Psychiatry 2000; 8:111.
  76. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, American Psychiatric Association, Washington DC 2000.
  77. The ICD-10 Classification of Mental and Behavioral Disorders: Clinical Descriptions and Diagnostic Guidelines. http://www.who.int/classifications/icd/en/bluebook.pdf (Accessed on June 08, 2012).
  78. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.
  79. Black DW, Grant JE. DSM-5 Guidebook: The Essential Companion to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric Publishing, Washington, DC 2014.
  80. Bailer J, Witthöft M, Bayerl C, Rist F. Syndrome stability and psychological predictors of symptom severity in idiopathic environmental intolerance and somatoform disorders. Psychol Med 2007; 37:271.
  81. Sparks PJ, Daniell W, Black DW, et al. Multiple chemical sensitivity syndrome: a clinical perspective. I. Case definition, theories of pathogenesis, and research needs. J Occup Med 1994; 36:718.
  82. Yutzy, SH, Parish, BS. Somatoform disorders. In: The American Psychiatric Publishing Textbook of Psychiatry, 5th ed, Hales, RE, Yudofsky, SC, Gabbard, GO (Ed), American Psychiatric Publishing, Washington, DC 2008. p.618.
  83. Salvaggio JE. Clinical and immunologic approach to patients with alleged environmental injury. Ann Allergy 1991; 66:493.
  84. Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA 1999; 282:1737.
  85. Staudenmayer H. Clinical consequences of the EI/MCS "diagnosis": two paths. Regul Toxicol Pharmacol 1996; 24:S96.
  86. Guglielmi RS, Cox DJ, Spyker DA. Behavioral treatment of phobic avoidance in multiple chemical sensitivity. J Behav Ther Exp Psychiatry 1994; 25:197.
  87. Sumathipala A. What is the evidence for the efficacy of treatments for somatoform disorders? A critical review of previous intervention studies. Psychosom Med 2007; 69:889.
  88. Kroenke K. Efficacy of treatment for somatoform disorders: a review of randomized controlled trials. Psychosom Med 2007; 69:881.
  89. Kroenke K, Swindle R. Cognitive-behavioral therapy for somatization and symptom syndromes: a critical review of controlled clinical trials. Psychother Psychosom 2000; 69:205.
  90. Sharpe M, Peveler R, Mayou R. The psychological treatment of patients with functional somatic symptoms: a practical guide. J Psychosom Res 1992; 36:515.
  91. Stenn P, Binkley K. Successful outcome in a patient with chemical sensitivity. Treatment with psychological desensitization and selective serotonin reuptake inhibitor. Psychosomatics 1998; 39:547.
  92. Black DW. Paroxetine for multiple chemical sensitivity syndrome. Am J Psychiatry 2002; 159:1436.
  93. Andiné P, Rönnbäck L, Järvholm B. Successful use of a selective serotonin reuptake inhibitor in a patient with multiple chemical sensitivities. Acta Psychiatr Scand 1997; 96:82.
  94. FDA Drug Safety Communication: Abnormal heart rhythms associated with high doses of Celexa (citalopram hydrobromide). http://www.fda.gov/Drugs/DrugSafety/ucm269086.htm (Accessed on August 25, 2011).
  95. FDA Drug Safety Communication: Revised recommendations for Celexa (citalopram hydrobromide) related to a potential risk of abnormal heart rhythms with high doses http://www.fda.gov/Drugs/DrugSafety/ucm297391.htm (Accessed on March 28, 2012).
  96. O'Malley PG, Jackson JL, Santoro J, et al. Antidepressant therapy for unexplained symptoms and symptom syndromes. J Fam Pract 1999; 48:980.
  97. Hannonen P, Malminiemi K, Yli-Kerttula U, et al. A randomized, double-blind, placebo-controlled study of moclobemide and amitriptyline in the treatment of fibromyalgia in females without psychiatric disorder. Br J Rheumatol 1998; 37:1279.
  98. Bailer J, Witthöft M, Rist F. Psychological predictors of short- and medium term outcome in individuals with idiopathic environmental intolerance (IEI) and individuals with somatoform disorders. J Toxicol Environ Health A 2008; 71:766.
  99. Skovbjerg S, Christensen KB, Ebstrup JF, et al. Negative affect is associated with development and persistence of chemical intolerance: a prospective population-based study. J Psychosom Res 2015; 78:509.
  100. Black DW, Okiishi C, Schlosser S. A nine-year follow-up of people diagnosed with multiple chemical sensitivities. Psychosomatics 2000; 41:253.
  101. Black DW, Okiishi C, Schlosser S. The Iowa follow-up of chemically sensitive persons. Ann N Y Acad Sci 2001; 933:48.