Possible time-dependent sensitization to xenobiotics: self-reported illness from chemical odors, foods, and opiate drugs in an older adult population

Italian Expert Consensus on Clinical and Therapeutic Management of Multiple Chemical Sensitivity (MCS)

Multiple chemical sensitivity (MCS) is a multisystem, recurrent, environmental disorder that flares in response to different exposures (i.e., pesticides, solvents, toxic metals and molds) under the threshold limit value (TLV) calculated for age and gender in the general population. MCS is a syndrome characterized by cutaneous, allergic, gastrointestinal, rheumatological, endocrinological, cardiological and neurological signs and symptoms. We performed a systematic review of the literature to summarize the current clinical and therapeutic evidence and then oriented an eDelphi consensus. Four main research domains were identified (diagnosis, treatment, hospitalization and emergency) and discussed by 10 experts and an MCS patient. Thus, the first Italian MCS consensus had the double aim: (a) to improve MCS knowledge among healthcare workers and patients by standardizing the clinical and therapeutic management to MCS patients; and (b) to improve and shed light on MCS misconceptions not supported by evidence-based medicine (EBM).

EEG Responses to Low-Level Chemicals in Normals and Cacosmics

Recent studies from the University of Arizona indicate that normal subjects, both college students and the elderly, can register the presence of low-intensity odors in the electroencephalogram (EEG) in the absence of conscious awareness of the odors. The experimental paradigm involves subjects sniffing pairs of bottles, one containing an odorant (e.g. isoamyl acetate) dissolved in an odorless solvent (water or liquid silicone), the other containing just the solvent, while 19 channels of EEG are continuously recorded. For the low-intensity odor conditions, concentrations are adjusted downward (decreased) until subjects correctly identify the odor bottle at chance (50). The order of odorants, concentrations, and hand holding the control bottle, are counterbalanced within and across subjects. Three previous experiments found that alpha activity (8-12 hz) decreased in midline and posterior regions when subjects sniffed the low-intensity odors. The most recent study suggests that decreased theta activity (4-8 hz) may reflect sensory registration and decreased alpha activity may reflect perceptual registration. In a just completed experiment involving college students who were selected based on combinations of high and low scores on a scale measuring cacosmia (chemical odor intolerance) and high and low scores on a scale measuring depression, cacosmic subjects (independent of depression) showed greater decreases in low-frequency alpha (8-10 hz) and greater increases in low-frequency beta (12-16 hz) to the solvent propylene glycol compared to an empty bottle. Topographic EEG mapping to low-intensity odorants may provide a useful tool for investigating possible increased sensitivity to specific chemicals in chemically sensitive individuals.

White Paper: Neuropsychiatric Aspects of Sensitivity to Low-Level Chemicals: A Neural Sensitization Model

The present paper summarizes the proposed time-dependent sensitization (TDS) and partial limbic kindling model for illness from low-level chemicals; reviews and critiques prior studies on CNS aspects of multiple chemical sensitivity (MCS); and outlines possible experimental approaches to future studies. TDS is the progressive and persistent amplification of behavioral, neurochemical, endocrine, and/or immunological responses to repeated intermittent stimuli over time. Partial limbic kindling is a progressive and persistent lowering of the threshold for eliciting electrical afterdischarges, but not motor seizures, in certain brain structures such as amygdala and hippocampus; behavioral consequences include increased avoidant behaviors.

The focus of the paper is the controversial claim of altered sense of smell and illness from low levels of environmental chemicals (i. e., cacosmia), levels that should not have any biologically harmful effects by the rules of classical neurotoxicology. A major perspective of this paper is that the phenomenology of MCS is similar to that of time-dependent sensitization (reverse tolerance) and tolerance as studied in the substance abuse literature.

The TDS model for MCS proposes that neurobiological amplification underlies the symptoms and phenomenology of these patients, including their behavioral features of heightened affective and somatic distress. It is hypothesized that MCS patients, who are mostly women, may be individuals who sensitize to substances rapidly and to the extreme, to the point of aversive symptomatology with less complete capacity for development of tolerance. Possible parallels between MCS and TDS include: (a) initiation by single or multiple intermittent

Profile of Patients with Chemical Injury and Sensitivity, Part II

Exposures which can induce multiple chemical sensitivity (MCS) involve symptomatic, usually repeated, exposures to pesticides, solvents, combustion products, remodeling, sick buildings, carbonless copy paper (occupational heavy use) and other irritants and petrochemicals. Accompanying toxic injury often involves the immune, endocrine and nervous systems as well as impairments in detoxification, energy and neurotransmitter metabolism, protein, mineral, and other nutrient deficiencies and gastrointestinal changes such as Candida, parasites, reduced chymotrypsin (marker enzyme for reduced pancreatic enzyme function), gluten intolerance, and reduced Secretory IgA. Chronic cortisol elevation leading to adrenal insufficiency if not corrected is common. Such elevation can lead to protein and mineral deficiencies with increased osteoporosis and reduced steroid precursors for normal estrogen and testosterone production. Detoxification changes often involve reduction in one or more Phase II pathways which causes excess free radical production. Impaired digestive enzymes can reduce breakdown of foods, with larger more antigenic molecules being absorbed and consequent food intolerances. Many of these conditions are treatable. There is extensive overlap of MCS with Chronic Fatigue Syndrome and Fibromyalgia which may be one condition in many cases. Current occupational exposure limits are not health based and thus may not prevent MCS and are totally inadequate to accommodate sensitive persons. Warning symptoms indicating increased risk for MCS onset include repeated headache, eye and respiratory irritation and fatigue. Eliminating exposures which cause repeated symptoms is a critical strategy for preventing sensitization and MCS. It also significantly reduces the degree of disability in persons with MCS, the single most important factor from the literature. Affected persons with disability can utilize the Americans With Disability Act to request reasonable accommodations for work, home (condo, apartment), and school.

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.

Review of evidence for a toxicological mechanism of idiopathic environmental intolerance

Idiopathic environmental intolerance (IEI) is a medically unexplained disorder characterised by a wide variety of unspecific symptoms in different organ systems and attributed to nontoxic concentrations of chemicals and other environmental factors that are tolerated by the majority of individuals. Both exposure to chemicals and behavioural conditioning are considered as possible contributors to the development of IEI. However, owing to the heterogeneity of the condition, it is difficult to separate the toxicological, physiological and psychological aspects of IEI. Here, we review the evidence for postulated toxicologically mediated mechanisms for IEI. Available data do not support either a classical receptor-mediated or an idiosyncratic toxicological mechanism. Furthermore, if there were convincing evidence for a psychological cause for many patients with IEI, then this would suggest that the priority for the future is the development of psychological treatments for IEI. Finally, we advocate genome wide screening of IEI patients to elucidate genotypic features of the condition.

Activation of cell-mediated immunity in depression: association with inflammation, melancholia, clinical staging and the fatigue and somatic symptom cluster of depression

BACKGROUND

Depression is characterized by activation of cell-mediated immunity (CMI), including increased neopterin levels, and increased pro-inflammatory cytokines (PICs), such as interleukin-1 (IL-1) and tumor necrosis factor-α (TNFα). These PICs may induce depressive, melancholic and chronic fatigue (CF) symptoms.

METHODS

We examined serum neopterin and plasma PIC levels in depressive subgroups in relation to the depressive subtypes and the melancholic and CF symptoms of depression. Participants were 85 patients with depression and in 26 normal controls. Severity of depression was assessed with the Hamilton Depression Rating Scale (HDRS) and severity of CF with the Fibromyalgia and Chronic Fatigue Syndrome (FF) Rating Scale.

RESULTS

Serum neopterin was significantly higher in depressed patients and in particular in those with melancholia. There were positive correlations between serum neopterin, the plasma PICs and the number of previous depressive episodes. Neopterin and TNFα were associated with melancholia, while both PICs were associated with CF. Melancholia-group membership was predicted by the HDRS and neopterin, and CF group membership by age, the FF score and serum TNFα.

DISCUSSION

Depression and melancholia are accompanied by CMI activation, suggesting that neopterin plays a role in their pathophysiology, e.g. through activation of oxidative and nitrosative stress and apoptosis pathways. The intertwined CMI and inflammatory responses are potentially associated with the onset of depression and with the melancholic and CF symptoms of depression. Exposure to previous depressive episodes may magnify the size of CMI and PIC responses, possibly increasing the likelihood of new depressive episodes. CMI activation and inflammation may contribute to the staging or recurrence of depression.

Psychiatric morbidity and toxic burden in patients with environmental illness: a controlled study

OBJECTIVE

Patients with environmental illness experience a large number of psychological symptoms. The nature of these symptoms and their pathogenesis (toxicogenic versus psychogenic) is controversial. The objective was to (1) characterize the nature of the psychological symptoms according to well-established diagnostic criteria, and (2) to investigate the association between toxicological factors and psychological symptoms.

METHODS

Toxic burden, somatic morbidity, and psychiatric morbidity were assessed in 309 outpatients with environmental illness and 59 semiconductor industry workers matched for age and gender. Psychiatric disorders were assessed by a structured psychiatric interview (SCID), and distress was assessed by the Symptom-Checklist-90-Revised (SCL-90-R). Routine and specific laboratory tests in blood and urine samples were used to assess chemical exposures.

RESULTS

Overall psychiatric morbidity was significantly higher in patients than in controls according to SCID (75% versus 24%). Somatoform, mood, and anxiety disorders were significantly more frequent in patients with environmental illness. They also revealed marked stress on the SCL-90-R somatization subscale and scored significantly higher than controls on most of the other subscales. Industry workers from the control group tended to have higher urine metal concentrations than environmental illness patients and similar concentrations of solvents in blood.

CONCLUSION

Our data extend previous findings of high psychiatric morbidity in patients with environmental illness. They do not support the notion of a direct causal link between chemical exposure and the psychological symptoms.

Idiopathic environmental intolerance: Part 1: A causation analysis applying Bradford Hill's criteria to the toxicogenic theory

Idiopathic environmental intolerance (IEI) is a descriptor for a phenomenon that has many names including environmental illness, multiple chemical sensitivity and chemical intolerance. Toxicogenic and psychogenic theories have been proposed to explain IEI. This paper presents a causality analysis of the toxicogenic theory using Bradford Hill's nine criteria (strength, consistency, specificity, temporality, biological gradient, biological plausibility, coherence, experimental intervention and analogy) and an additional criteria (reversibility) and reviews critically the scientific literature on the topic. The results of this analysis indicate that the toxicogenic theory fails all of these criteria. There is no convincing evidence to support the fundamental postulate that IEI has a toxic aetiology; the hypothesised biological processes and mechanisms are implausible.

Multiple chemical sensitivity and idiopathic environmental intolerance (part one)

Multiple chemical sensitivity/idiopathic environmental intolerance (MCS/IEI) is a commonly used diagnostic term for a group of symptoms. These symptoms have been described and commented on for more than 15 years in the USA. Recently, it has also been observed in Japan. The main features of this syndrome are multiple symptoms involving in multiple organ systems that are precipitated by a variety of chemical substances with relapses and exacerbation under certain conditions when exposed to very low levels which do not affect the population at large. There are no laboratory markers or specific investigative findings. Although traditional medical organizations have not agreed on a definition for this syndrome due to the lack of obvious evidence to demonstrate the existence of these symptoms, it is being increasingly recognized. It constitutes an increasing percentage of the caseload at occupational/environmental medical clinics.Part one of this review article discusses pathophysiological theories, substances which cause symptoms, prevalence in the general and specific populations, past history and family history, and clinical symptoms of MCS/IEI patients.

The inflammatory response following delivery is amplified in women who previously suffered from major depression, suggesting that major depression is accompanied by a sensitization of the inflammatory response system

BACKGROUND

There is now evidence that some patients with major depression show an activation of the inflammatory response system (IRS). This study was carried out to examine whether major depression may induce sensitization with increased IRS responses to the stress of child birth.

METHODS

Serum concentrations of interleukin-6 (IL-6), the soluble IL-6 receptor (sIL-6R), sgp130 (the IL-6 signal transducing protein) and the sIL-1R antagonist (sIL-1RA) were determined in 16 and 50 women with and without a lifetime history of major depression, respectively. Blood was collected 3-6 days before delivery and 1 and 3 days after delivery. On each occasion the women completed the Zung Depression Rating Scale (ZDS).

RESULTS

Serum IL-6, sIL-6R, sIL-1RA were significantly higher 1 and 3 days after delivery than before. Women who had suffered from a lifetime history of major depression had greater increases in serum IL-6 and sIL-1RA in the early puerperium than women without a lifetime history. Women who had suffered from a lifetime history of major depression had significantly higher IL-6, and sIL-1RA concentrations 1 and 3 days after delivery than women with a negative life-time history.

CONCLUSIONS

The responses of IL-6 and sIL-1RA following delivery are amplified in women who previously suffered from major depression. The results suggest that major depression is accompanied by a sensitization of the IRS.

Pavlovian conditioning of emotional responses to olfactory and contextual stimuli: a potential model for the development and expression of chemical intolerance

Chemical intolerance (CI) in humans is a poorly understood phenomenon of uncertain etiology, seemingly influenced by multiple factors both within and between affected individuals. Several authors have suggested that the development of CI in some individuals may be due, at least in part, to Pavlovian conditioning processes in which the expression of overt symptoms to certain substances reflects classically conditioned responses to previously neutral olfactory and contextual stimuli. In this paper, we describe the potential relationship between olfactory and contextual conditioning in experimental animals and the development and expression of CI in humans. Furthermore, as significant advances have been made in delineating the brain areas that underlie these learned responses, we also review recent research on the contributions of the amygdala and perirhinal cortical region to olfactory and contextual fear conditioning.

Patterns of waking EEG spectral power in chemically intolerant individuals during repeated chemical exposures

Previous studies indicate that low level chemical intolerance (CI) is a symptom of several different controversial conditions with neuropsychiatric features, e.g., chronic fatigue syndrome, fibromyalgia, multiple chemical sensitivity, and "Persian Gulf Syndrome". Prior studies suggest that limbic and/or mesolimbic sensitization may contribute to development of CI. The purpose of this report was to document the waking electroencephalographic (EEG) patterns of individuals with CI during chemical exposures presented over repeated sessions. Three groups of adult subjects who were recruited from the community participated in the study: self-reported CI who had made associated lifestyle changes due to their intolerance (CI/ LSC), self-reported CI who had not made such changes (CI), and normal controls without self-reported CI. Subjects underwent two sessions involving one-minute EEG recordings during exposures to low level chemical odors (a probe for limbic activation). The CI, but not the CI/ LSC, subjects had increased absolute delta power after the chemical exposures during the second, but not the first, session. The findings support the neural sensitization hypothesis for intolerance to low levels of environmental chemicals in vulnerable individuals. As in human studies of stimulant drug sensitization, those with the strongest past history with sensitizing agents may not show-term sensitization to low level exposures in the laboratory.

A review of multiple chemical sensitivity

OBJECTIVE

To review critically the scientific literature on multiple chemical sensitivity (MCS). Definitions of MCS vary but, for this review, a broad definition of MCS was adopted as symptoms in more than one organ system elicited by various unrelated chemicals at very low levels of exposure.

METHODS

A systematic literature search identified several hundred references from which key papers were selected. Two questions are considered, does MCS exist and what causes MCS.

RESULTS AND CONCLUSIONS

Despite extensive literature on the existence of MCS, there is no unequivocal epidemiological evidence; quantitative exposure data are singularly lacking; and qualitative exposure data are, at best, patchy. There is also some evidence to suggest that MCS is sometimes used as an indiscriminate diagnosis for undiagnosed disorders. Despite this, the collated evidence suggests that MCS does exist although its prevalence generally seems to be exaggerated. Many causal mechanisms have been proposed, some suggesting a physical origin--such as MCS reflecting an immunological overload (total body load)--others favouring a psychological basis--such as MCS symptoms being evoked as part of a conditioned response to previous trauma. The available evidence seems most strongly to support a physical mechanism involving sensitisation of part of the midbrain known as the limbic system. However, it is increasingly being recognised that the psychological milieu of a person can considerably influence physical illness, either through generating a predisposition to disease or in the subsequent prognosis. Work is needed to establish the prevalence of MCS and to confirm or refute selected causal mechanisms.

Increased cardiopulmonary disease risk in a community-based sample with chemical odor intolerance: implications for women's health and health-care utilization

Chemical intolerance, or reported illness from odors of common environmental chemicals (e.g., car exhaust, pesticides), is emerging as an important environmental and public health-care issue. Epidemiologic methods provide relevant heuristic devices for studies of complex disorders, such as chemical intolerance. The authors examined personal and reported parental cardiopulmonary disease prevalence rates in a community sample of chemically intolerant and control individuals. A county government (Tucson, Arizona) employee and kin subset (N = 181; 113 households) completed standard health questionnaires. Investigators determined chemical intolerance (n = 41/181) from self-reports of individuals who felt "moderately" to "severely" ill from exposure to at least three of five chemicals (i.e., car exhaust, pesticides, paint, new carpet, and perfume) on a Chemical Odor Intolerance Index. The authors chose the control group (n = 57/181) on the basis of self-reports of "never" feeling ill on the Chemical Odor Intolerance Index. The chemically intolerant group, which primarily comprised women (78% versus 51% of controls, p < .05), was significantly more likely to report-and to have sought--medical attention for heart problems, bronchitis, asthma, and pneumonia. Reports of heart problems in the chemically intolerant index cases and the occurrence of heart disease in both of their parents were significant (Fisher's p < .05). The chemically intolerant individuals were also significantly more likely to report maternal histories of chest problems (e.g., inhalant allergens, tuberculosis) than controls. The findings of the study suggested that the chemically intolerant individuals (a preponderance of whom were women [sex-related risk]) were more likely to have (a) reported cardiopulmonary problems (i.e., greater health risk); (b) actively sought medical care for these problems (i.e., increased medical utilization); and (c) reported more parental illnesses-particularly heart disease, asthma, and diabetes (i.e., genetic risk). Additional community-based studies of chemical intolerance are needed.

A critical analysis of multiple chemical sensitivities

Multiple chemical sensitivities (MCS) is a chronic condition of irritation and inflammation of sensory organs, gastrointestinal distress, fatigue, and compromised neurological function, including learning and memory deficits, unpleasant smells, tingling of nerves, and sensory discomfort. Victims report these symptoms after exposure to unfamiliar chemicals. Some studies have linked MCS to immune system dysregulation. MCS is believed to be a disease that spreads between various target organs, and is caused by sensitization to chemicals with very different structures. MCS is often attributed to free radical production and stress, which indirectly cause spreading because of damage to the immune system.

Differential resting quantitative electroencephalographic alpha patterns in women with environmental chemical intolerance, depressives, and normals

BACKGROUND

Previous research suggests that a subset of individuals with intolerance to low levels of environmental chemicals have increased levels of premorbid and/or comorbid psychiatric disorders such as depression, anxiety, and somatization. The purpose of this study was to evaluate the psychological profiles and quantitative electroencephalographic (qEEG) profiles at baseline of women with and without chemical intolerance (CI).

METHODS

Participants were middle-aged women who reported illness from the odor of common chemicals (CI, n = 14), depressives without such intolerances (D, n = 10), and normal controls (N, n = 11). They completed a set of psychological scales and underwent two separate qEEG recording laboratory sessions spaced 1 week apart, at the same time of day for each subject.

RESULTS

CI were similar to D with increased lifetime histories of physician-diagnosed depression (71% vs. 100%), Symptom Checklist 90 (revised) (SCL-90-R) somatization scores, Barsky Somatic Symptom Amplification, and perceived life stressfulness, although D had more distress than either CI or N on several other SCL-90-R subscales. CI scored significantly higher on the McLean Limbic Symptom Checklist somatic symptom subscale than did either D or N. On qEEG, CI exhibited significantly greater overall resting absolute alpha activity with eyes closed, especially at the parietal midline site (Pz), and increased (sensitized) frontal alpha from session 1 to 2, in contrast with the D and N groups. D showed right frontal asymmetry in both sessions, in comparison with CI.

CONCLUSIONS

The data indicate that CI with affective distress diverge from both D without chemical intolerance and N in qEEG alpha patterns at resting baseline. Although CI descriptively resemble D with increased psychological distress, the CI's greater alpha suggests the possibility of a) central nervous system hypo-, not hyper-, activation; and/or b) an overlap with EEG alpha patterns of persons with positive family histories of alcoholism.

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.

Time-dependent sensitization of heart rate and blood pressure over multiple laboratory sessions in elderly individuals with chemical odor intolerance

In this study, we tested the hypothesis that low-level chemical odor intolerance (i.e., "cacosmia") is a manifestation of heightened sensitizability to environmental stimuli. We examined supine heart rate and blood pressure of elderly individuals, who were classified as either having a higher degree of chemical odor intolerance (n = 12) or a lower degree of chemical odor intolerance (n = 13), upon awakening in a sleep research laboratory on 6 different days during an 8-wk protocol. During the 2 initial wk, they consumed a customary baseline diet (including ad lib milk and other dairy products), followed by 3 wk each of nondairy-containing and dairy-containing diets in randomly assigned, counterbalanced order. Measurements were made on 3 pairs of successive days, distributed over a 6-wk period, and on which different diets were consumed. The high-intolerance group had significantly higher mean supine systolic and diastolic blood pressures than did the low-intolerance group. Although subjects consumed milk products during both the initial baseline and subsequent dairy diet periods, the high-intolerance group had significantly higher heart rates and diastolic blood pressures later in the study than at baseline, especially when they were on the dairy diet. In contrast, the cardiovascular measures of the low-intolerance group lowered on average with time. The high-intolerance subjects had an increased mean diastolic blood pressure on the second days versus the first days in the laboratory (averaged across all diets). Collectively, the data suggest that elderly individuals with a high degree of chemical odor intolerance evidence (a) increased sympathetic tone in the cardiovascular system at rest over multiple measurements; and (b) greater sensitizability and/or lesser habituation of heart rate and diastolic blood pressure over time as a function, in part, of repeated environmental stressor exposures (i.e., a novel laboratory contextual setting and/or specific dietary constituents). Consistent with a sensitization model, the findings emphasize the need for two or more identical sessions at least 24 h apart in physiological studies of individuals with a high degree of intolerance for chemical odors versus normal individuals. The results of the blood pressure observations suggest that the possibility of abnormally labile autonomic function and cognitive sequelae in individuals with a high degree of intolerance for chemical odor increases with age.

Toxicological considerations in evaluating indoor air quality and human health: impact of new carpet emissions

This review article considers evidence regarding the toxicological impact of new carpet emissions on indoor air quality and human health. It compares emissions data from several studies and describes the dominant compounds found in those emissions. The toxicity of each these compounds is assessed for animal and human data, with a focus on inhalation exposure. Data for acute and chronic exposures are presented, and synergistic effects are considered. Differences and similarities between health responses caused by toxicity and/or by immunological reactions are discussed. Possible neurogenic pathways and associations between these and immune changes are considered as they might relate to inflammatory-based human reactions. Additionally, factors affecting human odor responses are described. The roles that a variety of psychological factors may also play in the etiology of potentially related phenomena, such as the sick building syndrome, pathogenic illness, and multiple chemical sensitivity, are considered. Gaps in the literature are identified within the article and suggestions for future research are offered. In particular, it is noted that few, if any, prior studies have evaluated both neurogenic and immune-mediated inflammation status within the same study. Based on the present information available, it is concluded that under normal environmental circumstances, VOC emissions from new carpets are sufficiently low such that they should not adversely affect indoor air quality or pose significant health risk to people.

Multiple chemical sensitivity (MCS) : Idiopathic environmental intolerances (IEI)

Multiple Chemical Sensitivity (MCS) is a systemic disorder causing central nervous, irritative and gastrointestinal symptoms, and can be included in the category of "idiopathic environmental intolerance" (IEI). This term describes phenomena with multiple, recurrent symptoms associated with various environmental factors that are tolerated by most people without problems. Those advocating these concepts attribute the symptoms to exogenous substances. Those opposing them explain the phenomena by classical conditioning or other psychopathological processes. To the extent that controlled studies are available, they have not furnished any hard evidence for toxic or immunological causes. In addition to psychopathological origins, neurobiological processes are also implicated.

Sensitization induced by kindling and kindling-related phenomena as a model for multiple chemical sensitivity

It has been suggested that the neurobehavioral dysfunction observed in persons presenting with symptoms of Multiple Chemical Sensitivity (MCS) syndrome involves sensitization of neural circuits. Two hypotheses for the route of exposure in induction of neural sensitization in MCS are: (a) direct chemical stimulation of olfactory processes, or (b) general systemic response to inhaled chemicals. In either case, the mechanism of action may involve chemical kindling or kindling-related phenomena. A neural sensitization mechanism based on kindling or kindling-related phenomena is attractive and has been previously demonstrated in both in vitro and in vivo animal models. Without a testable animal model for chemically mediated induction of MCS, however, any argument that MCS is mediated by kindling or kindling-related phenomena is reduced to the circular argument "the mechanism of sensitization is sensitization." The present survey provides an overview of the experimental paradigms that result in sensitization, differentiated on the basis of probable neurophysiological and neurochemical mechanisms. Neurophysiological potentiation, electrical kindling, chemical kindling and behavioral sensitization are evaluated and discussed in relationship to MCS.

Clinically relevant EEG studies and psychophysiological findings: possible neural mechanisms for multiple chemical sensitivity

This paper addresses the evidence for the face, construct, and criterion-related validity of the olfactory-limbic/neural sensitization model for multiple chemical sensitivity (MCS). MCS is a poorly-understood, controversial condition in which low levels of environmental chemicals are reported to trigger disabling levels of illness in certain individuals. Neural sensitization processes could generate an endogenous amplification of responsivity to exogenous substances, thereby providing a plausible explanation for the apparent lack of a classical toxicological dose-response relationship in MCS. Convergent data from both survey and psychophysiological studies of MCS patients and of persons from the community without MCS, but who report elevated frequency of illness from chemical odors (cacosmics), support the involvement of the limbic system and the sensitizability of cacosmics, as predicted by the model. Recent studies show that cacosmics do sensitize their heart rate, blood pressure, and plasma beta-endorphin responses to repeated exposures to a novel laboratory procedure involving dietary manipulations over time. Cacosmia may represent a pathological form of neural plasticity. Taken together, the model and the available evidence suggest the need for more intensive investigation of MCS from the standpoint of possible neurobiological mechanisms affecting cognitive, emotional, and somatic functions.

Phenotypic variation in xenobiotic metabolism and adverse environmental response: focus on sulfur-dependent detoxification pathways

Proper bodily response to environmental toxicants presumably requires proper function of the xenobiotic (foreign chemical) detoxification pathways. Links between phenotypic variations in xenobiotic metabolism and adverse environmental response have long been sought. Metabolism of the drug S-carboxymethyl-L-cysteine (SCMC) is polymorphous in the population, having a bimodal distribution of metabolites, 2.5% of the general population are thought to be nonmetabolizers. The researchers developing this data feel this implies a polymorphism in sulfoxidation of the amino acid cysteine to sulfate. While this interpretation is somewhat controversial, these metabolic differences reflected may have significant effects. Additionally, a significant number of individuals with environmental intolerance or chronic disease have impaired sulfation of phenolic xenobiotics. This impairment is demonstrated with the probe drug acetaminophen and is presumably due to starvation of the sulfotransferases for sulfate substrate. Reduced metabolism of SCMC has been found with increased frequency in individuals with several degenerative neurological and immunological conditions and drug intolerances, including Alzheimer's disease, Parkinson's disease, motor neuron disease, rheumatoid arthritis, and delayed food sensitivity. Impaired sulfation has been found in many of these conditions, and preliminary data suggests that it may be important in multiple chemical sensitivities and diet responsive autism. In addition, impaired sulfation may be relevant to intolerance of phenol, tyramine, and phenylic food constituents, and it may be a factor in the success of the Feingold diet. These studies indicate the need for the development of genetic and functional tests of xenobiotic metabolism as tools for further research in epidemiology and risk assessment.

A polysomnographic study of sleep disturbance in community elderly with self-reported environmental chemical odor intolerance

Subjective sleep complaints and food intolerances, especially to milk products, are frequent symptoms of individuals who also report intolerance for low-level odors of various environmental chemicals. The purpose of the present study was to evaluate the objective nature of nocturnal sleep patterns during different diets, using polysomnography in community older adults with self-reported illness from chemical odors. Those high in chemical odor intolerance (n = 15) exhibited significantly lower sleep efficiency (p = .005) and lower rapid-eye-movement (REM) sleep percent (p = .04), with a trend toward longer latency to REM sleep (p = .07), than did those low in chemical intolerance (n = 15), especially on dairy-containing as compared with nondairy (soy) diets. The arousal pattern of the chemical odor intolerant group differed from the polysomnographic features of major depression, classical organophosphate toxicity, and subjective insomnia without objective findings. The findings suggest that community elderly with moderate chemical odor intolerance and minimal sleep complaints exhibit objectively poorer sleep than do their normal peers. Individual differences in underlying brain function may help generate these observations. The data support the need for similar studies in clinical populations with chemical odor intolerance, such as multiple chemical sensitivity patients and perhaps certain veterans with "Persian Gulf Syndrome."

Time-dependent sensitization of plasma beta-endorphin in community elderly with self-reported environmental chemical odor intolerance

This study examined plasma beta-endorphin as a marker of the physiological stress response in community elderly who were either high (n = 15) or low (n = 15) in self-rated frequency of illness from environmental chemical odors. Individuals who report nonatopic multiple sensitivities to or intolerances for low levels of environmental chemicals also claim high rates of comorbid food sensitivities or intolerances. Subjects gave 9 AM blood samples for plasma beta-endorphin 90 min after ingesting either 1% fat cow's milk or a soy-based nondairy drink, on six different mornings in the laboratory after all-night sleep recordings. The six sessions-were divided into three sets of two successive days each, with each set [involving baseline (ad lib milk), nondairy (soy-based), and dairy diets] separated from the next by 3 weeks. In the chemically tolerant subjects, stably lower beta-endorphin levels suggested that milk may have been a physiologically less stressful beverage than was the soy drink. In contrast, the chemical odor intolerant group exhibited a) increased levels of plasma beta-endorphin averaged over the 6 days (p = .02); and b) marked fluctuations in endorphin from one laboratory day to the next (Group x Diet x Day interaction, p = .005). The findings were consistent with time-dependent, context-dependent sensitization of beta-endorphin in the chemical odor intolerant individuals.

Prevalence and nature of allergy and chemical sensitivity in a general population

The objectives of this study were (a) to determine the self-reported prevalence of allergy and chemical sensitivity in a rural population of eastern North Carolina, (b) to determine the type and frequency of symptoms for each condition, and (c) to determine the demographic groups affected. A random general telephone survey was conducted during the period May 14, 1993, to September 10, 1993, and questions about allergy and chemical sensitivity were asked. Of the 1 446 households contacted, 1 027 (71%) individuals agreed to participate. Allergies were reported by 365 (35%) individuals. Thirty percent of allergic individuals reported that symptoms occurred once or more each week, whereas 61% reported that symptoms occurred, at most, once each month. Allergic symptoms that occurred daily were reported by 5.3% of the total population. Chemical sensitivity was reported by 336 (33%) individuals. Thirty-five per cent of chemically sensitive individuals reported symptoms at least once each week, whereas 53% reported that symptoms occurred once (or less) each month. Symptoms of chemical sensitivity that occurred daily were reported by 3.9% of the total population. Both allergy and chemical sensitivity were distributed widely across age, income, race, and educational groups. Simultaneous allergy and chemical sensitivity were reported by 16.9% of the population, allergy without chemical sensitivity by 16.0%, chemical sensitivity without allergy by 18.2%, and neither condition by 48.9%. If the prevalence of sensitivity to chemical irritants is, in fact, equivalent to that of allergy, as was found in this study, then support for the scientific investigation of chemical sensitivity is justified.

Psychiatric Aspects of Air Pollution

Psychological and toxic effects of air pollution can lead to psychiatric symptoms, including anxiety and changes in mood, cognition, and behavior. Increased levels of some air pollutants are accompanied by an increase in psychiatric admissions and emergency calls and, in some studies, by changes in behavior and a reduction in psychological well-being. Numerous toxic pollutants interfere with the development and adult functioning of the nervous system. Manifestations are often insidious or delayed, but they can provide a more sensitive indicator of toxic effects than cancer rates or mortality data. Other medical effects of air pollution, such as asthma, can indirectly affect psychological health. The sick building syndrome and multiple chemical sensitivity are conditions with toxicologic and psychiatric aspects. Psychosocial stress can cause symptoms similar to those of organic mental disorders. Reactions to stress depend on cultural, individual, and situational variables. We must understand these factors to be able to alleviate and prevent the consequences of environmental trauma. Expanded research is recommended in three main areas: (1) how people perceive and cope with environmental health risks, (2) the effects of air pollution on behavior and neuropsychological functioning, and (3) neurotoxicologic evaluation of air pollutants with both behavioral and in Vitro Studies.

Slowed reaction time performance on a divided attention task in elderly with environmental chemical odor intolerance

Previous research has suggested an association between the subjective report of illness from environmental chemical odors and poorer cognitive task performance in persons with industrial levels of xenobiotic exposures. The present study investigated baseline morning performance on a computerized divided attention task in active retired adults without occupational exposures or clinical disorders who nonetheless rated themselves currently high versus low in episodic illness from the odor of certain environmental chemicals. The chemically intolerant group showed slower reaction times in registering both centrally and peripherally placed stimuli, but no difference in making target tracking errors. Measures of negative affect did not account for these findings. Taken together with evidence for heightened neurobehavioral sensitization in this population, the data suggest disturbances in allocation of attention and related cognitive functions.

Neuropsychiatric and somatic characteristics of young adults with and without self-reported chemical odor intolerance and chemical sensitivity

The psychological, neuropsychiatric, and somatic characteristics of young adults who have different degrees of cacosmia (i.e., feeling "ill" from the odor of xenobiotic chemicals) and who have self-described "chemical sensitivity" were examined. A total of 800 college students completed the following: a self-rating scale for frequency of odor intolerance for 10 common substances, Simon Environmental Illness Symptom Survey, the SCL-90-R, Barsky Amplification Scale, Pearlin-Schooler Mastery Scale, Cheek-Buss and Kagan Shyness scales, Marlowe-Crowne Social Desirability Scale, and a health-symptom and physician-diagnosed checklist. Two pairs of groups were compared: (1) subjects in the top 16% (i.e., cacosmics) and bottom 15% (noncacosmics) of the sample with respect to odor intolerance scale scores; and (2) subjects from the entire sample who did (28%) or did not (72%) consider themselves to be "especially sensitive to certain chemicals.¿ Cacosmics and the chemically sensitive subjects scored significantly higher on measures of psychological distress and amplification of somatic symptoms, but there was little evidence of lifestyle change, as assessed by the Simon Survey. Compared with their respective comparison groups, cacosmic and chemically sensitive groups had significantly higher incidences of illnesses associated with chemicals, alcohol intake, opiate drug use, and caffeine use, even after controlling for the psychological measures and histories of atopic allergy. Subjects with and without neuropsychiatric symptoms were differentiated with respect to chemical odor intolerance, but subjects with and without atopic allergies and possible autoimmune diseases were differentiated with respect to chemical sensitivity. Females were more cacosmic than males. Cacosmia is defined by a population subset, with or without occupational xenobiotic exposures or disability, that has distress and symptom amplification and neuropsychiatric and somatic symptoms, none of which are explained fully by psychological measures. Prospective clinical studies are possible with such individuals. The data are also consistent with a time-dependent sensitization model for illness from low-level chemical exposures.

Sensitization to early life stress and response to chemical odors in older adults

This study examined the hypothesis that older persons who currently report illness from environmental chemical odors (cacosmia) may have experienced higher levels of stress early in life than did noncacosmic controls. The hypothesis derives from a time-dependent sensitization (TDS) model for cacosmia (Bell et al 1992) that predicts a relative interchangeability of stress and chemicals in inducing and eliciting sensitized responses in vulnerable individuals. Subjects were selected from those in the top 24% (cacosmic) and bottom 27% (noncacosmic) of a sample of 192 older adults (mean age 73.8 years) for self-reported frequency of illness form the odors of pesticide, car exhaust, paint, perfume, and new carpet. As in previous investigations, cacosmics were younger, more depressed, and more shy; cacosmics also included a higher proportion of women (83% versus 61%). As predicted, cacosmics rated themselves higher in stress for the first four decades of their lives, but not the recent past or present, even after controlling for depression, anxiety, hostility, shyness, age, and gender. Cacosmics reported increased prevalence of physician-diagnosed nasal allergies, breast cysts, hypothyroidism, sinusitis, food sensitivities, irritable bowel, and migraine headache. Only 4% of the overall sample (including 9% of the cacosmics) acknowledged the controversial physician diagnosis of "chemical sensitivity." The replicated observation of greater shyness in cacosmics is consistent with the ability of hyperreactivity to novelty to predict enhanced susceptibility to TDS from low levels of pharmacological agents in animals. The findings support a TDS model for cacosmia and suggest that cacosmia as a symptom identifies a large subset of the nonindustrial population with significant psychophysiological health problems that merit further objective examination.