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‘Allergic to everything’: A medical subculture
CARROLL M. BRODSKY, M.D., Ph.D.
'Allergic to everything': A medical subculture ABSTRACT: With the emerging medical subculture called
"clinical ecology," patients are diagnosed as "allergic" or "environmentally ill" and treated with special techniques and avoidance of whole environments. In reviewing a group of eight persons who had filed worker's compensation claims for injury ostensibly caused by allergic response to substances in the workplace yet who showed no physical evidence of injury, the author found withdrawal from work, a life-style engineered to avoid exposure to putative noxious substances, and an identity as a disabled person. Some changes in medicine are more revolutionary than others, precipitating a change in pattern, while others remain well within the established mold, but rise in stature, becoming more prevalent as diagnoses and more immediate in the inventory of explanations of disease. Many of these changes are merely fads or fashions in medicine; some, such as the concept of stress, gain acceptance and recognition by organized medicine. One such movement on the fringe of established medicine is
clinical ecology, sometimes also referred to as human ecology or bioecologic medicine. Its practitioners describe themselves as "ecologically-oriented" allergists "primarily concerned with the environmental causes of illnesses.'" Patients are said to be "environmentally ill" or "hypersensitive" or "allergic" to unusual or common substances in the environment. The group of patients described in this article had been given this diagnosis by physician adherents of clinical ecology. The patients are
Dr. Brodsky is professor ofpsychiatry at the University ofCalifornia, San Francisco, School of Medicine. Reprint requests 10 him at Langley Porter Neuropsychiatric Institute, 401 Parnassus St., San Francisco, CA 94143. AUGUST 1983 ' VOL 24 • NO 8
unusual, however, in that they were diagnosed as allergic to chemicals or substances in their work environment and have filed for worker's compensation benefits, claiming that the exposure made them hypersensitive to common or unusual substances not only in the work setting but also in most other situations. They are also -exceptional in that (l) their claim of injury by toxic elements in the work environment rarely began with a specific event of exposure, (2) no physical evidence of injury was found by traditional medical examination, (3) most have a history of overt psychiatric symptoms, (4) all but one are women, (5) all too frequently they are seen by the same network of physicians who subscribe to clinical ecology, and (6) their self-perception and diagnosis of "allergic" to most substances have becoRl( an organizing principle in their lives, central to their identity and life-style. Because these cases have been rarely described except from the vantage point of the clinical ecologists,1.2 we will present a model case 731
'Allergic to everything'
and describe the elements that recur in our patient sample. We will then examine the medical subculture entered by these people and which has shaped their illness careers, some of the ways this disease explanation serves the psychological needs of a problem patient population, and conditions contributing to confluence of this subculture and this patient population. Patient sample The eight persons examined by the author had .filed claims for injury from primarily airborne substances, following diagnosis by clinical ecologists as "environmentally ill" or "chemically hypersensitive." However, established medical examiners detected no physical evidence of injury. These eight were part of a larger group of 70 people claiming injury or disability from intoxication in the workplace that was not supported by clear physical evidence. All these cases were selected from over 2,000 seen by the author in a psychiatric examination of extent of disability for worker's compensation. The psychiatric examination lasted from two to three hours. When indicated, the patient was referred for psychological testing. Because these cases were in litigation, the patients were examined by a variety of specialists representing both parties. Medical records of health-care contacts prior to the alleged exposure were obtained and reviewed. Reports from relatives or concerned parties were evaluated, as were rehabilitation reports. Some of these records were gathered under the power of subpoena issued by lawyers representing employers or the patients, thus providing the author access to information not usually available in
such research. Seven of the eight in the sample are women. Practitioners of clinical ecology have found that among patients experiencing similar symptoms women outnumbered men by 2\12 to 1. 3 All had completed high school, and all but one had further formal education. Three had received the baccalaureate and two others the master's degree. Six of the eight are between the ages of 30 and 39, two in their early fifties. Four are married, and two of the four single persons have been di-
She was relieved to discover tlult her symptoms were a reaction to substances in the air and part ofher 'clinical sensitivity. ' vorced. Four have children. Four patients worked at professional levels: a statistician, a program analyst, a staff researcher, and a chemical engineer. The other three were a flight attendant, a printingpress operator, and a psychiatric technician. A representative patient A 50-year-old retired woman on disability arrived for our interview carrying a large container of oxygen and a bag for her oxygen mask and tube. She warned me that she was fragile and that if I had any hard questions to ask, I had better ask them early, because as she breathes the fumes of hydrocarbons in the room her symptoms become progressively worse. She pointed out that the abundance of printed material, such as books and journals, in my office added to the concentration of hydrocarbons. Despite her warning, she showed
no sign of distress during the interview nor did she resort to the oxygen. She had formerly worked as a statistician in a state bureau for two years, holding other jobs for the state for II years previously. She said that her first symptoms occurred about seven years earlier when she noticed that she was unable to remember what she read. At that time a physician told her that she· was "sensitive to chemical fumes." It was "like a detective story," she recounted. At first they thought she might be reacting to foods; elimination diets were prescribed, but did not help. Two years later she was sent to a specialist in Chicago who provided a "chemical-free" environment in a hospital for two weeks. For the first five days she fasted, ingesting nothing but water. After the study, she was told that she was reacting to a group of common chemicals and that she might not be able to continue working at her job. Initially she continued to work, wearing a mask with a filter. While that helped, she found that "it scared people." Given this situation, she took an examination to qualify her for a job involving work outdoors. Failing to qualify, she had to remain working indoors at her desk as a statistician. Her symptoms became more pronounced until she was "passing out four or five times a day." She would have enough warning to get to the restroom and lie down; after that she was sometimes unconscious for an hour. She complained of stupor and lethargy. Because of these symptoms, she had stopped working three years before I examined her. She retired and became "an outdoor person." In fact, she had to stay outdoors almost all of the time to avoid the (continued)
732
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dation. Terminate dosage gradually SinCe abrupt withdrawal any antianxiety agent may result in symptoms like those being treated: anxiety. agitation. irrilabitity. tension. insomnia and occasional convulsions. Observe usual precautions _ impaired renaJ or hepatic function. Where gastroin~nal or cardiovascular disorders coexiS! _ anxiety. note lhaJ Iorazepam has not been shown slgni'icant benet" in treating gastrointestinal or cardiovascular component. EsophageaJ dilation occurred in rats treated wijh Iorazepam 'or more than 1 year at 6mg/kg/day. No elIec1 dose was 1.25mg/kg/day (aboul 6 times maximum human therapeutic dose IOmg/day). Ellect was rewrsible only wilen treatment was withdrawn _in 2 months of first obeeMIlion. CMnlcal signillcance Is unknown; but use of Iorazepam tor prolonged periods and in geriatrics requires caution and frequent monitoring for symptoms of upper G.I. disease. Safety and ~ in children under 12 years have not been--.ed.
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ESSENTIAl LAllORATORY TESTS: Some patients have daveIoped leukopenia; some have had elevations of LDH. As _ other benzodiazepines. periodic blood counlS and liver function _ are recommended during long-term therapy. CLINICALLY SIGNIFICANT DRUG INTERACTIONS: Benzodiazepines produce CNS depressant ellects wilen adminiS!ered _ SUCh medications as barbiturates or aJcohoI. CARCINOGENESIS AND MUTAGENESIS: No evidence 0' carcinogenic potenti81 emerged in ralS during an IlHnonth study. No studies regarding mutagenesis have been performed. PREGNANCY: Reproductive studies were performed in mice. ralS. and 2 strains of rabbits. tarsals. tibia. metatarsals. malrota1ed limbs. gastroschisis. Occasional anomaJles (reduction malformed skull and microphlhaJmia) were seen in drug-treated rabbits wilhoul reI81ionship to dosage. Although all these anomalies were not preeenl in the concurrent control group. they have been reported to occur randomly in historic:aJ controls. At 40mg/kg and higher. there was evidence of telal resorption and increased telalloss in rabbits whic:h was not seen at lower doses. Clinical slgnnicance 01 these findings is not known. However. increased risk 01 congenital mallor· mations associated with use of minor tranquilizers (chlordiazepo)(ide, diazepam and meprobamate) during lirst trim8S1er pregnancy has been sugges1ed in several studies. Because use of these drugs Is rarely ~ maner of urgency. use of Iorazepam during this period should almost always be avoided. Possibilijy !hal a woman 0' chikl-bearing polenti8I may be pregnant at inSlijution therapy shoold be conSidered Advise palien1S they become pregnant to communicate _ their physician about _ l i l y discontinuing the drug. In humans. blood _ from umbilical cord blood indicate placenlaJ transfer Iorazepam and its glucuronide.
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overdosage _ any drug. bear in mind multiple agents may have been taken. Mani'estations overdosage include somnolence. con'usion and coma. Induce vomiting and/or undertake gastric lavage 'ollowed by general supportive care. moni1oring vijal signs and close obserVation. Hypotension. though unMkeIy. usually may be controlled _ Levarterenol Bitartrate lnjec1ion U.S.P Usefulness dialysis has not been _mined.
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symptoms. To accommodate her needs, her husband retired and moved with his wife to the mountains. In the winter they travel to a warmer climate where they can continue to live with complete exposure to the fresh air. In this environment, she leads a full and active life, such as playing tennis and running. She comes indoors only to cook and sleep, and even then leaves the windows wide open. She drives without difficulty, making sure to keep all windows open. Because she carries the container of oxygen and the oxygen mask wherever she goes, she and her husband avoid socializing. Nevertheless, she says her life is "like a vacation." She maintains that this regimen works and that it has greatly reduced her symptoms. When she does not follow the regimen, ie, when she spends too much time in enclosed areas, she experiences memory loss, hearing and visual difficulties because "things do not come through clearly," and weakness, such that she cannot stand or sit up without support. The patient was raised as a Christian Scientist. She completed college and earned an additional degree in the arts. Her health history showed that while in college she had been hospitalized for two months with hepatitis. She had suffered from emotional problems all her life. As a child she was described as "languid" and experienced recurring periods of depression. These depressions continued throughout her college years. Because of them she consulted a psychotherapist and participated in therapy for four to five years. When the depression did not diminish, she began taking a prescribed amphetamine-sedative combination, which she still uses. 734
PSYCHOSOMATICS
She continued to visit physicians qntil she found one who diagnosed her problems as environmentallyCaused, stating that she was allergic to many substances in the work environment. She was relieved to discover that her symptoms were a reaction to substances in the air and part of her "clinical sensitivity." ~ysis
In addition to the recurring depressions all her life, this patient was mildly claustrophobic. For many years, she had sought relief for her
The treatment plan for these patknts is characterizedfirst bJ' a set ofmultiple avoidances of whole mJ1ironments, not just specific substances. symptoms in the psychiatric channel; however, she was never convinced that their origin was emoti9l1al and she never did find such relief. In the back of her mind, she ~lieved there must be some physical cause and cure for them. She continued looking until she found a physician who told her that her problems were the result of allergy. While living in the mountains and the open air, she seems to function well. She has fully adopted the somatic explanation and treatment of her problems. She now believes she has control over her symptoms. Patterns common to the patients With this representative patient we see a number of elements that are found in many of the eight cases. Onset ofsymptoms. In the majority of these cases, the symptoms
commenced gradually and tended to intensify over time. It was not the environment that changed but the person's reaction to it. It was sometimes impossible to determine exactly when and why these subjects became concerned about symptoms and their physical environment. They described their symptoms in vague terms: "I just kept getting sicker and sicker"; "I wasn't feeling up to par"; or "I was feeling very tired." In most cases, the symptoms intensified until they reached a crisis, such as loss of consciousness. These symptoms included fatigue, gastrointestinal dysfunction, fainting, difficulty thinking, lightheaded ness, memory deficits, rashes, and recurring migraine headaches. Several patients reported recent depression. Most indicated that once they left the work environment that had initially triggered the problem, their symptoms recurred only with exposure to a host of generically related substances. Illness history. Similarly to the model case, the patients in the sample had a long history of recurring physical complaints unsupported by objective physical findings. Three women had a history of migraine headaches; five had experienced at least one serious bout ofdepression; and five patients had been treated by a psychiatrist. Most were acutely aware of their bodily functions and believed that their symptoms were physical rather than mental, despite contrary opinions from psychiatrists or other physicians. Search for a healer. The patients went from one physician to another either because they were told that nothing was wrong with them, while they were convinced there
was, or because they had been diagnosed as suffering from mental rather than physical illness, a conclusion contrary to their own convictions. Once they found physicians who suspected hypersensitivity or allergy, most underwent a battery of confirming tests. Four were referred to specialists in Dallas and Chicago, where they remained in a controlled environment while their conditions were carefully studied. Once diagnosed allergic, they described an "Aha!" experience. As one woman put it: All of a sudden. a lot of enlightenment took place. In my case. I began to realize all the potential sources of my symptoms and to see a direct correlation between them and the substances causing them. Another patient recounted: My husband could hardly believe that in one hour a diagnosis was reached, after one year of tests had suggested it was all in my head. After a visit to the library, we both knew the diagnosis was absolutely correct.
Treatment through avoidance. The treatment plan for these patients is characterized first by a set of multiple avoidances of whole environments, not just specific substances. In contrast to persons diagnosed allergic to specific irritants and prescribed avoidance of one or two items, these patients were diagnosed allergic to a wide array of commonly encountered substances (such as soap, smoke, perfume. hydrocarbons) and prescribed avoidance of entire environments that include these substances. Such avoidance inevitably led to major changes in their lives, most frequently a move to a "clean" climate, such as the moun(continued)
AUGUST 1983 • VOL 24 • NO 8
735
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BRIEF SUMMARY OF PRESCRIBING INFORMATION
INDlCATIONS.Parkinson·s Disease/Syndrome and Drug·lnduced Extrapyramidal Reac· tions SYMMETREL.s ind,cated In the treatment of,d,opathic Parklnson's disease (Paral· YSls Agitans). poslencephalltic park.nson,sm. drug·induced extrapyramidal reactions. and
tains or the desert or near the ocean. Their choice of "clean" environments over "polluted" ones was based on popular notions of cleanliness vs pollution; rural vs urban; ocean vs inland; outside vs inside; and high vs low altitude. In addition, some patients received injections of the indicted substances, administered either by others or by themselves. These could be quite costly; one woman noted that her antigens cost $60 per bottle and that she sometimes had to use as many as ten different
Clinical ecology stresses 'the environmental causes of mental and physical iUs, , particularly illnesses that have been previously labeled psychiatric. bottles. In many cases, the treatment also included diet manipulation. Like our representative patient, some persons also carried an oxygen tank and mask with them when they went out. In this way, they carried their environment with them, wherever they went, as well as symbolically communicating to others that they were afflicted. LifNty/e organized around the illness. Almost all the patients had completely stopped working and organized their own and often their spouses' lives around their condition. Much time was spent on diets, tests for sensitivity, reading about allergies, participating in a support group, and attending to the worker's compensation claims. While two persons remained relatively inactive, the others, even though they said that they could not work, freely admitted being (continued) 736
symptomat'c parkinsonism which may follow Injury to the nervous sySlem by carbon m0noxide intoxication. It IS indicated In those elderly pallents believed to develop parkinsonism In aSSOCiation With cerebral arteriosclerosis In the treatment of Parkinson·s disease. SYMMETREL IS less eHeclove than levodopa (. )·3-(3.4-dihydroxyphenyl)·L·alan,ne. and its efficacy In comparison With the anticholinerglC anti parkinson drugs has not yet been estab· IIshed Although anlochollnerg,c type side eHects have been noted w.th SYMMETREL when used In patients WIth drug"nduced extrapyramidal reactions there IS a lower incidence of these Side eHects Ihan that observed w'th anloCholinerg,c ant,park,nson drugs CONTRAINDICATIONS. SYMMETREL IS contraIndicated ,n paloents With known hypersenSitiVIty 10 the drug WARNINGS. Paloenls With a h,story of epilepsy or Olher "seIzures" should be Observed closely for pOSSible Increased seizure activity. PatienlS w.th a hlSlory of congesl,ve heart lallure or peripheral edema should be fOllowed closely as there are pallenls who developed congestive heart failure while receiving SYMMETREL Pallents With Park,nsons disease ,mprovlng on SYMMETREL ShOuld resume normal aChvllies gradually and cautiOUsly. conSlstenl With Olher medical conSlderahons. such as Ihe presence of osteoporosis or phlebOlhrombOSIS Pallenls rece,.,ng SYMMETREL who note central nervous system eHects 0< blurring ot VISion shOUld be cautioned against driVing or working in Sltuallons where alertness IS Important PRECAUTIONS. SYMMETREL (amantadine hydrochlOride) shOUld nol be dlsconllnued abruptly since a few pahents With Parkinson's disease expenenced a parkinsonian cnSIS, i.e a sudden marked Clinical deterioration when Ih.s medlcallon was suddenly Slopped. The dose ot anlocholinergic drugs or of SYMMETREL shOuld be reduced ,f atropine-like effects appear when these drugs are used concurrenlly. The dose ot SYMMETREL may need carelul adlustment ,n pallenls With renal ,mpalrment. congestive heart failure. peripheral edema. or orthostatic hypotenSion Since SYMMETREL IS not metaoohzed and IS mainly el(Creted In the unne. II may accumulate when renal funChon IS Inadequate. Care should be exerCised when administering SYMMETREL to pattenIs wlfh liver diSease. a history of recurrenl eczematold rash. or 10 patients With psychOSIS or severe psyChOneurOSIS not conlrolled by Chemotherapeul.c agents. Caretul Observation IS reqUired when SYMMETREL IS adm,n,slered concurrently w.th cenlral nervous system stimulants No long-term studies ,n animals have been perf()(med to evaluate the CarCinogeniC pOlenloal of SYMMETREL The mulagen,c potenl,at of the drug has not yet been determIned in expe1lmental SySlems Pregllllncy category C: SYMMETREL tamantadlne hydrochlOride) has been shown to be embryotoXiC and teratogenic ,n ralS at 50 mg/kg/day. about 12t.mes Ihe recommended human dose. but not al37 mg/kg/day EmbryotoXiC and teralogenlc drug eHecls werf' nol seen In rabbits which received up to 25ttmes Ihe recommended human dose. There are no adequale and well-conlrOlled studies In pregnant women SYMMETREL should be used dUring pregnancy only ,I the potenllal bene'" lustlhes the porenlial nsk to the embryo or the fetus Nursing Moth...: SYMMETREL IS excreted In human mIlk. Caut,on should be exerCIsed when SYMMETREL is administered to a nurSing woman Pedletrlc U. .: The safety and eH,cacy 01 SYMMETREL In newborn Inlants. and Infants below Ihe age of 1year have not been established ADVERSE REAcnoNS. The most frequently occurring seriOuS adverse reacllons are: depreSSion congeshve heartlallure, orthostatiC hypotensive episodes. psychOSIS. and U1lnary retenllon, Rarely convulSions. leukopenIa. and neutropenia have been reported Olher adverse reaClIons of a less serious nature whiCh have been observed are the 101lOWing' hallUCInatIons. confUSion. aO)uety and Irritability: anoreXia, nausea. and constlpa· lion: alaxla and diZZiness (hghtheadedness). lIvedo retlcularis and penpheral edema Adverse reaclion~ observed less frequently are the follOWing vomlllOg: dry moulh: headache. dyspnea: fatigue. ,nsomn,a. and a sense of weakness Inlrequenlly. skin rash. slurred speeCh and Visual dlSfurbances have been Observed. Rarely eczematOtd derma fills and OCulogYriC epISodes have been reponed DOSAGE AND ADMINISTRATION. Adu" DoNge for P8r1dn8onI8m: The usual dose 01 SYMMETREL (amantad,ne hydrochlOride) 's 100 mg tWice a day when used alone SYMMETREL haS an onset 01 act,on usually wlth,n 48 hours The 'niloal dose of SYMMETREL is 100 mg da,ly lor patients wllh serious assOCiated med,· calltlnesses or who are receiving high doses of olher antiparkinson drugs, After one to several weeks at 100 mg once da'ly. Ihe dose may be ,ncreased 10 100 mg tWice dally. II necessary OccaSionally. pal,ents whose responses are not optimal Wllh SYMMETREL al200 mg dally may benet,t Irom an Increase up 10 400 mg dally In diVided doses. However. suCh pahents should be superVised Closely by their phySICians PallenlS Inlltally denving benefit from SYMMETREL nol uncommonly expenence a 'all-off of eHectlveness after a few months Beneht may be regained by Increasing the dose 10 300 mg da,'Y. Alternahvely. temporary d,sconl,nuatlon 01 SYMMETREL for several weeks. followed by relnltlahon of the drug. may result In regaining benefit In some patients A decIsion to use Olher antlparkinson drugs may be necessary DoAge for Concomltllnt Therapy: Some pallenls who do nol respond 10 anhChOllner· g'c ant,p~rklnsondrugs may respond 10 SYMMETREL When SYMMETREL or anhChOllner· glc anllparklnson drugs are eaCh used With margInal benefit. concomitant use may produce additional benel,l When SYMMETREL and levodopa are .nlt,ated concurrenlly. the paloenl can exhlbot rapid therapeuhc benef,ts. SYMMETREL should be held constanl at 100 mg dally or tw,ce dally while the dally dose oflevodopa IS gradually Inc,edsed to opt,mal beneht When SYMMETREL 's added to opllmal well· tOlerated doses oflevodopa. additIonal benehl may resull. InCluding smoothing out the fluctuations in Improvement which sometimes occur In patients on levodopa alone. Pallents who reqUire a reduction in their usual dose ollevodopa oecause of development of Side effects may pOSSIbly regain lost benelit WIth the add,tlon of SYMMETREL DoNge for Drug-lndvced Extr8Pyr8mld81 "-tion8: Adult The usual dose 01 SYMMETREL (amantadine hydrochlo
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MELLA'RII:
(thioridazine) Hel, USP Before prescribing or administering. see Sandoz literature for full product information. The following is a briefsummary. Contralndlcatlons: Severe central netvous system depression. comatose states from any cause. hypertensive or hypotensive heart disease of extreme degree. Warnings: Administer cautiously to patients who have previously exhibited a hypersensitivity reaction (e.g.. blood dyscrasias. jaundice) to phenothiazines. Phenothiazines are capable of potentiating central nervous system depressants (e.g.. anesthetics. opiates. alcohol. etc.) as well as atropine and phosphorus insecticides; carefully consider benefit versus risk in less severe disorders. During pregnancy. administer only when the potential benefits exceed the possible risks to mother and fetus. Precautions: There have been infrequent reports of leukopenia and/or agranulocytosis and convulsive seizures. In epileptic patients. anticonvulsant medication should also be maintained. Pigmentary retinopathy. observed primarily in patients receiving larger than recommended doses. is characterized by diminution of visual acuity. brownish coloring of vision. and impairment of night vision; the possibility of its occurrence may be reduced by remaining within recommended dosage limits. Administer cautiously to patients participating in activities requiring complete mental alertness (e.g.. driving). and increase dosage gradually. Orthostatic hypotension is more common in females than in males. Do not use epinephrine in treating druginduced hypotension since phenothiazines may induce a reversed epinephrine effect on occasion. Neuroleptic drugs elevate prolactin levels: the elevation persists during chronic administration. TIssue culture experiments indicate that apprOXimately one-third of human breast cancers are prolactin dependent in vitro. a factor of potential importance if the prescription of these drugs is contemplated in a patient with a preViously detected breast cancer. Although disturbances such as galactorrhea. amenorrhea. gynecomastia. and impotence have been reported. the clinical significance of elevated serum prolactin levels is unknown for most patients. Daily doses in excess of 300 mg should be used only in severe neuropsychiatric conditions. Adverse Reactions: Central Neruous System -Drowsiness. especially with large doses. early in treatment; infrequently. pseudoparkinsonism and other extrapyramidal symptoms: rarely. nocturnal confusion. hyperactivity. lethargy. psychotic reactions. restlessness. and headache. Autonomic Nervous System -Dryness of mouth. blurred vision. constipation. nausea. vomiting. diarrhea. nasal stuffiness. and pallor. Endocrine System -Galactorrhea. breast engorgement. amenorrhea. inhibition of ejaculation. and peripheral edema. Skin-Dermatitis and skin eruptions of the urticarial type. photosensitivity. Cardiovascular System -ECG changes (see Cardiovascular Effects below). Other -Rare cases described as parotid swelling.
It should be noted that efficacy. indications and untoward effects have varied with the different phenothiazines. It has been reported that old age lowers the tolerance for phenothiazines; the most common neurologic side effects are parkinsonism and akathisia. and the risk of agranulocytosis and leukopenia increases. The following reactions have occurred with phenothiazines and should be considered whenever one of these drugs is used: Autonomic Reactions -Miosis. obstipation. anorexia. paralytic ileus. Cutaneous Reactions -Erythema. exfoliative dermatitis. contact dermatitis. Blood Dyscrasias -Agranulocytosis. leukopenia. eosinophilia. thrombocytopenia. anemia. aplastic anemia. pancytopenia. Allergic Reactions-Fever. laryngeal edema. angioneurotic edema. asthma. Hepatotoxicity -Jaundice. biliary stasis. Cardiovascular Effects -Changes in terminal portion of electrocardiogram including prolongation of Q-T interval. lowering and inversion of T-wave. and appearance of a wave tentatively identified as a bifid Tor a U wave have been observed with phenothiazines. including Mellaril (thioridazine); these appear to be reversible and due to altered repolarization. not myocardial damage. While there is no evidence of a causal relationship between these changes and significant disturbance of cardiac rhythm. several sudden and unexpected deaths apparently due to cardiac arrest have occurred in patients showing characteristic electrocardiographic changes while taking the drug. While proposed. periodic electrocardiograms are not regarded as predictive. Hypotension. rarely resulting in cardiac arrest. Extrapyramidal Symptoms -Akathisia. agitation. motor resdessness. dystonic reactions. trismus. torticollis. opisthotonus. oculogyric crises. tremor. muscular rigidity. and akinesia. Persistent Tardive Dyskinesia -Persistent and sometimes irreversible tardive dyskinesia. characterized by rhythmical involuntary movements of the tongue. face. mouth. or jaw (e.g.. protrusion of tongue. puffing of cheeks. puckering of mouth. chewing movements) and sometimes of extremities may occur on long-term therapy or after discontinuation of therapy. the risk being greater in elderly patients on high-dose therapy. especially females; if symptoms appear. discontinue all antipsychotic agents. Syndrome may be masked if treatment is reinstituted. dosage is increased. or antipsychotic agent is switched. Fine vermicular movements of tongue may be an early sign. and syndrome may not develop if medication i~ stopped at that time. Endocrine Disturbances-Menstrual irregularities. altered libido. gynecomastia. lactation. weight gain. edema. false positive pregnancy tests. Urinary Disturbances -Retention. incontinence. Others -Hyperpyrexia; behavioral effects suggestive of a paradOXical reaction. including excitement. bizarre dreams. aggravation of psychoses. and toxic confusional states; following long-term treatment. a peculiar skin-eye syndrome marked by progressive pigmentation of skin or conjunctiva and/or accompanied by discoloration of exposed sclera and cornea; stellate or irregular opacities of anterior lens and cornea; systemic lupus erythematosus-like syndrome. Dosage: Dosage must be individualized according to the degree of mental and emotional disturbance. and the smallest effective dosage should be determined for each patient. (MEL-Z36 5/9/83)
A
Pharmeceutlcal Division SANOOZ,"C. East Hanover, NJ 07936
'Allergic to everything'
very active physically in their daily lives. This may appear as malingering, yet it must be emphasized that they judge their activities differently than do the orthodox physicians who examine them. When presented with the notion that repairing one's house differs little from working at a job, for example, they maintain that there is a significant difference-they can rest whenever they choose in their own activities, they can work for as long or short a period as they like, and they can keep the windows open to ensure a clean environment. They believe that not only are rest and exercise vital to their well-being, but that it is vital to rest and exercise at the precise moment they feel the need. The patients' social life was also structured around their condition. In a few cases, the husbands joined the caretaking team and became the guardians of their wives' health-and their defenders if anyone suggested that the symptoms might be spurious or the result of mental rather than physical factors. On the other hand, relationships with others were often jeopardized by the patients' symptoms and avoidances and by their feelings of being different or stigmatized. As one woman put it, "It's very hard to socialize with people when you can't stand the perfume or soap they use." This sense of isolation and differentness from most others, coupled with an affinity with people who believe themselves similarly afflicted, has contributed to the growth of voluntary support groups, such as the Environmental Illness Association in California. All of these factors support the patients' perceptions of themselves as sick and afflicted, and, in turn, support their nonrecovery. 740
PSYCHOSOMATICS
The medical subculture At the center of this subculture is a particular medical ideologt consisting of shared ideas about the etiology and treatment of their illness. Clinical ecology2.3.~ stresses "the environmental causes of mental and physical ills,"2 particularly illnesses that have been previously labeled psychiatric. Its theme is stated in the dedication of An Alternative Approach to A//ergies,2 written by the pioneers of the movement: "This book is dedicated to all patients who have ever been called neurotic, hypochondriac, hysterical, or starved for attention, while actually suffering from environmentally-induced illness." The clinical ecologists describe themselves as presenting "an alternative to conventional medicine" and "an alternative approach to heaiing."2 They differentiate themselves from traditional allergists, who they claim are "principally interested in the bodily mechanisms .ofallergic reactions and in the drug treatment of symptoms."· Rather, as the name "clinical ecologist" denotes, they are "primarily concerned with the environmental causes ofillnesses. "I In etiology, the clinical ecologists differ in their location of the problem in the environment; in diagnosis, in their use of special diagnostic techniques, such as sublingual testing.' They have also designed controlled environmental hospital settings and regimens of fasting and chemical control to diagnose and treat the more difficult cases.1.2.6 The clinical ecologists' treatment approach tends to stress the avoidance of substances rather than the use of drugs. l .2 Because of this, their treatment program is claimed to be inexpensive. The clinical ecology movement is AUGUST \983 • VOL 24 • NO 8
supported through a number of organizations. 2.7 Their views have been published for medical professionals in books2.3.5.7.& and articles.9 For the layman, several recent publications present the clinical ecologic model of illness and health}.2,lo.11 In addition, the movement has recently been described in the popular media. Voluntary associations for people with "environmental illness" have been established in some cities. The previously mentioned Environmental Illness Association
Many probkm patient populations such as this one cannot find places for themselves in the traditional medical channels. is open to all people, whether they have "environmental illness" or not. Like the pioneers of the movement, the members of this subculture believe that many people have environmental illness but are unaware of it; the goal is to inform them and to educate the nonaffticted about the nature of the illness.
Discussion Many persons shop for physicians in the marketplace of American health care: Lawyers look for those who will provide an opinion advantageous to their clients. Patients seek physicians who will offer care, affection, and love. Other persons, who have been told that there is no definitive hope ofcure, go to distant places or disreputable clinics looking for the "healer" who promises to do what others have said could not be done. In some instances, the motives for the quest are conscious
and articulated, such as the terminal cancer patient who is willing to try any treatment that promises to contain or cure his disease; in others, the motives seem unconscious and can be understood only when the patient declares satisfaction with the end result. Many patients go to physicians seeking authoritative answers and comply with their directives. Others are dissatisfied until they find a physician whose opinions and practices crystallize their own inchoate theories. This process has been described by students of religious and political belief formation. 12 The present patients had rejected the more orthodox medical beliefs and practices and become adherents of physicians who believed that symptoms attributed by orthodox physicians to psychiatric causes are in fact due to common substances in air, food, and water. This medical subculture does not talk about cures; the health-care professionals neither promise nor . give hope of eliminating the offending condition, and the patients do not seem to expect it. Like people with diabetes or with longstanding inflammatory bowel disease, they accept the inevitable. In contrast, however, our patients seem content with their condition and with the reassurance that their symptoms have a physical cause. We have described the ways in which the patients benefit from membership in this medical subculture. How are they harmed by it? If we assume that the theories of those treating them are incorrect and that the restrictions are unnecessary and the treatment ineffective, we can conclude that money is being spent uselessly and that the patients' lives are diverted into channels that permit little growth 741
'Allergic to everything'
in their personal and occupational lives. Yet we must also recognize that these patients have had symptoms for many years, and whether seen as neurasthenic, hypochondriacal, or phobic, they are among the most resistant and difficult persons to treat. Based on our experience, we conclude that many problem patient populations such as this one cannot find places for themselves in the traditional medical channels. These patients search for healers who will provide them with an explanation of their experiences and symptoms that makes sense to them and that fulfills a number of psychological needs. Given the medical histories of such persons, it is evident that physical and psychological symptoms existed prior to the alleged exposure at work. Factors contributing to adherence to clinical ecology include: • A society with a heightened awareness of the potential dangers of inhaling and ingesting noxious substances in usual environments • A group of professionals who de-
velop a theory that utilizes concepts from allergy and immunology to explain symptom patterns formerly explained by psychological theories • Dissatisfaction with and nonacceptance of psychological explanations suggesting that the defect is in the patients rather than external to them • A worker's compensation system designed by law to favor the applicant and in the process to favor his or her explanation of the symptoms • A support system of lawyers and physicians who themselves may not espouse the allergic and immunologic explanation but who support the patient in the drive to convince others • A support group ofother patients who believe themselves similarly afflicted. At present, the views of the clinical ecologists are not shared by most academic and practicing immunologists,I3·14 and they themselves admit that they have been shunned by "conventional medicine."2 The reasons for this shunning must be seriously considered,
and not just dismissed as a case of traditionalism, fear of change, or difference of opinion among practitioners of established medicine. The tests used, the pattern of avoidance prescribed, and, perhaps most important, the life-style and world view fostered must be seriously evaluated. This subculture seems to appeal to patients with a history ofchronic psychiatric symptoms, and for this reason psychiatrists must be aware of this problem population and the solutions selected by it. Its views conflict with those of psychosomatic medicine. While psychiatrists explain why psychiatric symptoms are mistakenly attributed to physical causes,'5 this subculture holds that in fact they are due to physical causes, a disorder of the immune mechanism. We can regard it as likely that the emergence of this ideology may be a result, at least in part, of the failure of psychiatry to provide explanations and regimens that provide the benefits described above. 0
III, Charles C Thomas. 1976. 6. Associated Press: A sealed refuge for people allergic to the 20th century. San Francisco Sunday Examiner and Chronicle, October 13, 1981. pAlO. 7. Rinkel HJ. Randolph TG. Zeller M: Food Allergy. Norwalk, Conn, New England Foundation of Allergic and Environmental Diseases. 1951. 8. Randolph TG: Human Ecology and Susceptibility to the Chemical Environment. Springfield, III, Charles C Thomas. 1962. 9. Rea WJ. Bell IR, Suits CW, et al: Food and chemical susceptibility after environmental chemical exposure: Case histories. Ann AI· lergy41:101-110, 1978.
10. Golos N, Golbitz FG, Leighton FS: Coping with Your Allergies. New York, Simon and Schuster, 1979. 11. Forman R: How to Control Your Allergies. New York, Larchmont Books. 1979. 12. Festinger L. Rieken HW, Schacter H: When Prophecy Fails. New York, Harper and Row. 1956. 13. Grieco MH: Controversial practices in allergy. JAMA 247:3106-3111. 1982. 14. Seligman J. Donosky L. Shapiro D. et al: A shadowy area. Allergies: New insighls. Newsweek Magazine. August 23.1982. P 45. 15. Schwab JJ: Psychiatric illness in medical patients: Why it goes undiagnosed. Psychosomatics 23:225-229. 1982.
REFERENCES 1. Mandell M, Scanlon LW: Dr. Mandell's 5-Day Allergy Relief System. New York, Thomas Y Crowell, 1979. 2. Randolph TG. Moss RW: An Alternative Approach to Allergies: The New Field of Clinical Ecology Unravels the Environmental Causes of Mental and Physical Ills. New York, lippin· cott & Cromwell, 1980. 3. Bell IR: Clinical Ecology: A New Medical Approach to Environmental Illness. Bolinas, California, Common Knowledge Press, 1982, p 28. 4. Slrauss A. Schatzman L. Bucher R: Psychiat· ric Ideologies and Institutions. New York, Free Press, 1964. 5. Dickey LD (ed): Clinical Ecology. Springfield.
742
PSYCHOSOMATICS
'Allergic to everything': A medical subculture ABSTRACT: With the emerging medical subculture called
"clinical ecology," patients are diagnosed as "allergic" or "environmentally ill" and treated with special techniques and avoidance of whole environments. In reviewing a group of eight persons who had filed worker's compensation claims for injury ostensibly caused by allergic response to substances in the workplace yet who showed no physical evidence of injury, the author found withdrawal from work, a life-style engineered to avoid exposure to putative noxious substances, and an identity as a disabled person. Some changes in medicine are more revolutionary than others, precipitating a change in pattern, while others remain well within the established mold, but rise in stature, becoming more prevalent as diagnoses and more immediate in the inventory of explanations of disease. Many of these changes are merely fads or fashions in medicine; some, such as the concept of stress, gain acceptance and recognition by organized medicine. One such movement on the fringe of established medicine is
clinical ecology, sometimes also referred to as human ecology or bioecologic medicine. Its practitioners describe themselves as "ecologically-oriented" allergists "primarily concerned with the environmental causes of illnesses.'" Patients are said to be "environmentally ill" or "hypersensitive" or "allergic" to unusual or common substances in the environment. The group of patients described in this article had been given this diagnosis by physician adherents of clinical ecology. The patients are
Dr. Brodsky is professor ofpsychiatry at the University ofCalifornia, San Francisco, School of Medicine. Reprint requests 10 him at Langley Porter Neuropsychiatric Institute, 401 Parnassus St., San Francisco, CA 94143. AUGUST 1983 ' VOL 24 • NO 8
unusual, however, in that they were diagnosed as allergic to chemicals or substances in their work environment and have filed for worker's compensation benefits, claiming that the exposure made them hypersensitive to common or unusual substances not only in the work setting but also in most other situations. They are also -exceptional in that (l) their claim of injury by toxic elements in the work environment rarely began with a specific event of exposure, (2) no physical evidence of injury was found by traditional medical examination, (3) most have a history of overt psychiatric symptoms, (4) all but one are women, (5) all too frequently they are seen by the same network of physicians who subscribe to clinical ecology, and (6) their self-perception and diagnosis of "allergic" to most substances have becoRl( an organizing principle in their lives, central to their identity and life-style. Because these cases have been rarely described except from the vantage point of the clinical ecologists,1.2 we will present a model case 731
'Allergic to everything'
and describe the elements that recur in our patient sample. We will then examine the medical subculture entered by these people and which has shaped their illness careers, some of the ways this disease explanation serves the psychological needs of a problem patient population, and conditions contributing to confluence of this subculture and this patient population. Patient sample The eight persons examined by the author had .filed claims for injury from primarily airborne substances, following diagnosis by clinical ecologists as "environmentally ill" or "chemically hypersensitive." However, established medical examiners detected no physical evidence of injury. These eight were part of a larger group of 70 people claiming injury or disability from intoxication in the workplace that was not supported by clear physical evidence. All these cases were selected from over 2,000 seen by the author in a psychiatric examination of extent of disability for worker's compensation. The psychiatric examination lasted from two to three hours. When indicated, the patient was referred for psychological testing. Because these cases were in litigation, the patients were examined by a variety of specialists representing both parties. Medical records of health-care contacts prior to the alleged exposure were obtained and reviewed. Reports from relatives or concerned parties were evaluated, as were rehabilitation reports. Some of these records were gathered under the power of subpoena issued by lawyers representing employers or the patients, thus providing the author access to information not usually available in
such research. Seven of the eight in the sample are women. Practitioners of clinical ecology have found that among patients experiencing similar symptoms women outnumbered men by 2\12 to 1. 3 All had completed high school, and all but one had further formal education. Three had received the baccalaureate and two others the master's degree. Six of the eight are between the ages of 30 and 39, two in their early fifties. Four are married, and two of the four single persons have been di-
She was relieved to discover tlult her symptoms were a reaction to substances in the air and part ofher 'clinical sensitivity. ' vorced. Four have children. Four patients worked at professional levels: a statistician, a program analyst, a staff researcher, and a chemical engineer. The other three were a flight attendant, a printingpress operator, and a psychiatric technician. A representative patient A 50-year-old retired woman on disability arrived for our interview carrying a large container of oxygen and a bag for her oxygen mask and tube. She warned me that she was fragile and that if I had any hard questions to ask, I had better ask them early, because as she breathes the fumes of hydrocarbons in the room her symptoms become progressively worse. She pointed out that the abundance of printed material, such as books and journals, in my office added to the concentration of hydrocarbons. Despite her warning, she showed
no sign of distress during the interview nor did she resort to the oxygen. She had formerly worked as a statistician in a state bureau for two years, holding other jobs for the state for II years previously. She said that her first symptoms occurred about seven years earlier when she noticed that she was unable to remember what she read. At that time a physician told her that she· was "sensitive to chemical fumes." It was "like a detective story," she recounted. At first they thought she might be reacting to foods; elimination diets were prescribed, but did not help. Two years later she was sent to a specialist in Chicago who provided a "chemical-free" environment in a hospital for two weeks. For the first five days she fasted, ingesting nothing but water. After the study, she was told that she was reacting to a group of common chemicals and that she might not be able to continue working at her job. Initially she continued to work, wearing a mask with a filter. While that helped, she found that "it scared people." Given this situation, she took an examination to qualify her for a job involving work outdoors. Failing to qualify, she had to remain working indoors at her desk as a statistician. Her symptoms became more pronounced until she was "passing out four or five times a day." She would have enough warning to get to the restroom and lie down; after that she was sometimes unconscious for an hour. She complained of stupor and lethargy. Because of these symptoms, she had stopped working three years before I examined her. She retired and became "an outdoor person." In fact, she had to stay outdoors almost all of the time to avoid the (continued)
732
PSYCHOSOMATICS
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dation. Terminate dosage gradually SinCe abrupt withdrawal any antianxiety agent may result in symptoms like those being treated: anxiety. agitation. irrilabitity. tension. insomnia and occasional convulsions. Observe usual precautions _ impaired renaJ or hepatic function. Where gastroin~nal or cardiovascular disorders coexiS! _ anxiety. note lhaJ Iorazepam has not been shown slgni'icant benet" in treating gastrointestinal or cardiovascular component. EsophageaJ dilation occurred in rats treated wijh Iorazepam 'or more than 1 year at 6mg/kg/day. No elIec1 dose was 1.25mg/kg/day (aboul 6 times maximum human therapeutic dose IOmg/day). Ellect was rewrsible only wilen treatment was withdrawn _in 2 months of first obeeMIlion. CMnlcal signillcance Is unknown; but use of Iorazepam tor prolonged periods and in geriatrics requires caution and frequent monitoring for symptoms of upper G.I. disease. Safety and ~ in children under 12 years have not been--.ed.
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ESSENTIAl LAllORATORY TESTS: Some patients have daveIoped leukopenia; some have had elevations of LDH. As _ other benzodiazepines. periodic blood counlS and liver function _ are recommended during long-term therapy. CLINICALLY SIGNIFICANT DRUG INTERACTIONS: Benzodiazepines produce CNS depressant ellects wilen adminiS!ered _ SUCh medications as barbiturates or aJcohoI. CARCINOGENESIS AND MUTAGENESIS: No evidence 0' carcinogenic potenti81 emerged in ralS during an IlHnonth study. No studies regarding mutagenesis have been performed. PREGNANCY: Reproductive studies were performed in mice. ralS. and 2 strains of rabbits. tarsals. tibia. metatarsals. malrota1ed limbs. gastroschisis. Occasional anomaJles (reduction malformed skull and microphlhaJmia) were seen in drug-treated rabbits wilhoul reI81ionship to dosage. Although all these anomalies were not preeenl in the concurrent control group. they have been reported to occur randomly in historic:aJ controls. At 40mg/kg and higher. there was evidence of telal resorption and increased telalloss in rabbits whic:h was not seen at lower doses. Clinical slgnnicance 01 these findings is not known. However. increased risk 01 congenital mallor· mations associated with use of minor tranquilizers (chlordiazepo)(ide, diazepam and meprobamate) during lirst trim8S1er pregnancy has been sugges1ed in several studies. Because use of these drugs Is rarely ~ maner of urgency. use of Iorazepam during this period should almost always be avoided. Possibilijy !hal a woman 0' chikl-bearing polenti8I may be pregnant at inSlijution therapy shoold be conSidered Advise palien1S they become pregnant to communicate _ their physician about _ l i l y discontinuing the drug. In humans. blood _ from umbilical cord blood indicate placenlaJ transfer Iorazepam and its glucuronide.
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NURSING MOTHERS: n is not known norallorazepam is excreted in human milk like other benzodiazepines. As a general rule. nursing should not be undertaken while on a drug since many drugs are excreted in milk.
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~ Ae&tlona, they occur. are usually observed at beginning therapy and generally disappear on continued medication or on decreasing dose. In a sample of aboul 3.500 anxious patients. most frequent ~ reaction Is sedation (15.9'11.). followed by dizziness (6.9'll». weak· ness (4.2%) and unst6adiness (3.4'11.). Less frequent are disorientation. depression. nausea. change in appeli1e. headache. sleep disturbance. agitation. dermatological symp4oms. eye func· tion disturbance. various gastrointestinal symPlOmS and autonomic man~tions. Incidence of sedation and unsteadiness increased _ age. Small decreases in blood preaure have been noted but are not clinically significant probably being related to reIlel anxiety.
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overdosage _ any drug. bear in mind multiple agents may have been taken. Mani'estations overdosage include somnolence. con'usion and coma. Induce vomiting and/or undertake gastric lavage 'ollowed by general supportive care. moni1oring vijal signs and close obserVation. Hypotension. though unMkeIy. usually may be controlled _ Levarterenol Bitartrate lnjec1ion U.S.P Usefulness dialysis has not been _mined.
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symptoms. To accommodate her needs, her husband retired and moved with his wife to the mountains. In the winter they travel to a warmer climate where they can continue to live with complete exposure to the fresh air. In this environment, she leads a full and active life, such as playing tennis and running. She comes indoors only to cook and sleep, and even then leaves the windows wide open. She drives without difficulty, making sure to keep all windows open. Because she carries the container of oxygen and the oxygen mask wherever she goes, she and her husband avoid socializing. Nevertheless, she says her life is "like a vacation." She maintains that this regimen works and that it has greatly reduced her symptoms. When she does not follow the regimen, ie, when she spends too much time in enclosed areas, she experiences memory loss, hearing and visual difficulties because "things do not come through clearly," and weakness, such that she cannot stand or sit up without support. The patient was raised as a Christian Scientist. She completed college and earned an additional degree in the arts. Her health history showed that while in college she had been hospitalized for two months with hepatitis. She had suffered from emotional problems all her life. As a child she was described as "languid" and experienced recurring periods of depression. These depressions continued throughout her college years. Because of them she consulted a psychotherapist and participated in therapy for four to five years. When the depression did not diminish, she began taking a prescribed amphetamine-sedative combination, which she still uses. 734
PSYCHOSOMATICS
She continued to visit physicians qntil she found one who diagnosed her problems as environmentallyCaused, stating that she was allergic to many substances in the work environment. She was relieved to discover that her symptoms were a reaction to substances in the air and part of her "clinical sensitivity." ~ysis
In addition to the recurring depressions all her life, this patient was mildly claustrophobic. For many years, she had sought relief for her
The treatment plan for these patknts is characterizedfirst bJ' a set ofmultiple avoidances of whole mJ1ironments, not just specific substances. symptoms in the psychiatric channel; however, she was never convinced that their origin was emoti9l1al and she never did find such relief. In the back of her mind, she ~lieved there must be some physical cause and cure for them. She continued looking until she found a physician who told her that her problems were the result of allergy. While living in the mountains and the open air, she seems to function well. She has fully adopted the somatic explanation and treatment of her problems. She now believes she has control over her symptoms. Patterns common to the patients With this representative patient we see a number of elements that are found in many of the eight cases. Onset ofsymptoms. In the majority of these cases, the symptoms
commenced gradually and tended to intensify over time. It was not the environment that changed but the person's reaction to it. It was sometimes impossible to determine exactly when and why these subjects became concerned about symptoms and their physical environment. They described their symptoms in vague terms: "I just kept getting sicker and sicker"; "I wasn't feeling up to par"; or "I was feeling very tired." In most cases, the symptoms intensified until they reached a crisis, such as loss of consciousness. These symptoms included fatigue, gastrointestinal dysfunction, fainting, difficulty thinking, lightheaded ness, memory deficits, rashes, and recurring migraine headaches. Several patients reported recent depression. Most indicated that once they left the work environment that had initially triggered the problem, their symptoms recurred only with exposure to a host of generically related substances. Illness history. Similarly to the model case, the patients in the sample had a long history of recurring physical complaints unsupported by objective physical findings. Three women had a history of migraine headaches; five had experienced at least one serious bout ofdepression; and five patients had been treated by a psychiatrist. Most were acutely aware of their bodily functions and believed that their symptoms were physical rather than mental, despite contrary opinions from psychiatrists or other physicians. Search for a healer. The patients went from one physician to another either because they were told that nothing was wrong with them, while they were convinced there
was, or because they had been diagnosed as suffering from mental rather than physical illness, a conclusion contrary to their own convictions. Once they found physicians who suspected hypersensitivity or allergy, most underwent a battery of confirming tests. Four were referred to specialists in Dallas and Chicago, where they remained in a controlled environment while their conditions were carefully studied. Once diagnosed allergic, they described an "Aha!" experience. As one woman put it: All of a sudden. a lot of enlightenment took place. In my case. I began to realize all the potential sources of my symptoms and to see a direct correlation between them and the substances causing them. Another patient recounted: My husband could hardly believe that in one hour a diagnosis was reached, after one year of tests had suggested it was all in my head. After a visit to the library, we both knew the diagnosis was absolutely correct.
Treatment through avoidance. The treatment plan for these patients is characterized first by a set of multiple avoidances of whole environments, not just specific substances. In contrast to persons diagnosed allergic to specific irritants and prescribed avoidance of one or two items, these patients were diagnosed allergic to a wide array of commonly encountered substances (such as soap, smoke, perfume. hydrocarbons) and prescribed avoidance of entire environments that include these substances. Such avoidance inevitably led to major changes in their lives, most frequently a move to a "clean" climate, such as the moun(continued)
AUGUST 1983 • VOL 24 • NO 8
735
~.
'Allergic to everything'
~~~'OJM:;CAPSUES
fAfv1A/\lTADNE J-OI
BRIEF SUMMARY OF PRESCRIBING INFORMATION
INDlCATIONS.Parkinson·s Disease/Syndrome and Drug·lnduced Extrapyramidal Reac· tions SYMMETREL.s ind,cated In the treatment of,d,opathic Parklnson's disease (Paral· YSls Agitans). poslencephalltic park.nson,sm. drug·induced extrapyramidal reactions. and
tains or the desert or near the ocean. Their choice of "clean" environments over "polluted" ones was based on popular notions of cleanliness vs pollution; rural vs urban; ocean vs inland; outside vs inside; and high vs low altitude. In addition, some patients received injections of the indicted substances, administered either by others or by themselves. These could be quite costly; one woman noted that her antigens cost $60 per bottle and that she sometimes had to use as many as ten different
Clinical ecology stresses 'the environmental causes of mental and physical iUs, , particularly illnesses that have been previously labeled psychiatric. bottles. In many cases, the treatment also included diet manipulation. Like our representative patient, some persons also carried an oxygen tank and mask with them when they went out. In this way, they carried their environment with them, wherever they went, as well as symbolically communicating to others that they were afflicted. LifNty/e organized around the illness. Almost all the patients had completely stopped working and organized their own and often their spouses' lives around their condition. Much time was spent on diets, tests for sensitivity, reading about allergies, participating in a support group, and attending to the worker's compensation claims. While two persons remained relatively inactive, the others, even though they said that they could not work, freely admitted being (continued) 736
symptomat'c parkinsonism which may follow Injury to the nervous sySlem by carbon m0noxide intoxication. It IS indicated In those elderly pallents believed to develop parkinsonism In aSSOCiation With cerebral arteriosclerosis In the treatment of Parkinson·s disease. SYMMETREL IS less eHeclove than levodopa (. )·3-(3.4-dihydroxyphenyl)·L·alan,ne. and its efficacy In comparison With the anticholinerglC anti parkinson drugs has not yet been estab· IIshed Although anlochollnerg,c type side eHects have been noted w.th SYMMETREL when used In patients WIth drug"nduced extrapyramidal reactions there IS a lower incidence of these Side eHects Ihan that observed w'th anloCholinerg,c ant,park,nson drugs CONTRAINDICATIONS. SYMMETREL IS contraIndicated ,n paloents With known hypersenSitiVIty 10 the drug WARNINGS. Paloenls With a h,story of epilepsy or Olher "seIzures" should be Observed closely for pOSSible Increased seizure activity. PatienlS w.th a hlSlory of congesl,ve heart lallure or peripheral edema should be fOllowed closely as there are pallenls who developed congestive heart failure while receiving SYMMETREL Pallents With Park,nsons disease ,mprovlng on SYMMETREL ShOuld resume normal aChvllies gradually and cautiOUsly. conSlstenl With Olher medical conSlderahons. such as Ihe presence of osteoporosis or phlebOlhrombOSIS Pallenls rece,.,ng SYMMETREL who note central nervous system eHects 0< blurring ot VISion shOUld be cautioned against driVing or working in Sltuallons where alertness IS Important PRECAUTIONS. SYMMETREL (amantadine hydrochlOride) shOUld nol be dlsconllnued abruptly since a few pahents With Parkinson's disease expenenced a parkinsonian cnSIS, i.e a sudden marked Clinical deterioration when Ih.s medlcallon was suddenly Slopped. The dose ot anlocholinergic drugs or of SYMMETREL shOuld be reduced ,f atropine-like effects appear when these drugs are used concurrenlly. The dose ot SYMMETREL may need carelul adlustment ,n pallenls With renal ,mpalrment. congestive heart failure. peripheral edema. or orthostatic hypotenSion Since SYMMETREL IS not metaoohzed and IS mainly el(Creted In the unne. II may accumulate when renal funChon IS Inadequate. Care should be exerCised when administering SYMMETREL to pattenIs wlfh liver diSease. a history of recurrenl eczematold rash. or 10 patients With psychOSIS or severe psyChOneurOSIS not conlrolled by Chemotherapeul.c agents. Caretul Observation IS reqUired when SYMMETREL IS adm,n,slered concurrently w.th cenlral nervous system stimulants No long-term studies ,n animals have been perf()(med to evaluate the CarCinogeniC pOlenloal of SYMMETREL The mulagen,c potenl,at of the drug has not yet been determIned in expe1lmental SySlems Pregllllncy category C: SYMMETREL tamantadlne hydrochlOride) has been shown to be embryotoXiC and teratogenic ,n ralS at 50 mg/kg/day. about 12t.mes Ihe recommended human dose. but not al37 mg/kg/day EmbryotoXiC and teralogenlc drug eHecls werf' nol seen In rabbits which received up to 25ttmes Ihe recommended human dose. There are no adequale and well-conlrOlled studies In pregnant women SYMMETREL should be used dUring pregnancy only ,I the potenllal bene'" lustlhes the porenlial nsk to the embryo or the fetus Nursing Moth...: SYMMETREL IS excreted In human mIlk. Caut,on should be exerCIsed when SYMMETREL is administered to a nurSing woman Pedletrlc U. .: The safety and eH,cacy 01 SYMMETREL In newborn Inlants. and Infants below Ihe age of 1year have not been established ADVERSE REAcnoNS. The most frequently occurring seriOuS adverse reacllons are: depreSSion congeshve heartlallure, orthostatiC hypotensive episodes. psychOSIS. and U1lnary retenllon, Rarely convulSions. leukopenIa. and neutropenia have been reported Olher adverse reaClIons of a less serious nature whiCh have been observed are the 101lOWing' hallUCInatIons. confUSion. aO)uety and Irritability: anoreXia, nausea. and constlpa· lion: alaxla and diZZiness (hghtheadedness). lIvedo retlcularis and penpheral edema Adverse reaclion~ observed less frequently are the follOWing vomlllOg: dry moulh: headache. dyspnea: fatigue. ,nsomn,a. and a sense of weakness Inlrequenlly. skin rash. slurred speeCh and Visual dlSfurbances have been Observed. Rarely eczematOtd derma fills and OCulogYriC epISodes have been reponed DOSAGE AND ADMINISTRATION. Adu" DoNge for P8r1dn8onI8m: The usual dose 01 SYMMETREL (amantad,ne hydrochlOride) 's 100 mg tWice a day when used alone SYMMETREL haS an onset 01 act,on usually wlth,n 48 hours The 'niloal dose of SYMMETREL is 100 mg da,ly lor patients wllh serious assOCiated med,· calltlnesses or who are receiving high doses of olher antiparkinson drugs, After one to several weeks at 100 mg once da'ly. Ihe dose may be ,ncreased 10 100 mg tWice dally. II necessary OccaSionally. pal,ents whose responses are not optimal Wllh SYMMETREL al200 mg dally may benet,t Irom an Increase up 10 400 mg dally In diVided doses. However. suCh pahents should be superVised Closely by their phySICians PallenlS Inlltally denving benefit from SYMMETREL nol uncommonly expenence a 'all-off of eHectlveness after a few months Beneht may be regained by Increasing the dose 10 300 mg da,'Y. Alternahvely. temporary d,sconl,nuatlon 01 SYMMETREL for several weeks. followed by relnltlahon of the drug. may result In regaining benefit In some patients A decIsion to use Olher antlparkinson drugs may be necessary DoAge for Concomltllnt Therapy: Some pallenls who do nol respond 10 anhChOllner· g'c ant,p~rklnsondrugs may respond 10 SYMMETREL When SYMMETREL or anhChOllner· glc anllparklnson drugs are eaCh used With margInal benefit. concomitant use may produce additional benel,l When SYMMETREL and levodopa are .nlt,ated concurrenlly. the paloenl can exhlbot rapid therapeuhc benef,ts. SYMMETREL should be held constanl at 100 mg dally or tw,ce dally while the dally dose oflevodopa IS gradually Inc,edsed to opt,mal beneht When SYMMETREL 's added to opllmal well· tOlerated doses oflevodopa. additIonal benehl may resull. InCluding smoothing out the fluctuations in Improvement which sometimes occur In patients on levodopa alone. Pallents who reqUire a reduction in their usual dose ollevodopa oecause of development of Side effects may pOSSIbly regain lost benelit WIth the add,tlon of SYMMETREL DoNge for Drug-lndvced Extr8Pyr8mld81 "-tion8: Adult The usual dose 01 SYMMETREL (amantadine hydrochlo
Du Pont Pharmaceutk:als D.'.......
w_.......
BIodI....caII E.I."P_del'l_&Co.(Inc.) DeI8w8n .....
MELLA'RII:
(thioridazine) Hel, USP Before prescribing or administering. see Sandoz literature for full product information. The following is a briefsummary. Contralndlcatlons: Severe central netvous system depression. comatose states from any cause. hypertensive or hypotensive heart disease of extreme degree. Warnings: Administer cautiously to patients who have previously exhibited a hypersensitivity reaction (e.g.. blood dyscrasias. jaundice) to phenothiazines. Phenothiazines are capable of potentiating central nervous system depressants (e.g.. anesthetics. opiates. alcohol. etc.) as well as atropine and phosphorus insecticides; carefully consider benefit versus risk in less severe disorders. During pregnancy. administer only when the potential benefits exceed the possible risks to mother and fetus. Precautions: There have been infrequent reports of leukopenia and/or agranulocytosis and convulsive seizures. In epileptic patients. anticonvulsant medication should also be maintained. Pigmentary retinopathy. observed primarily in patients receiving larger than recommended doses. is characterized by diminution of visual acuity. brownish coloring of vision. and impairment of night vision; the possibility of its occurrence may be reduced by remaining within recommended dosage limits. Administer cautiously to patients participating in activities requiring complete mental alertness (e.g.. driving). and increase dosage gradually. Orthostatic hypotension is more common in females than in males. Do not use epinephrine in treating druginduced hypotension since phenothiazines may induce a reversed epinephrine effect on occasion. Neuroleptic drugs elevate prolactin levels: the elevation persists during chronic administration. TIssue culture experiments indicate that apprOXimately one-third of human breast cancers are prolactin dependent in vitro. a factor of potential importance if the prescription of these drugs is contemplated in a patient with a preViously detected breast cancer. Although disturbances such as galactorrhea. amenorrhea. gynecomastia. and impotence have been reported. the clinical significance of elevated serum prolactin levels is unknown for most patients. Daily doses in excess of 300 mg should be used only in severe neuropsychiatric conditions. Adverse Reactions: Central Neruous System -Drowsiness. especially with large doses. early in treatment; infrequently. pseudoparkinsonism and other extrapyramidal symptoms: rarely. nocturnal confusion. hyperactivity. lethargy. psychotic reactions. restlessness. and headache. Autonomic Nervous System -Dryness of mouth. blurred vision. constipation. nausea. vomiting. diarrhea. nasal stuffiness. and pallor. Endocrine System -Galactorrhea. breast engorgement. amenorrhea. inhibition of ejaculation. and peripheral edema. Skin-Dermatitis and skin eruptions of the urticarial type. photosensitivity. Cardiovascular System -ECG changes (see Cardiovascular Effects below). Other -Rare cases described as parotid swelling.
It should be noted that efficacy. indications and untoward effects have varied with the different phenothiazines. It has been reported that old age lowers the tolerance for phenothiazines; the most common neurologic side effects are parkinsonism and akathisia. and the risk of agranulocytosis and leukopenia increases. The following reactions have occurred with phenothiazines and should be considered whenever one of these drugs is used: Autonomic Reactions -Miosis. obstipation. anorexia. paralytic ileus. Cutaneous Reactions -Erythema. exfoliative dermatitis. contact dermatitis. Blood Dyscrasias -Agranulocytosis. leukopenia. eosinophilia. thrombocytopenia. anemia. aplastic anemia. pancytopenia. Allergic Reactions-Fever. laryngeal edema. angioneurotic edema. asthma. Hepatotoxicity -Jaundice. biliary stasis. Cardiovascular Effects -Changes in terminal portion of electrocardiogram including prolongation of Q-T interval. lowering and inversion of T-wave. and appearance of a wave tentatively identified as a bifid Tor a U wave have been observed with phenothiazines. including Mellaril (thioridazine); these appear to be reversible and due to altered repolarization. not myocardial damage. While there is no evidence of a causal relationship between these changes and significant disturbance of cardiac rhythm. several sudden and unexpected deaths apparently due to cardiac arrest have occurred in patients showing characteristic electrocardiographic changes while taking the drug. While proposed. periodic electrocardiograms are not regarded as predictive. Hypotension. rarely resulting in cardiac arrest. Extrapyramidal Symptoms -Akathisia. agitation. motor resdessness. dystonic reactions. trismus. torticollis. opisthotonus. oculogyric crises. tremor. muscular rigidity. and akinesia. Persistent Tardive Dyskinesia -Persistent and sometimes irreversible tardive dyskinesia. characterized by rhythmical involuntary movements of the tongue. face. mouth. or jaw (e.g.. protrusion of tongue. puffing of cheeks. puckering of mouth. chewing movements) and sometimes of extremities may occur on long-term therapy or after discontinuation of therapy. the risk being greater in elderly patients on high-dose therapy. especially females; if symptoms appear. discontinue all antipsychotic agents. Syndrome may be masked if treatment is reinstituted. dosage is increased. or antipsychotic agent is switched. Fine vermicular movements of tongue may be an early sign. and syndrome may not develop if medication i~ stopped at that time. Endocrine Disturbances-Menstrual irregularities. altered libido. gynecomastia. lactation. weight gain. edema. false positive pregnancy tests. Urinary Disturbances -Retention. incontinence. Others -Hyperpyrexia; behavioral effects suggestive of a paradOXical reaction. including excitement. bizarre dreams. aggravation of psychoses. and toxic confusional states; following long-term treatment. a peculiar skin-eye syndrome marked by progressive pigmentation of skin or conjunctiva and/or accompanied by discoloration of exposed sclera and cornea; stellate or irregular opacities of anterior lens and cornea; systemic lupus erythematosus-like syndrome. Dosage: Dosage must be individualized according to the degree of mental and emotional disturbance. and the smallest effective dosage should be determined for each patient. (MEL-Z36 5/9/83)
A
Pharmeceutlcal Division SANOOZ,"C. East Hanover, NJ 07936
'Allergic to everything'
very active physically in their daily lives. This may appear as malingering, yet it must be emphasized that they judge their activities differently than do the orthodox physicians who examine them. When presented with the notion that repairing one's house differs little from working at a job, for example, they maintain that there is a significant difference-they can rest whenever they choose in their own activities, they can work for as long or short a period as they like, and they can keep the windows open to ensure a clean environment. They believe that not only are rest and exercise vital to their well-being, but that it is vital to rest and exercise at the precise moment they feel the need. The patients' social life was also structured around their condition. In a few cases, the husbands joined the caretaking team and became the guardians of their wives' health-and their defenders if anyone suggested that the symptoms might be spurious or the result of mental rather than physical factors. On the other hand, relationships with others were often jeopardized by the patients' symptoms and avoidances and by their feelings of being different or stigmatized. As one woman put it, "It's very hard to socialize with people when you can't stand the perfume or soap they use." This sense of isolation and differentness from most others, coupled with an affinity with people who believe themselves similarly afflicted, has contributed to the growth of voluntary support groups, such as the Environmental Illness Association in California. All of these factors support the patients' perceptions of themselves as sick and afflicted, and, in turn, support their nonrecovery. 740
PSYCHOSOMATICS
The medical subculture At the center of this subculture is a particular medical ideologt consisting of shared ideas about the etiology and treatment of their illness. Clinical ecology2.3.~ stresses "the environmental causes of mental and physical ills,"2 particularly illnesses that have been previously labeled psychiatric. Its theme is stated in the dedication of An Alternative Approach to A//ergies,2 written by the pioneers of the movement: "This book is dedicated to all patients who have ever been called neurotic, hypochondriac, hysterical, or starved for attention, while actually suffering from environmentally-induced illness." The clinical ecologists describe themselves as presenting "an alternative to conventional medicine" and "an alternative approach to heaiing."2 They differentiate themselves from traditional allergists, who they claim are "principally interested in the bodily mechanisms .ofallergic reactions and in the drug treatment of symptoms."· Rather, as the name "clinical ecologist" denotes, they are "primarily concerned with the environmental causes ofillnesses. "I In etiology, the clinical ecologists differ in their location of the problem in the environment; in diagnosis, in their use of special diagnostic techniques, such as sublingual testing.' They have also designed controlled environmental hospital settings and regimens of fasting and chemical control to diagnose and treat the more difficult cases.1.2.6 The clinical ecologists' treatment approach tends to stress the avoidance of substances rather than the use of drugs. l .2 Because of this, their treatment program is claimed to be inexpensive. The clinical ecology movement is AUGUST \983 • VOL 24 • NO 8
supported through a number of organizations. 2.7 Their views have been published for medical professionals in books2.3.5.7.& and articles.9 For the layman, several recent publications present the clinical ecologic model of illness and health}.2,lo.11 In addition, the movement has recently been described in the popular media. Voluntary associations for people with "environmental illness" have been established in some cities. The previously mentioned Environmental Illness Association
Many probkm patient populations such as this one cannot find places for themselves in the traditional medical channels. is open to all people, whether they have "environmental illness" or not. Like the pioneers of the movement, the members of this subculture believe that many people have environmental illness but are unaware of it; the goal is to inform them and to educate the nonaffticted about the nature of the illness.
Discussion Many persons shop for physicians in the marketplace of American health care: Lawyers look for those who will provide an opinion advantageous to their clients. Patients seek physicians who will offer care, affection, and love. Other persons, who have been told that there is no definitive hope ofcure, go to distant places or disreputable clinics looking for the "healer" who promises to do what others have said could not be done. In some instances, the motives for the quest are conscious
and articulated, such as the terminal cancer patient who is willing to try any treatment that promises to contain or cure his disease; in others, the motives seem unconscious and can be understood only when the patient declares satisfaction with the end result. Many patients go to physicians seeking authoritative answers and comply with their directives. Others are dissatisfied until they find a physician whose opinions and practices crystallize their own inchoate theories. This process has been described by students of religious and political belief formation. 12 The present patients had rejected the more orthodox medical beliefs and practices and become adherents of physicians who believed that symptoms attributed by orthodox physicians to psychiatric causes are in fact due to common substances in air, food, and water. This medical subculture does not talk about cures; the health-care professionals neither promise nor . give hope of eliminating the offending condition, and the patients do not seem to expect it. Like people with diabetes or with longstanding inflammatory bowel disease, they accept the inevitable. In contrast, however, our patients seem content with their condition and with the reassurance that their symptoms have a physical cause. We have described the ways in which the patients benefit from membership in this medical subculture. How are they harmed by it? If we assume that the theories of those treating them are incorrect and that the restrictions are unnecessary and the treatment ineffective, we can conclude that money is being spent uselessly and that the patients' lives are diverted into channels that permit little growth 741
'Allergic to everything'
in their personal and occupational lives. Yet we must also recognize that these patients have had symptoms for many years, and whether seen as neurasthenic, hypochondriacal, or phobic, they are among the most resistant and difficult persons to treat. Based on our experience, we conclude that many problem patient populations such as this one cannot find places for themselves in the traditional medical channels. These patients search for healers who will provide them with an explanation of their experiences and symptoms that makes sense to them and that fulfills a number of psychological needs. Given the medical histories of such persons, it is evident that physical and psychological symptoms existed prior to the alleged exposure at work. Factors contributing to adherence to clinical ecology include: • A society with a heightened awareness of the potential dangers of inhaling and ingesting noxious substances in usual environments • A group of professionals who de-
velop a theory that utilizes concepts from allergy and immunology to explain symptom patterns formerly explained by psychological theories • Dissatisfaction with and nonacceptance of psychological explanations suggesting that the defect is in the patients rather than external to them • A worker's compensation system designed by law to favor the applicant and in the process to favor his or her explanation of the symptoms • A support system of lawyers and physicians who themselves may not espouse the allergic and immunologic explanation but who support the patient in the drive to convince others • A support group ofother patients who believe themselves similarly afflicted. At present, the views of the clinical ecologists are not shared by most academic and practicing immunologists,I3·14 and they themselves admit that they have been shunned by "conventional medicine."2 The reasons for this shunning must be seriously considered,
and not just dismissed as a case of traditionalism, fear of change, or difference of opinion among practitioners of established medicine. The tests used, the pattern of avoidance prescribed, and, perhaps most important, the life-style and world view fostered must be seriously evaluated. This subculture seems to appeal to patients with a history ofchronic psychiatric symptoms, and for this reason psychiatrists must be aware of this problem population and the solutions selected by it. Its views conflict with those of psychosomatic medicine. While psychiatrists explain why psychiatric symptoms are mistakenly attributed to physical causes,'5 this subculture holds that in fact they are due to physical causes, a disorder of the immune mechanism. We can regard it as likely that the emergence of this ideology may be a result, at least in part, of the failure of psychiatry to provide explanations and regimens that provide the benefits described above. 0
III, Charles C Thomas. 1976. 6. Associated Press: A sealed refuge for people allergic to the 20th century. San Francisco Sunday Examiner and Chronicle, October 13, 1981. pAlO. 7. Rinkel HJ. Randolph TG. Zeller M: Food Allergy. Norwalk, Conn, New England Foundation of Allergic and Environmental Diseases. 1951. 8. Randolph TG: Human Ecology and Susceptibility to the Chemical Environment. Springfield, III, Charles C Thomas. 1962. 9. Rea WJ. Bell IR, Suits CW, et al: Food and chemical susceptibility after environmental chemical exposure: Case histories. Ann AI· lergy41:101-110, 1978.
10. Golos N, Golbitz FG, Leighton FS: Coping with Your Allergies. New York, Simon and Schuster, 1979. 11. Forman R: How to Control Your Allergies. New York, Larchmont Books. 1979. 12. Festinger L. Rieken HW, Schacter H: When Prophecy Fails. New York, Harper and Row. 1956. 13. Grieco MH: Controversial practices in allergy. JAMA 247:3106-3111. 1982. 14. Seligman J. Donosky L. Shapiro D. et al: A shadowy area. Allergies: New insighls. Newsweek Magazine. August 23.1982. P 45. 15. Schwab JJ: Psychiatric illness in medical patients: Why it goes undiagnosed. Psychosomatics 23:225-229. 1982.
REFERENCES 1. Mandell M, Scanlon LW: Dr. Mandell's 5-Day Allergy Relief System. New York, Thomas Y Crowell, 1979. 2. Randolph TG. Moss RW: An Alternative Approach to Allergies: The New Field of Clinical Ecology Unravels the Environmental Causes of Mental and Physical Ills. New York, lippin· cott & Cromwell, 1980. 3. Bell IR: Clinical Ecology: A New Medical Approach to Environmental Illness. Bolinas, California, Common Knowledge Press, 1982, p 28. 4. Slrauss A. Schatzman L. Bucher R: Psychiat· ric Ideologies and Institutions. New York, Free Press, 1964. 5. Dickey LD (ed): Clinical Ecology. Springfield.
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