Multiple chemical sensitivity

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Multiple chemical sensitivity (MCS), also known as idiopathic environmental intolerances (IEI), is an acquired, chronic, multi-system illness, in which people experience a range of symptoms in response to exposure to certain everyday chemicals.

A 2017 scientific review described MCS as "a complex syndrome that manifests as a result of exposure to a low level of various common contaminants."[1] A 2019 review described the condition as an "acquired disorder characterized by recurrent symptoms, affecting multiple organs and systems, which arise in response to a demonstrable exposure to chemicals, even at low doses, much lower than those that would cause a reaction in the general population."[2]

Chemicals that are common triggers for MCS symptoms include pesticides, petrochemicals, formaldehyde and fragranced products.[3] Natural irritants like mold and wood-fire smoke are also often triggers.[4]

MCS in ME and ME/CFS

MCS has been described as a comorbidity of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and fibromyalgia.[5][6] The Canadian Consensus Criteria for diagnosing ME/CFS lists "new sensitivities to food, medications and/or chemicals" as a symptom and lists "Multiple Chemical Sensitivities (MCS)" as a comorbidity. The International Consensus Criteria for diagnosing myalgic encephalomyelitis (ME) lists "sensitivities to food, medications, odours or chemicals" as a symptom and lists "multiple chemical sensitivities" as a comorbidity. A 2019 publication of the U.S. ME/CFS Clinician Coalition lists "chemical sensitivity" as a symptom of ME/CFS and lists "Multiple Chemical Sensitivities" as a commonly comorbid condition.[7]

However, it is important to note that MCS has specific diagnostic criteria which do not include medication, food or odor sensitivities.[8]

Signs and symptoms

In 1999, an international consensus on MCS was published in The Archives of Environmental Health.[8] The consensus was the conclusion of a ten-year study by an international multidisciplinary team of 89 clinicians and researchers, with different points of view about MCS.[9] What they agreed upon was that the clinical characteristics of MCS should be defined as follows: “[1] a chronic condition, [2] with symptoms that recur reproducibly, [3] in response to low levels of exposure, [4] to multiple and unrelated chemicals, and [5] improve or resolve when [[triggers]] are removed, [6] MCS involves symptoms in different organs.”[8][9]

The symptoms of MCS affect multiple organs and body systems,[3][8][10][11] range from mild to disabling[3][11][12] and decrease quality of life.[10][13][12][14][15][16][17][18][19][20]

Common symptoms of MCS include headache, migraine, neurocognitive deficits, dizziness, fatigue, cardiac arrhythmia, tachycardia, hypotension, hypertension, gastrointestinal problems, nausea, vomiting, muscle and joint pain, skin rashes, visual disturbances, seizures, asthma and anaphylaxis.[3][11][21][12][13][22][23][24]

A 2017 review of MCS studies said: “MCS is a syndrome that progresses to increasingly serious stages, with the gradual onset of multiple pathologies”.[1]

Diagnosis

The 1999 international consensus on MCS is still the primary set of criteria used to assess a patient for MCS. To receive an MCS diagnosis, the patient must satisfy all the following criteria: The patient has (1) a chronic condition (2) with symptoms that recur reproducibly (3) in response to low levels of exposure (4) to multiple and unrelated chemicals, (5) which improve or resolve when triggers are removed and (6) suggest a relation to different organs.[8][9] The Quick Environmental Exposure and Sensitivity Inventory (QEESI), is a diagnostic tool that is often used to assess a patient for these criteria.[3][9]

Treatment and management

At this time, there is no clinically proven cure for MCS.[12][25] There is also no scientific consensus on supportive therapies for MCS, "but the literature agrees on the need for patients with MCS to avoid the specific substances that trigger reactions for them and also on the avoidance of xenobiotics in general, to prevent further sensitization."[25][26][12][27][11][28]

There is also consensus that a multidisciplinary approach is required for adequately managing the health of someone with MCS.[10][25] Some studies suggest a special focus on correcting any nutritional deficiencies may be beneficial.[10][25][29]

To avoid their condition being aggravated or worsened while in hospital, patients with MCS require special adjustments around chemical use, medications and anesthetics in hospitals.[30][31][32][33][34][35][36]

There is evidence that some patients with MCS have poor tissue oxygenation when exposed to triggers,[37] likely because of oxidative stress[38][39] or because neural inflammation has reduced blood flow.[37][40] Breathing medical oxygen following accidental chemical exposures is a suggested remedy for these patients.[37]

The 2019 consensus and clinical guidelines on MCS said that people with MCS "must be guaranteed, according to their individual needs and level of disability" medical oxygen and the necessary equipment to use it (that is, tubing and a mask from non-triggering materials).[41]

The other aids the 2019 consensus said were necessary for patients with MCS to manage the functional impacts of their condition were: face masks (with HEPA and VOC filters), portable air purifiers for the home and for inside vehicles (made of metal, with HEPA and activated carbon filters) and water purifiers.[41]

These aids may be especially important when sufferers live in areas where they are exposed to agricultural or urban pollution or smoke from forest fires or bushfires.

Epidemiology

Prevalence rates for MCS vary according to the diagnostic criteria used.[2][42] What is clear is that the condition is reported across industrialized countries and it affects women more than men.[26][43][44][45][46][47][48][49][50]

The most extensive epidemiological study into MCS in the United States was in 2005.[2][51] It found that the national prevalence rate for MCS diagnosed by a doctor was 2.5% and self-reported MCS was 11.2%.[2][52][53]

In 2018, the same researchers reported that the prevalence rate of diagnosed MCS had increased by more than 300% and self-reported chemical sensitivity by more than 200% in the previous decade.[2][54] They found that 12.8% of those surveyed reported medically diagnosed MCS and 25.9% reported having chemical sensitivities.[2][54]

A 2014 study by the Canadian Ministry of Health estimated, based on its survey, that 0.9% of Canadian males and 3.3% of Canadian females had a diagnosis of MCS by a health professional.[55][56]

In Denmark, the Ministry of the Environment estimated in 2004 that 10% of the Danish population was sensitive to certain everyday chemicals and that 1% of the population had MCS to a level that was disabling.[57]

While a 2018 study at the University of Melbourne found that 6.5% of Australian adults reported having a medical diagnosis of MCS and that 18.9% reported having adverse reactions to multiple chemicals.[2][58][59][60] The study also found that for 55.4% of those with MCS, the symptoms triggered by chemical exposures could be disabling.[59][13]

These findings suggest that, in the above countries, MCS is not a rare disease.

Causes

There is a lack of agreement among MCS researchers on the cause or causes of the condition.[12]

In 2017, a Canadian government Task Force on Environmental Health said that there had been very little rigorous peer-reviewed research into MCS and almost a complete lack of funding for such research in North America.[61] "Most recently," it said, "some peer-reviewed clinical research has emerged from centres in Italy, Denmark and Japan suggesting that there are fundamental neurobiologic, metabolic, and genetic susceptibility factors that underlie ES/MCS."[61]

One of the most thorough academic reviews of MCS research to be undertaken was published in Italy in May 2019.[62] It said that the current predominant hypotheses about the causes of MCS were: biochemical, neuro-physiological and related to the limbic system and genetic predisposition.[63]

Some researchers say a consensus that the causes are multifactorial has been reached.[64]

When speaking at an Australian federal parliamentary inquiry into environmental illness, Dr Graeme Edwards, the Royal Australasian College of Physicians' representative[65], said that there was "relatively good consensus" that causation was multifactorial. "There is no single causative factor," he said. "It is a combination of factors [...] unless you have all the pieces of the puzzle lining up, you actually don't get the disease. And because we are talking about multi-dimensional triggers, any one individual, at any one point in time, may not have exposure to all of those triggers to get a pathological result. And therein lies the complexity."[66]

Toxicological

It has been hypothesized that MCS is caused by exposure to particular chemicals—most commonly certain pesticides.

Professor Martin L. Pall proposed that MCS had a toxicological and biochemical cause, and that "seven individual chemicals or chemical classes—organophosphorus/carbamate, organochloride and pyrethroid pesticides, organic solvents, carbon monoxide, hydrogen sulphide and mercury/mercurial compounds—could initiate MCS through their ability to increase N-methyl-D-aspartate (NMDA) receptor activity."[4][67]

Pall hypothesized that overactivity of the NMDA receptors, coupled with stress-related increases in nitric oxide and the oxidative product peroxynitrite (known as the NO/ONOO cycle) caused MCS symptoms and worsened the condition.[68][69] He suggested that hypersensitivity occurred because of limbic kindling, neural sensitization, and/or neurogenic inflammation—processes which could be driven by the NO/ONOO cycle.[67]

A 2019 scientific review said that while further research was required to confirm Pall's theory, that his hypothesis "had found broad consensus in the scientific community” and was compatible with previous hypotheses,[63] including Dr. Iris Bell's theory of neuronal sensitization[70][71] and William Meggs’ theory of neurogenic inflammation.[72] It also said that Pall's theory may explain the comorbidity of MCS and other pathologies hypothesized to be related to the same mechanism, including Fibromyalgia (FM) and Myalgic Encephalomyelitis / Chronic Fatigue Syndrome (ME/CFS), and that it might be why MCS symptoms tend to lessen after exposure to inhibitors and/or antagonists of NMDA receptors.[63]The review also said that "pesticides, including herbicides, insecticides and agricultural chemicals, are among the substances most commonly implicated in the activation of MCS cases in the United States."[73]

Pall's theory has also been used to explain why Gulf War veterans, particularly those who were exposed to organophosphate pesticides, have been found to be more likely to have MCS than the general population[74][68] as well as the fact that chemical sensitivities are a known symptom reported in Gulf war syndrome or post-deployment syndrome.[75][76][77]

The U.S. Department of Veterans Affairs concluded that "risk factors that may be associated with predisposing, precipitating, and perpetuating chronic multi system illnesses [including MCS] among veterans" included chemical exposure, and notably chemical exposure in the Gulf War, where some military personel were exposed to nerve agents (like sarin and cyclosarine) and toxic smoke.[76]

Mold and mycotoxin exposures have also been hypothesized to trigger the onset of MCS. [78][79][80][81] Exposure to mold has already been associated with initiating inflammation and higher incidences of certain chronic conditions (like asthma), which are common symptoms of MCS.[82][83][84][85][86]

Neurological

Many common symptoms of MCS are neurological[26][10][3] (for example, "dizziness, seizures, head pain, fainting, loss of coordination"[13]). And neurogenic inflammation and sensitization are widely thought to be mechanisms involved in causing, perpetuating and worsening MCS.[3][70][71][72]

William Meggs said that neurogenic inflammation was a well-defined pathophysiological process, in which chemical irritants triggered nerve fibers to release inflammatory mediators, which led to disease. In a 2017 review, he said that with MCS, an initiating chemical exposure (commonly a respiratory irritant or pesticide) was usually identified in association with the onset of the disease.[72]

Iris Bell researched brain-wave patterns in people with MCS. He showed, in several studies using Electroencephalograms (EEG), that people with MCS often had certain abnormal brain wave patterns.[63][87] For example, he found that women with MCS were more likely to have greater resting alpha waves than controls, which he said suggested the possibility of central nervous system hypo-activation.[88]

Multiple neuro-imaging studies have shown that people with MCS often have other neurological abnormalities, including abnormal cerebral perfusion patterns, especially in the autonomic nervous system areas.[63][89][90][91][92][93] These abnormalities have been documented both in studies using PET (Positron Emission Tomography) and SPECT (Single Photon Emission Computed Tomography) scans.[63][94][95]

In addition to people with MCS having documented neurological abnormalities, neuroplasticity is thought by some researchers to be an important mechanism in the disease. In 2018, a representative of the Royal Australasian College of Physicians said: “It could be a multiple chemical sensitivity phenomenon. It could be an irritable bowel phenomenon. It could be fibromyalgia... The common unifying features in all of these conditions is related to what we do know is happening, which is neuroplasticity in the nervous system. We know that, regardless of the initiating trigger—whether it was an overwhelming infection of a mould related organism or some other viral infection—it sets up, within the biological system called the nervous system, neuroplastic changes. They can be, and have been, documented by evidence based research. We can document that there are changes in the nervous system, and that change in the nervous system results in a change in the sensitivity and responsiveness of the human being.”[64][65]

Immunological

MCS is not an allergy, and subjects with MCS having adverse reactions do not routinely exhibit the immune markers associated with allergies.[96] Nevertheless, certain immune irregularities have been identified in subjects with MCS in a range of studies.[26][63][96]

In the 1980s and 1990s, some researchers hypothesized that these immune irregularities suggested that MCS was caused by a chemically induced disturbance of the immune system, which resulted in chronic immune dysfunction.[96][22] While others concluded that allergic or immunotoxicological reactions could be contributing factors in at least a subset of MCS patients.[96][97][98] As more studies were conducted, however, some argued that there was no consistent pattern of immunological reactivity or abnormality in MCS.[99][100][101]

More recently, a French study found that subjects with MCS had higher levels of histamine than controls.[63][102] It also identified damage to the blood-brain barrier in MCS subjects, the production of antibodies against myelin and evidence of inflammatory processes involving the limbic system and thalamus.[63][102] These findings led the research team to conclude that some level of immune activation was likely occurring in the condition.[63][102]

There is also evidence that subjects with MCS are more likely than controls to have proper allergies[103] and autoimmune diseases, and the 2019 consensus on MCS notes an association between the condition and Hashimoto's Thyroiditis, Systemic Lupus Erythematosus (SLE), psoriasis[104] and atopic eczema.[105][106][107][108]

Psychological

It has also been hypothesized that MCS is a psychiatric or psychosomatic disorder.

The main arguments used to support these theories have been: (1) there is no certainty about biological causes of MCS, therefore it must be psychological[109][110] (2) that nocebo responses may operate in MCS[111] and (3) that people with MCS are more likely than controls to have anxiety, depression and the personality trait absorption.[112][113] These theories have attracted considerable criticism.[12][63][114][115][116][117][118][119]

The 2019 Italian consensus on MCS concluded that the studies that hypothesize that the condition has a psychological cause "have been the object of strong criticism, both for methodological deficiencies as well as for the conflict of interests of the scientists who propose this thesis."[63] It said there was consensus that MCS reactions could cause psychiatric symptoms through biological processes (eg. neurogenic inflammation) and that symptoms of the condition should not be mistaken for the cause.[63] It also highlighted that "it was researchers at Johns Hopkins University who pointed out that it is ineffective to use personality tests such as MMP2 (i.e. Minnesota Multiphasic Personality Inventory 2) for the study of the pathogenesis of environmental diseases...concluding that the presence of psychological-psychiatric symptoms in patients with MCS was compatible with the objective limitations imposed by the disease, rather than being the cause."[63][120][121]

Other researchers have emphasized that the psychosocial impacts of the disease (especially isolation and stigmatization) are likely to have significant impacts on mental health.[122][123][124][125][126][127][128] One study showed that anxiety and depression typically started in people with MCS post onset of the condition.[129]

The presence of nocebo responses in MCS does not indicate the cause of the disease.[130] Nocebo responses are found in many biologically caused conditions[131], like asthma, and they are known to be especially pronounced in neurological conditions.[132]

It is noteworthy that psychological approaches to care in MCS patients have had “very limited success,”[133] and that neither MCS, MCS/ES nor IEI have been included in any edition of the DSM (American Psychiatric Association Diagnostic and Statistical Manual[134]) nor have they been listed among somatoform disorders in the International Classification of Diseases.[135]

In Canada, in 2017, following a three-year government inquiry into environmental illness, it was recommended that a public statement be made by the health department dispelling the misperception that MCS/ES is psychological.[136]

Genetic

The 2019 consensus on MCS said that the condition could, at least in part, be caused by genetic alterations affecting detoxification pathways—something which in combination with toxin exposures could make some people more vulnerable to developing MCS than the rest of the population.[63]

Recent Italian studies found that compared to controls, patients with MCS had higher levels of the nitrites and nitrates that are involved in oxidative stress and inflammatory processes, including those that contribute to the oxidative damage of DNA.[63] They also found that the presence of the following genetic polymorphisms were more likely in people with MCS than controls: NOS3, NOS2 and GPX1.[63][137][138]

Other genetic markers known to affect detoxification pathways have been identified as being more common in subjects with MCS than controls,[63][137][138][139][140][141] including polymorphisms and differences in expression of the following: CYP2D6, NAT2, GSTM1, and PON1 and PON2.[142][143]

These findings could support the hypothesis that MCS is caused by a synergy of environmental exposures to toxic substances and the impaired ability to metabolize toxic substances, due to factors related to genetic predisposition.[63]

Recognition

MCS is not included as a separate, discrete disease by the World Health Organization's (WHO) index of diseases (ICD-11). However, existing disease codes can be used to codify the condition, including: "(1) J68.9: unspecified respiratory conditions due to inhalation of fumes, gas, and chemical vapors; and (2) T78.4: unspecified allergies (allergic reaction Nitrous Oxide System (NOS)-hypersensitivity NOS-idiosyncrasy NOS)."[144]

In 1996, an expert panel at WHO/ICPS (International Classification for Patient Safety) was set up to examine MCS.[145] The panel "accepted the existence of a disease of unclear pathogenesis" and proposed that the disease was acquired, that its symptoms were "in close relationship to multiple environmental influences, which are well tolerated by the majority of the population," and that "the condition could not be explained by a known clinical or psychic disorder."[145] The panel also suggested that the broader term "idiopathic environmental intolerances" (IEI) be adopted instead of MCS, to incorporate MCS and several other conditions under a single umbrella term.[145]

MCS is recognized as a discrete pathology, however, on some countries' national indexes of diseases, including in Germany, Austria and Japan.[146][147][148] And in some countries, like Sweden, chemical sensitivities are classified as a form of sensory hyperreactivity (CSS-SHR).[149]

History

In 1956, American allergist Dr. Theron G. Randolph coined the term "environmental illness," to describe symptoms and disorders he observed in some of his patients after they were exposed to various unrelated chemical compounds.[148][145]

Then in 1987, Dr. Mark R. Cullen, also an American allergist, introduced the term MCS in journals of occupational medicine. He proposed that MCS described: an acquired disorder, characterized by recurrent symptoms, affecting multiple organs and systems, which arose in response to a demonstrable exposure to chemicals, even for low doses, much lower than those causing reactions in the general population.[148][145]

Two years later, an international multidisciplinary team of 89 clinicians and researchers commenced a study into MCS, which culminated in the first real international consensus on the condition being agreed upon and published in The Archives of Environmental Health in 1999.[1][8]

In 1996, an expert panel of the World Health Organization/International Classification for Patient Safety (WHO/ICPS) accepted the existence of MCS as a health condition with a cause unknown, and suggested that it be called "idiopathic environmental intolerances"(IEI), a term that incorporates a number of conditions sharing similar symptoms.[145]

In May 2019, the Italian Workgroup on MCS, a group of physicians, research scientists and clinical staff, published a detailed, 30-page consensus paper called the Italian Consensus on MCS.[150] This document may be the most detailed scientific review of research about MCS to date, and it goes into considerable detail about ways the condition can be better managed in clinical environments, particularly in hospitals. The workgroup put their consensus out in Italian and English, asking for input from MDs and other health professionals, biologists and chemists. At the time of writing, the response to the consensus had not been published.

Occupational health and safety

Various organisations and workplaces have policies that include fragrance and/or chemical sensitivities as occupational health and safety (OH&S) issues.[151]

The most significant of these may be the Centers for Disease Control and Prevention (CDC)—the largest health agency in the United States, which in 2009 issued an indoor air quality policy, which says:

  1. "Scented or fragranced products are prohibited at all times in all interior space owned, rented, or leased by CDC;"[152]
  2. "CDC encourages employees to be as fragrance-free as possible when they arrive in the workplace...Employees should avoid using scented detergents and fabric softeners on clothes worn to the office. Many fragrance-free personal care and laundry products are easily available and provide safer alternatives;" and
  3. "Fragrance is not appropriate for a professional work environment, and the use of some products with fragrance may be detrimental to the health of workers with chemical sensitivities, allergies, asthma, and chronic headaches/migraines."[152]

Common ingredients in synthetic fragrance are recognized as irritants for a range of respiratory conditions.[153][154][155][156][157][158][159][160][161][162][163][164] The American Lung Association lists fragrance on their list of "indoor air pollutants" and recommends that healthy workplaces establish fragrance-free policies for employees and visitors."[165] With this in mind, some experts have called for fragrance-free policies in hospitals and healthcare settings, and in some countries (like Sweden and Canada) these already exist.[166][167][12][168]

Controversy

In the tradition of the Merchants of Doubt—industry-funded groups deliberately casting doubt on science about environmental damage and environmental illness—MCS sufferers and the physicians treating them have been subject to campaigns aimed at undermining the veracity of the condition.[169] This has played out in the media[170] and on Wikipedia.[171][172][173][174][175][176]

The blogs Quackwatch and Science-Based Medicine (SBM)—related blogs dominated by the same brand of skepticism[177]—for example, have repeatedly claimed MCS is a fake disease and that MCS sufferers are prey to pseudoscientific concepts, charlatans and purveyors of pseudoscience, fringe science and quackery.[178][179][180][181][182][183][184][185][186][187][188][189][190][191][192][193][194]

These claims made by Quackwatch/SBM, however, are at odds with: (1) the current medical consensus about MCS,[1][8][10][12][21][62][66] (2) conclusions of the most recent academic reviews of MCS research, which are in respected scientific journals,[1][10] and (3) the recognition of the condition by the WHO/ICPS,[145] national and state health agencies and hospitals and physicians' organizations.[1][148][27][147][29][32][33][34][35][36][66][145][195][196]

Some legal actions (including defamation suits in the U.S.) have alleged that Quackwatch and its founder—who has written prolifically about MCS—have been actively and knowingly promoting inaccurate information on a range of medical topics on Wikipedia.[197][198][199] In 2003, a California Appeals Court found Quackwatch's founder “to be biased and unworthy of credibility.”[200][199]

In popular culture

Safe (1995), a cult film by director Todd Haynes is an iconic depiction of MCS.

Voted best film of the nineties by The Village Voice Film Poll[201], and described by critics as ”the scariest film of the year”,[201] “a mesmerizing horror movie”[202] and “a work of feminist counter-cinema,”[203]Safe depicts MCS as a destabilizing and alienating condition.

Protagonist Carol White, played by Julianne Moore, is a quiet and subdued housewife, who suddenly develops a range of symptoms following the renovation of her home, in an affluent suburb of polluted Los Angeles. As Carol’s symptoms worsen, the chemicals that are triggering them seem ubiquitous.

Carol's condition isn't given a name in the film, but Haynes has said he is depicting MCS.[204] Doctors are at a loss of how to cure or help Carol. She is initially referred for psychotherapy, but it doesn't improve her symptoms.

Her husband is skeptical; her community, who seem dubious that MCS is real, are indifferent and unsupportive.

So Carol leaves her home, possessions and world behind, and without her husband, moves to an eerie desert community for people with environmental illness. The community is strange, and it's led by a man who seems to blame the residents for the illnesses they developed.

“She is so excruciatingly alone,” Moore said of her character at the end of the film.[205] While Haynes said Carol’s isolation was both the answer and the problem for her.[201]

Twenty years after the film’s release, Haynes said its themes—disease and immunity in a post-industrial landscape and how recovery is a burden often put on victims of illness—were even more relevant than they were when he made the film.[205]

See also

Learn more

References

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  155. Nazaroff, W.W. Welsher, C.J. Cleaning products and air fresheners: exposure to primary and secondary air pollutants. Atmos. Environ., 38 (2004), pp. 2841-2865
  156. Kumar, P.; Caradonna, V.M; Graham, S. Gupta, X. Cai, P.N. Rao, J. Thompson Inhalation challenge effects of perfume scent strips in patients with asthma, Ann. Allergy Asthma Immunol., 75 (5) (1995), pp. 429-433
  157. Elberling J, Linneberg A, Mosbech H, Dirksen A, Frølund L, Madsen F, Nielsen NH, Johansen JD. 2004. A link between skin and airways regarding sensitivity to fragrance products? Br J Dermatol. 151(6): 1197-203.
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  164. Venkatachari P, Hopke PK. 2008. Characterization of products formed in the reaction of ozone with alpha-pinene: case for organic peroxides. J Environ Monit. 10(8): 966-74.
  165. Grenville, Kate. The case against fragrance. Text Publishing. Australia. 2017. p.30
  166. Bennett, Holly. Common chemical products making Australians sick, study finds. Melbourne University Press blog. Melbourne, Australia. 2 Jul 2018. Accessed 14 Feb 2020. "Professor Steinemann recommends choosing products without any fragrance, and implementing fragrance-free policies in workplaces, health care facilities, schools and other indoor environments."
  167. Grenville, Kate. The case against fragrance. Text Publishing. Australia. 2017.
  168. Wilson, Sarah. [null The post you send to your] friends who are STILL wearing perfume/ Sarah Wilson blog. October 5, 2017. Accessed 15 Feb 2020.
  169. Oreskes, Naomi; Conway, Erik M. (2011). Merchants of Doubt: How a Handful of Scientists Obscured the Truth on Issues from Tobacco Smoke to Climate Change. Bloomsbury. 
  170. Dusenberry, Maya. An open letter accuses Netflix's Afflicted of abandoning ethnics and science. PS Mag. 20 Sep 2018. "[The Netflix series Afflicted promised compassion for sufferers of poorly understood chronic illnesses. Instead, it peddled the tired narrative that their suffering is "all in their heads...I joined a group of physicians, scientists, filmmakers, and writers—including Lena Dunham, Monica Lewinsky, and Mario Carpecchi, a Nobel Laureate in genetics—in signing an open letter to Netflix detailing many ethical missteps, scientific errors, and omissions evident in the series. Allowing Afflicted to remain on the widely watched platform, the letter states, 'will reinforce barriers to appropriate medical care...and add to the stigma and social isolation of an already profoundly marginalized group of people.'"
  171. Talk page of Wikipedia's multiple chemical sensitivity page. https://en.wikipedia.org/wiki/Talk%3AMultiple_chemical_sensitivity Accessed 12 Feb 2020.
  172. Gale, Richard., Null, Gary. Can we trust Wikipedia and its medical skepticism? Originally published on the Progressive Radio Network, August 2, 2018. Skeptics about Skeptics blog. Accessed 12 Feb 2020.
  173. Wikipedia captured by skeptics Skeptics about skeptics blog. Accessed 12 Feb 2020. "Wikipedia currently is the area in which dogmatic skeptics are most successful and influential. One of these activist groups is called Guerrilla Skepticism on Wikipedia, founded by Susan Gerbic. Another leader of the online skeptical movement is Tim Farley, who runs the website Skeptical Software Tools...The Wikipedia skeptics work in teams (contrary to Wikipedia rules) and most are well trained."
  174. Rampant Harassment on Wikipedia from the series Wikipedia captured by skeptics. Skeptics about Skeptics blog. http://www.skepticalaboutskeptics.org/wikipedia-captured-by-skeptics/rampant-harassment-on-wikipedia/ Accessed 12 Feb 2020.
  175. Bundrant, Mike. Top 6 Things Wikipedia Health Editors Have Told Me Since Announcing the Book that Challenges Wiki Bias.  WikiWarn blog. April 15, 2015. Accessed 12 Feb 2020.
  176. The rise and fall of Wikipedia. Orthomolecular News Service. Greenmedinfo blog. 30 Sep 2020. Accessed 12 Feb 2020.
  177. Gale, Richard., Null, Gary. Can we trust Wikipedia and its medical skepticism? Originally published on the Progressive Radio Network, August 2, 2018. Skeptics about Skeptics blog. Accessed 12 Feb 2020. "This article will challenge a relatively recent group of Skeptics that identify themselves as the advocates of Science-Based Medicine (SBM), which is not to be confused with the widely accepted approach to decision-making in medical practice known as Evidence-Based Medicine (EBM). "
  178. Barrett, Stephen. "Multiple Chemical Sensitivity: A Spurious Diagnosis". "Quackwatch blog, 2016 https://www.quackwatch.org/01QuackeryRelatedTopics/mcs.html Is MCS psychosomatic?" "Is MCS psychological?" This article was adapted from A Close Look at Multiple Chemical Sensitivity, a booklet that can be ordered from Quackwatch, and the book Chemical Sensitivity: The Truth about Environmental Illness, by Stephen Barrett and Ronald E. Gots. "Critics charge that these approaches are bogus and that MCS is not a valid diagnosis."
  179. Barrett, Stephen. Questionable Organizations: An Overview. Quackwatch blog. October 20, 2019. Accessed 14 Feb 2020. "The American Academy of Environmental Medicine, which promotes "clinical ecology" and the bogus concept of multiple chemical sensitivity."
  180. Barrett, Stephen. Regulatory Actions against AAEM Members. Quackwatch blog. 23 Nov 2016. Accessed 14 Feb 2020. "The American Academy of Environmental Medicine (AAEM), which was founded by Theron Randolph in 1965 as the Society for Clinical Ecology...most AAEM members espouse dubious concepts of multiple chemical sensitivity, toxic mold..."
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  183. Barrett, Stephen. MCS Proclamations Quackwatch blog. Accessed 14 Feb 2020.
  184. Barrett, Stephen; Ronald E. Gots. "Gulf War Syndrome" Quackwatch blog. Accessed 14 Feb 2020. "Some sufferers claim to have multiple chemical sensitivity (MCS)."
  185. Barrett, Stephen. Be Wary of "Fad" Diagnoses Quackwatch blog. 6 Oct 2018. Accessed 14 Feb 2020.
  186. Barrett, Stephen. Index to "Fad" Diagnoses. What Is a "Fad" Diagnosis? Quackwatch blog. 28 Mar 2019. Accessed 14 Feb 2020.
  187. Barrett, Stephen. A Close Look at "Multiple Chemical Sensitivity". Allentown, Pa: Quackwatch Inc. 1998.
  188. Barrett, Stephen. "An Analysis of the National Environmental Justice Advisory Council Enforcement Subcommittee's Resolution #21 on Multiple Chemical Sensitivity". October 16, 2000
  189. Paul R. Lees-Haley. Propaganda techniques related to enviromental scares. Quackwatch blog. This article was adapted from Lee-Haley PR. Manipulation of perception in mass tort litigation. 1997. Accessed 14 Feb 2020. "People tend to assume that sensational terms represent reality. Multiple chemical sensitiviyt and Gulf War syndrome are prime examples." 
  190. Gavura, Scott. Multiple Chemical Sensitivity: Separating facts from fiction. 'Does multiple chemical sensitivity exist? The symptoms certainly do, but it’s less clear if they are due to “chemicals.”' Blog: Science-based medicine: Exploring issues and controversies in science and medicine. July 3, 2014. Accessed 14 Feb 2020. <article id="post-32214" class="post full-post post-32214 type-post status-publish format-standard has-post-thumbnail hentry category-science-and-medicine tag-clinical-ecology tag-environmental-illness tag-fake-diseases tag-idiopathic-environmental-intolerance tag-iei tag-mcs tag-multiple-chemical-sensitivity tag-sensitivity-related-illness tag-sri">
  191. Lees-Haley, Paul R. Mold Neurotoxicity: Validity, Reliability and Baloney Quackwatch blog. 23 Dec 2002. 14 February 2020. "the bogus "multiple chemical sensitivity" diagnosis."
  192. "Multiple chemical sensitivty suffering is real, diagnosis isn't--Quackbusters" Probe Newsletter, Issue #07-03, January 1, 1999.
  193. Hall, Harriet. Environmental Medicine – Not Your Average Specialty Blog: Science-based medicine: Exploring issues and controversies in science and medicine. Accessed 14 Feb 2020. "Rea is best known for his promotion of the concept of multipel chemcial sensitivity (MCS), a diagnosis not recognized by the scientific community."
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ME/CFS - An acronym that combines myalgic encephalomyelitis with chronic fatigue syndrome. Sometimes they are combined because people have trouble distinguishing one from the other. Sometimes they are combined because people see them as synonyms of each other.

myalgic encephalomyelitis (ME) - A disease often marked by neurological symptoms, but fatigue is sometimes a symptom as well. Some diagnostic criteria distinguish it from chronic fatigue syndrome, while other diagnostic criteria consider it to be a synonym for chronic fatigue syndrome. A defining characteristic of ME is post-exertional malaise (PEM), or post-exertional neuroimmune exhaustion (PENE), which is a notable exacerbation of symptoms brought on by small exertions. PEM can last for days or weeks. Symptoms can include cognitive impairments, muscle pain (myalgia), trouble remaining upright (orthostatic intolerance), sleep abnormalities, and gastro-intestinal impairments, among others. An estimated 25% of those suffering from ME are housebound or bedbound. The World Health Organization (WHO) classifies ME as a neurological disease.

myalgic encephalomyelitis (ME) - A disease often marked by neurological symptoms, but fatigue is sometimes a symptom as well. Some diagnostic criteria distinguish it from chronic fatigue syndrome, while other diagnostic criteria consider it to be a synonym for chronic fatigue syndrome. A defining characteristic of ME is post-exertional malaise (PEM), or post-exertional neuroimmune exhaustion (PENE), which is a notable exacerbation of symptoms brought on by small exertions. PEM can last for days or weeks. Symptoms can include cognitive impairments, muscle pain (myalgia), trouble remaining upright (orthostatic intolerance), sleep abnormalities, and gastro-intestinal impairments, among others. An estimated 25% of those suffering from ME are housebound or bedbound. The World Health Organization (WHO) classifies ME as a neurological disease.

tachycardia - An unusually rapid heart beat. Can be caused by exercise or illness. A symptom of postural orthostatic tachycardia syndrome (POTS). (Learn more: www.heart.org)

adverse reaction - Any unintended or unwanted response to the treatment under investigation in a clinical trial.

central nervous system (CNS) - One of the two parts of the human nervous system, the other part being the peripheral nervous system. The central nervous system consists of the brain and spinal cord, while the peripheral nervous system consists of nerves that travel from the central nervous system into the various organs and tissues of the body.

antibody - Antibodies or immunoglobulin refers to any of a large number of specific proteins produced by B cells that act against an antigen in an immune response.

somatic symptom disorder - A psychiatric term to describe an alleged condition whereby a person's thoughts somehow cause physical symptoms. The actual existence of such a condition is highly controversial, due to a lack of scientific evidence. It is related to other psychiatric terms, such as "psychosomatic", "neurasthenia", and "hysteria". Older terms include "somatization", "somatoform disorder", and "conversion disorder". Such terms refer to a scientifically-unsupported theory that claims that a wide range of physical symptoms can be created by the human mind, a theory which has been criticized as "mind over matter" parapsychology, a pseudoscience. Although "Somatic Symptom Disorder" is the term used by DSM-5, the term "Bodily Distress Disorder" has been proposed for ICD-11. (Learn more: www.psychologytoday.com)

Diagnostic and Statistical Manual of Mental Disorders (DSM) - A psychiatric reference book published by the American Psychiatric Association, often referred to as "the psychiatrist's Bible". Although the most recent version (DSM-5) purports to be the authoritative guide to the diagnosis of mental disorders, the editors of both previous versions of the manual have heavily criticized the current version due to the climate of secrecy that shrouded the development of the latest version. 69% of the people who worked on DSM-5 reported having ties to the pharmaceutical industry. Dr. Allen Frances, who headed the development of the previous version, warned of dangerous unintended consequences such as new false 'epidemics'. The British Psychological Society criticized DSM-5 diagnoses as "clearly based largely on social norms, with 'symptoms' that all rely on subjective judgements" and expressed a major concern that "clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences". A petition signed by over 13,000 mental health professionals stated that the lowered diagnostic thresholds in DSM-5, combined with entirely subjective criteria based on western social norms, would "lead to inappropriate medical treatment of vulnerable populations". The director of the US National Institute of Mental Health, Dr. Thomas R. Insel, pointed out that the diagnoses in DSM-5 had no scientific validity whatsoever. (Learn more: www.scientificamerican.com)

American Psychiatric Association (APA) - The main professional organization of psychiatrists and trainee psychiatrists in the United States, and the largest psychiatric organization in the world. Not to be confused with the American Psychological Association (also APA).

Diagnostic and Statistical Manual of Mental Disorders (DSM) - A psychiatric reference book published by the American Psychiatric Association, often referred to as "the psychiatrist's Bible". Although the most recent version (DSM-5) purports to be the authoritative guide to the diagnosis of mental disorders, the editors of both previous versions of the manual have heavily criticized the current version due to the climate of secrecy that shrouded the development of the latest version. 69% of the people who worked on DSM-5 reported having ties to the pharmaceutical industry. Dr. Allen Frances, who headed the development of the previous version, warned of dangerous unintended consequences such as new false 'epidemics'. The British Psychological Society criticized DSM-5 diagnoses as "clearly based largely on social norms, with 'symptoms' that all rely on subjective judgements" and expressed a major concern that "clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences". A petition signed by over 13,000 mental health professionals stated that the lowered diagnostic thresholds in DSM-5, combined with entirely subjective criteria based on western social norms, would "lead to inappropriate medical treatment of vulnerable populations". The director of the US National Institute of Mental Health, Dr. Thomas R. Insel, pointed out that the diagnoses in DSM-5 had no scientific validity whatsoever. (Learn more: www.scientificamerican.com)

somatic symptom disorder - A psychiatric term to describe an alleged condition whereby a person's thoughts somehow cause physical symptoms. The actual existence of such a condition is highly controversial, due to a lack of scientific evidence. It is related to other psychiatric terms, such as "psychosomatic", "neurasthenia", and "hysteria". Older terms include "somatization", "somatoform disorder", and "conversion disorder". Such terms refer to a scientifically-unsupported theory that claims that a wide range of physical symptoms can be created by the human mind, a theory which has been criticized as "mind over matter" parapsychology, a pseudoscience. Although "Somatic Symptom Disorder" is the term used by DSM-5, the term "Bodily Distress Disorder" has been proposed for ICD-11. (Learn more: www.psychologytoday.com)

International Classification of Diseases (ICD) - A system of medical diagnostic codes, created by the World Health Organization (WHO), to classify diseases and other health related conditions for the purpose of international diagnostic consistency. By having common diagnostic codes around the world, health researchers are better able to quantify and track disease burdens. The most current version is called ICD-11. (Learn more: www.who.int)

World Health Organization (WHO) - "A specialized agency of the United Nations that is concerned with public health. It was established on 7 April 1948, and is headquartered in Geneva, Switzerland. The WHO is a member of the United Nations Development Group. Its predecessor, the Health Organization, was an agency of the League of Nations." The International Statistical Classification of Diseases and Related Health Problems (ICD) is maintained by WHO. (Learn more: en.wikipedia.org)

International Classification of Diseases (ICD) - A system of medical diagnostic codes, created by the World Health Organization (WHO), to classify diseases and other health related conditions for the purpose of international diagnostic consistency. By having common diagnostic codes around the world, health researchers are better able to quantify and track disease burdens. The most current version is called ICD-11. (Learn more: www.who.int)

World Health Organization (WHO) - "A specialized agency of the United Nations that is concerned with public health. It was established on 7 April 1948, and is headquartered in Geneva, Switzerland. The WHO is a member of the United Nations Development Group. Its predecessor, the Health Organization, was an agency of the League of Nations." The International Statistical Classification of Diseases and Related Health Problems (ICD) is maintained by WHO. (Learn more: en.wikipedia.org)

Centers for Disease Control and Prevention (CDC) - The Centers for Disease Control and Prevention is a U.S. government agency dedicated to epidemiology and public health. It operates under the auspices of the Department of Health and Human Services.

Centers for Disease Control and Prevention (CDC) - The Centers for Disease Control and Prevention is a U.S. government agency dedicated to epidemiology and public health. It operates under the auspices of the Department of Health and Human Services.

bias - Bias in research is "a systematic deviation of an observation from the true clinical state".

chronic fatigue syndrome (CFS) - A controversial term, invented by the U.S. Centers for Disease Control, that generally refers to a collection of symptoms as “fatigue”. There have been multiple attempts to come up with a set of diagnostic criteria to define this term, but few of those diagnostic criteria are currently in use. Previous attempts to define this term include the Fukuda criteria and the Oxford criteria. Some view the term as a useful diagnostic category for people with long-term fatigue of unexplained origin. Others view the term as a derogatory term borne out of animus towards patients. Some view the term as a synonym of myalgic encephalomyelitis, while others view myalgic encephalomyelitis as a distinct disease.

chronic fatigue syndrome (CFS) - A controversial term, invented by the U.S. Centers for Disease Control, that generally refers to a collection of symptoms as “fatigue”. There have been multiple attempts to come up with a set of diagnostic criteria to define this term, but few of those diagnostic criteria are currently in use. Previous attempts to define this term include the Fukuda criteria and the Oxford criteria. Some view the term as a useful diagnostic category for people with long-term fatigue of unexplained origin. Others view the term as a derogatory term borne out of animus towards patients. Some view the term as a synonym of myalgic encephalomyelitis, while others view myalgic encephalomyelitis as a distinct disease.

antibody - Antibodies or immunoglobulin refers to any of a large number of specific proteins produced by B cells that act against an antigen in an immune response.

metabolite - A chemical compound produced by, or involved in, metabolism. The term is often used to refer to the degradation products of drugs in the body.

Diagnostic and Statistical Manual of Mental Disorders (DSM) - A psychiatric reference book published by the American Psychiatric Association, often referred to as "the psychiatrist's Bible". Although the most recent version (DSM-5) purports to be the authoritative guide to the diagnosis of mental disorders, the editors of both previous versions of the manual have heavily criticized the current version due to the climate of secrecy that shrouded the development of the latest version. 69% of the people who worked on DSM-5 reported having ties to the pharmaceutical industry. Dr. Allen Frances, who headed the development of the previous version, warned of dangerous unintended consequences such as new false 'epidemics'. The British Psychological Society criticized DSM-5 diagnoses as "clearly based largely on social norms, with 'symptoms' that all rely on subjective judgements" and expressed a major concern that "clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences". A petition signed by over 13,000 mental health professionals stated that the lowered diagnostic thresholds in DSM-5, combined with entirely subjective criteria based on western social norms, would "lead to inappropriate medical treatment of vulnerable populations". The director of the US National Institute of Mental Health, Dr. Thomas R. Insel, pointed out that the diagnoses in DSM-5 had no scientific validity whatsoever. (Learn more: www.scientificamerican.com)

Diagnostic and Statistical Manual of Mental Disorders (DSM) - A psychiatric reference book published by the American Psychiatric Association, often referred to as "the psychiatrist's Bible". Although the most recent version (DSM-5) purports to be the authoritative guide to the diagnosis of mental disorders, the editors of both previous versions of the manual have heavily criticized the current version due to the climate of secrecy that shrouded the development of the latest version. 69% of the people who worked on DSM-5 reported having ties to the pharmaceutical industry. Dr. Allen Frances, who headed the development of the previous version, warned of dangerous unintended consequences such as new false 'epidemics'. The British Psychological Society criticized DSM-5 diagnoses as "clearly based largely on social norms, with 'symptoms' that all rely on subjective judgements" and expressed a major concern that "clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences". A petition signed by over 13,000 mental health professionals stated that the lowered diagnostic thresholds in DSM-5, combined with entirely subjective criteria based on western social norms, would "lead to inappropriate medical treatment of vulnerable populations". The director of the US National Institute of Mental Health, Dr. Thomas R. Insel, pointed out that the diagnoses in DSM-5 had no scientific validity whatsoever. (Learn more: www.scientificamerican.com)

somatic symptom disorder - A psychiatric term to describe an alleged condition whereby a person's thoughts somehow cause physical symptoms. The actual existence of such a condition is highly controversial, due to a lack of scientific evidence. It is related to other psychiatric terms, such as "psychosomatic", "neurasthenia", and "hysteria". Older terms include "somatization", "somatoform disorder", and "conversion disorder". Such terms refer to a scientifically-unsupported theory that claims that a wide range of physical symptoms can be created by the human mind, a theory which has been criticized as "mind over matter" parapsychology, a pseudoscience. Although "Somatic Symptom Disorder" is the term used by DSM-5, the term "Bodily Distress Disorder" has been proposed for ICD-11. (Learn more: www.psychologytoday.com)

International Classification of Diseases (ICD) - A system of medical diagnostic codes, created by the World Health Organization (WHO), to classify diseases and other health related conditions for the purpose of international diagnostic consistency. By having common diagnostic codes around the world, health researchers are better able to quantify and track disease burdens. The most current version is called ICD-11. (Learn more: www.who.int)

The information provided at this site is not intended to diagnose or treat any illness.
From MEpedia, a crowd-sourced encyclopedia of ME and CFS science and history.