Ann Allergy 1993 Dec;71(6):538-46
Adult sequelae of childhood abuse presenting as
environmental illness.
Staudenmayer H, Selner ME, Selner JC.
Allergy Respiratory Institute of Colorado, Denver 80222.

Sixty-three patients with polysomatic complaints
attributed to sensitivity to environmental
chemicals had detailed clinical assessments and
diagnostic psychologic evaluations. Objective
medical parameters failed to substantiate their
beliefs that multiple chemicals were the cause of
their problems. A group of 64 patients with chronic
medical conditions and defined psychologic
disorders not attributed to chemical exposure
served as controls. Approximately half the patients
in each group underwent long-term psychotherapy,
and in these patients, the prevalence of
physical and sexual childhood abuse was significantly
higher (P < .05) among the cohort of
women who attributed their symptoms to environmental
or chemically related illness. These data
suggest that somatization may reflect sequelae of
childhood abuse and may play an important role
in the illness experienced by women who believe
they are sensitive to environmental chemicals.

Med Hypotheses. 2003 Oct;61(4):419-30.
Are syndromes in environmental medicine variants
of somatoform disorders?
Wiesmuller GA, Ebel H, Hornberg C, Kwan O, Friel J.
Institute of Hygiene and Environmental Medicine,
University Hospital Aachen, Aachen, Germany.

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

Psychol Med 2002 Nov;32(8):1387-94
Psychiatric and somatic disorders and multiple
chemical sensitivity (MCS) in 264 'environmental
patients'.
Bornschein S, Hausteiner C, Zilker T, Forstl H.
Psychiatric Clinic and Department of Toxicology,
I, Medical Clinic, Technical University of
Munich, Germany.

BACKGROUND: An increasing number of
individuals with diverse health complaints are
currently seeking help in the field of environmental
medicine. Multiple chemical sensitivity (MCS)
or idiopathic environmental intolerances (IEI)
is defined as an acquired disorder with multiple
recurrent symptoms associated with environmental
chemicals in low concentrations that are well
tolerated by the majority of people. Their symptoms
are not explained by any known psychiatric
or somatic disorder.

METHOD: Within a 2-year period we
examined 264 of 267 consecutive
patients prospectively presenting to a university
based out-patient department for environmental
medicine. Patients underwent routine medical
examination, toxicological analysis and the
structured clinical interview for DSM-IV
psychiatric disorders (SCID).

RESULTS: Seventy-five per cent of the patients
met DSM-IV criteria for at least one psychiatric
disorder and 35% of all patients suffered from
somatoform disorders. Other frequent diagnoses
were affective and anxiety disorders, and
dependence or substance abuse. In 39%
a psychiatric disorder, in 23% a somatic
condition and in 19% a combination of the two
were considered to provide sufficient
explanation of the symptoms. Toxic chemicals
were regarded as the most probable cause in only
five cases. The suspected diagnosis of MCS/IEI
could not be sustained in the vast majority of cases.

CONCLUSION: This investigation confirms
previous findings that psychiatric morbidity is
high in patients presenting to specialized centres
for environmental medicine. Somatoform
disorders are the leading diagnostic category,
and there is reason to believe that certain
'environmental' or MCS patients form a special
subgroup of somatoform disorders. In most
cases, symptoms can be explained by well-defined
psychiatric and medical conditions other than
MCS, which need specific treatment. Further
studies should focus on provocation testing in order
to find positive criteria for MCS and on therapeutic
approaches that consider psychiatric aspects.

Psychol Med 1999 Mar;29(2):399-406
The association of sexual and physical abuse with somatization:
characteristics of patients presenting with irritable bowel syndrome
and non-epileptic attack disorder.
Reilly J, Baker GA, Rhodes J, Salmon P.
Department of Clinical Psychology, University of Liverpool.

BACKGROUND: Physical symptoms are
commonly presented for treatment in the absence of
physical pathology. This study tests predictions
arising from the theory that childhood sexual
abuse leads to emotional distress, illness orientation
and social dysfunction as adults and that one
or more of these effects, in turn, leads to presentation
of functional (i.e. unexplained) symptoms.

METHODS: Two groups of patients with physical
symptoms in the absence of organic disease
(non-epileptic attack disorder or irritable bowel
syndrome) were contrasted with organically
diseased groups with comparable symptoms
(epilepsy and Crohn's disease, respectively).

RESULTS: Despite their contrasting clinical presentation,
irritable bowel and non-epileptic attack
groups were similar in recalling more sexual and
physical abuse, as both children and adults, than
their comparison groups. They were also similar
in being more emotionally and socially disturbed
and illness-orientated, but these putative mediating
variables could not account for the relationship
of abuse with presentation of functional symptoms.

CONCLUSIONS: Adults presenting
functional neurological and abdominal symptoms
are characterized by history of abuse. The
current focus on childhood sexual abuse should
be broadened to include sexual, and particularly
physical, abuse in adulthood as well as childhood.
The intervening processes that link abuse to
somatization remain to be identified but are
unlikely to include adult emotional and social
disturbance or general illness-orientation.

In this study, the severity of the abuse correlated with
the severity of the psychosomatic symptoms.

Arch Fam Med 1999 Jan-Feb;8(1):35-43
Health-related quality of life and symptom profiles of female
survivors of sexual abuse.
Dickinson LM, deGruy FV 3rd, Dickinson WP, Candib LM.
Department of Family Practice and Community Medicine,
College of Medicine, University of South Alabama, Mobile, USA.

OBJECTIVES: To determine the association
between severity of sexual abuse and psychiatric or
medical problems in a sample of female patients
from primary care medical settings and to assess
the relationship between sexual abuse severity
and health-related quality of life before and after
controlling for the effects of a current psychiatric
or medical diagnosis.

DESIGN: Structured interview and self-report
questionnaire.

SETTING: Three family practice outpatient clinics.

SUBJECTS: A total of 252 women selected
by somatization status using a screen for
unexplained physical symptoms.

MAIN OUTCOME MEASURES: Patient assessment
after administering the Medical Outcomes Study
36-item Short-Form Health Survey and self-report
medical problems questionnaire; the quality-of-life
scale developed by Andrews and Withey;
Diagnostic and Statistical Manual of Mental
Disorders, Third Edition, Revised, diagnoses and
symptom counts from the Diagnostic Interview
Schedule; the Dissociative Experiences Scale; and
the modified Dissociative Disorders Interview
Schedule.

RESULTS: A history of sexual abuse is
associated with substantial impairment in
health-related quality of life and a greater number of
somatized symptoms (P < .001), medical problems
(P < .01), and psychiatric symptoms and
diagnoses (P < .001). In regression analyses,
sexual abuse severity was a significant predictor of
high scores on 6 of the 8 subscales of the Medical
Outcomes Study Short-Form Health Survey
(P < .05) and all of the quality-of-life subscales
developed by Andrews and Withey (P < .01),
with average decrements of up to 0.41 SDs for
moderately abused women and 0.56 SDs for
severely abused women. Furthermore, sexual abuse
severity remained a significant predictor of
high scores on the subscales mental health (P < .05),
social functioning (P < .05), and quality of
life (P < .05), even after adjusting for the presence
of several common psychiatric diagnoses.

CONCLUSIONS: Female primary care patients
with a history of sexual abuse have more
physical and psychiatric symptoms and lower
health-related quality of life than those without
previous abuse. In addition, a linear relationship
exists between the severity of sexual abuse and
impairment in health-related quality of life, both
before and after controlling for the effects of a
current psychiatric diagnosis.