MCS “Diagnosis”: Two Paths

REGULATORY TOXICOLOGY AND PHARMACOLOGY ARTICLE NO.

24, S96–S110 (1996)

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Clinical Consequences of the EI/MCS ‘‘Diagnosis’’: Two Paths HERMAN STAUDENMAYER1 Allergy Respiratory Institute of Colorado, Denver, Colorado; and Behavioral Medicine and Biofeedback Clinic of Denver, 5800 East Evans Avenue, Denver, Colorado 80222 Received May 17, 1996

There are two distinct paths down which patients ‘‘diagnosed’’ with environmental illness/multiple chemical sensitivities (EI/MCS) can travel. Along the first path, beliefs about low-level, multiple chemical sensitivities as the cause of physical and psychological symptoms are instilled and reinforced by a host of factors including toxicogenic speculation, iatrogenic influence mediated by unsubstantiated diagnostic and treatment practices, patient support/advocacy networks, and social contagion. Intrapsychic factors also reinforce this path through the motivational mechanism of factitious malingering, or unconscious primary and secondary gain, mediated through psychological defenses, particularly projection of cause of illness onto the physical environment. The second path involves restructuring distorted beliefs about chemical sensitivities. Explanations of the placebo effect, the physiology of the stress response, and the symptoms of anxiety and panic facilitate the direction of EI/MCS patients onto this path. A decision model is presented to discriminate among toxicogenic and psychogenic explanations of the EI/MCS phenomenon, based on appraisal of reaction and physiologic and cognitive responses during provocation chamber challenges under double-blind, placebo-controlled conditions. These studies have been helpful therapeutically for some patients in selecting the path that leads to wellness. This paper suggests how various therapeutic techniques can be employed with difficult patients. Often, supportive psychotherapy establishes a therapeutic alliance which facilitates cognitive therapy to restructure distorted beliefs. In the process of finding alternative explanations to chemical sensitivities, the etiology of symptoms is related to stressful life events, including childhood experiences which may have disrupted normal personality development and coping capacity. Furthermore, biological and physiological sequelae stemming from early, chronic trauma have been identified which could explain many of the multisystem complaints. The incidence of childhood abuse reported by EI/MCS patients is strikingly high, and it is recollection

1 Adjunct Professor of Psychology, New Mexico State University, Las Cruces, NM.

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INTRODUCTION

The environmental illness/multiple chemical sensitivities (EI/MCS) phenomenon is described as a systemic, polysymptomatic disorder characterized by general malaise with multisystem complaints that are believed to be caused by exposure to low levels of virtually any environmental agent known. The one common element of the ephemeral definitions proposed for this phenomenon is belief of illness. It is not recognized as a disease or syndrome, the diagnostic and treatments practices are unsubstantiated, the speculative theories advocating the phenomenon share a set of hard-core postulates that are empirically unfounded, and the practitioners of these theories are considered beyond the pale of acceptable medical practice. The first path to be discussed is degenerative, and along it we shall encounter allusion, illusion, and delusion. Many of the travellers are suggestible individuals with fragile personalities—sensitive, yes, but not necessarily to low-level chemicals. On the journey, they are subjected to unnecessary harm and suffering inflicted by misguided or dishonest health care providers—the iatrogenic component. These travellers are motivated by a host of complex intrapsychic factors including factitious malingering, secondary gain, and primary gain. The second path is progressive, a way by which these betrayed individuals may restructure their appraisal of a harmful physical environment and come to appreciate a less-threatening person-environment, defining a possible world in which they can cope.

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0273-2300/96 $18.00 Copyright q 1996 by Academic Press, Inc. All rights of reproduction in any form reserved.

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of trauma that many EI/MCS patients avoid by displacing the psychologic and physiologic adult sequelae onto the physical environment. The reenactment of these experiences may be necessary in the therapy of some affected individuals. Despite the significant therapeutic effort expended, some patients who are imprisoned by a closed belief system about the harmful effects of chemical sensitivities are resigned to travel down the path which ultimately leads to despair and depression, social isolation, and even death. q 1996 Academic Press, Inc.

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THE PATH TO DISTORTED BELIEFS

Many EI/MCS patients adamantly cling to their psychological defenses, in particular their overvalued beliefs about chemical sensitivities. Some patients are threatened by self-exploration and therefore tenaciously cling to the defenses and representations of a false-self, for fear of discovering and realizing their own true-self. Some of these patients think it ludicrous for someone to suggest that they might benefit from psychological or psychiatric intervention. These patients are seldom seen in a therapist’s office, and many manifest dynamics classified in the psychiatric textbooks as ‘‘rarely occurring.’’ THE SEDUCTION

Matter does not exist apart from our perception of it. Our ideas exist apart from matter. George Berkeley, A Treatise Concerning the Principles of Human Knowledge According to toxicogenic explanations, the EI/MCS phenomenon is said to account for any physical disease or mental disorder. It can be anything to anybody, left to personal impression. Berkeley’s immaterialist epistemology, first published in 1708, seems to have found an expression in the phenomenon, where there is no requirement of independent corroboration of subjective complaint and appraisal of causality. The practice is founded on the presupposition that the patient is the best judge of reality. And if the patient does not discern his/her personal reality, it may be available from a clinical ecology center, where patients have reported being diagnosed with a ‘‘chemically induced life-threatening illness’’ in an initial 5-min telephone evaluation by a receptionist. For patients who are highly suggestible or simply gullible, it can be argued that the beliefs are completely an iatrogenic effect. It is conceivable that there are EI/ MCS patients who are not motivated by secondary gain (e.g., getting attention, relief from obligation) or primary gain (displacing a deep-seated personality disturbance or trauma). My physician colleagues have seen patients whose belief in the phenomenon is no more than a curiosity or an inquiry. These individuals have not altered their lifestyle to accommodate an obsession about chemical sensitivities. They are more likely to be suffering from social contagion or media exposure, and usually respond to education. The hundreds of EI/MCS patients that I have become familiar with over the past 16 years showed conviction in their belief, albeit on a continuum ranging from being open to alternative explanations, to being closed with inexorable resolve. Their beliefs also showed a variability in how bizarre they are, ranging from over-

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valued ideas to frank delusions. Strength of conviction and bizarreness seem related to the extent to which the patient has taken Theron Randolph’s dedication to heart (Randolph and Moss, 1980): 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.

What is the attraction of this enticement? It offers an explanation for psychophysiologic and psychological symptoms, and an escape from those disorders which some patients associate with their fear of ‘‘being crazy.’’ The history of medicine and psychology is replete with examples of placebo therapies, some used for healing, others for exploitation. Placebo therapies have the common feature that they induce some temporary relief, but lose their effectiveness with time as the power of suggestion and autosuggestion wears off. It is well known that in a state of anxiety, a false path is often preferable to no path. But the most alluring aspect of Randolph’s dedication is the illusion of an escape from psychological conflicts. It plays on one of the fundamental psychological defenses, denial, and the illusion of an unsafe physical environment allows for the projection of causality away from the self. TOUR GUIDES

The proponents of the EI/MCS phenomenon either openly present themselves as clinical ecologists or espouse the principles of clinical ecology while protesting identification with the tour guides. In my experience, these guides are not only enthralled by the phenomenon, but also affected by it. They have a cornucopia of pseudoscientific theories to draw from, with enough allusion to scientific studies to make their speculations alluring and seemingly plausible. New technology offers new theories to exploit. The biological mechanisms proposed to explain the toxicodynamics of the phenomenon were originally focused on the immune system, initiated at a time when the science of allergy and immunology had not matured. A new field of medical subspecialty, like an infant, is more vulnerable to abuse. As the science of immunology matured, it accumulated enough empirical evidence and knowledge to cast off unfounded speculations. Well-designed, double-blind, placebo-controlled studies to test clinical ecology diagnostic and treatment methodologies invariable produced negative findings, leading to categorical rejection of these practices by the scientific and medical community. The immune dysregulation hypotheses lost favor and have now all but been cast aside by most advocates who are in the forefront of the other theoretical speculations, claiming no affiliation with those erroneous ideas. The speculations have shifted to the central nervous system, to mechanisms like limbic kindling, partial

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limbic kindling, sensitization and time-dependent sensitization, and cacosmia (Bell, 1994). And again, new functional brain imaging technologies like PET, SPECT, and fMRI are being misapplied and misinterpreted (Moser et al., 1995). Quantitative EEG’s are also being misinterpreted as evidence of toxic encephalopathy, when in fact the changes observed are typically normal variations associated with thinking, perception, or anxiety. Interpretation of decrements in performance on the more traditional psychometric measures employed in neuropsychological assessment are often indiscriminantly interpreted as evidence of toxic encephalopathy. The influence of confounding factors should be considered before judgment about what the performance indicates about the brain (Benton, 1994). Confounding factors include performance anxiety, mood, lack of effort or careless responding, and deliberate simulation or exaggeration motivated by factitious malingering, or unconscious primary gain. Both the neurophysiologic and psychometric measures are suspect in the inference of causality because they have relatively high sensitivity, but low specificity. Finally, the complex interaction of the central, endocrine, and immune systems has created a new avenue of hypotheses, beginning with the porphyrias.

A SEPARATE REALITY

The EI/MCS phenomenon has its own principles of toxicology. The time course of sensitivities is indeterminate, the effects can come and go in a flash, and consistency of cause and effect is not necessary. The dose– duration–response relation does not apply, and there is no lower threshold of an effect, even down to one molecule. The phenomenon features a set of flexible and bewildering postulates from which proponents have opportunistically argued any one of several conflicting outcomes. There are no postulates that generate testable hypotheses. The core postulates are impermeable to refutation. There is nothing that is predicted not to occur. The symptoms are nonspecific and may come from multiple systems; they need not be the same set from exposure to exposure. The effects spread such that they can be triggered by any and all environmental agents without regard to a molecular or a sensory basis of generalization. Chemicals of synthetic origin are deemed harmful, but not if they are of natural origin (so called organic). Alleged toxic agents are acceptable when attention is focused on an agent deemed to be more toxic (e.g., the replacement of amalgam tooth fillings with composite resin fillings). PROVISIONS AND REJUVENATING STOPS

WINDING ROADS, MULTIPLE ENTRY POINTS

The long and winding path through this mythical world of distorted beliefs has ever-changing sign posts as it winds around mountains of negative scientific evidence. The roads include neurasthenia, ecologic illness, environmental illness, 20th Century disease, chemical allergy/sensitivity, total allergy syndrome, chemical hypersensitivity syndrome, generalized immune deficiency, chemically induced immune dysregulation syndrome, cerebral allergy, toxic encephalopathy, chemical AIDS, universal reactivity, multiple chemical sensitivity, aircraft workers’ syndrome, toxic carpet syndrome, sick building syndrome, [Persian] Gulf War Syndrome, and others which I no longer recall. Despite the numerous labels, it is really only one path, defined by beliefs about harmful effects of agents in the physical environment as appraised by the patient and/or the proponents who treat or otherwise influence the patient. It also deserves mentioning that many of these roads were constructed by the same workers. There are several entry points into this possible world, representing refuge from foods, household products, the yeast connection, chemicals from buildings or toxic sites, and electromagnetic force fields. Many travellers are escorted by plaintiff attorneys seeking to fund the journey through the workers’ compensation system, product liability, tort law, and disability entitlement programs.

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The path through this mythical world would lose a great deal of its attractiveness were it not for stops to replenish one’s energy. VAS (vitamins, minerals, supplements) shacks, organic food stands, and special springs are set up at regular intervals along the path. Special clean housing is recommended to reinforce the illusion of safety. Removal of dental amalgams is also an option. Three times a day one may visit a depuration center to ‘‘clear’’ the poisons with dry saunas, exercise, and massage, following the method originally described by L. Ron Hubbard, the founder of Scientology (Hubbard, 1990). It is billed as physical therapy, and costs from $3500 to 4300 for 4 weeks. The program takes 4 to 5 hr per day and has been reviewed by Kurt (1995), who remarked on the inappropriate use of niacin. Niacin is administered six times in each daily cycle, to ‘‘tolerance,’’ sometimes in total doses exceeding several thousand milligrams. Dr. Kurt has pointed out that niacin promotes histamine release, which is a paradoxical approach in patients who allegedly have multiple chemical ‘‘allergies’’ or ‘‘sensitivities.’’ He noted the following side effects from niacin, listed in the U.S. Pharmacopoeia Drug Index: Feeling of warmth, flushing or redness of skin especially on face and neck, headache, diarrhea, dizziness or faintness, dryness of skin, nausea or vomiting, stomach pain, and other side effects may also occur in some patients. These symptoms are consistent with the general malaise, multisystem-presenting com-

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plaints characteristic of EI/MCS patients. Because patients are warned to temporarily experience toxic symptoms as the substances stored in body fat are mobilized during the sauna depuration, the side effects from the niacin reinforces the perception that the poisons are being ‘‘cleared,’’ and therefore poisoning must have occurred (Kurt, 1995). Histamine may also be taken directly to induce the same effects. The position statements of medical societies on the unsubstantiated practices of clinical ecology are unambiguous about the lack of scientific evidence for these practices. Unwittingly, they may leave the impression that further research will substantiate them. This is certainly within the realm of possibility, but is it probable? Of all the things I have seen passing for treatment, ‘‘imprinted water’’ is one I wish to share with the reader, described first hand by a clinical ecologist in a deposition reproduced in Table 1.

conflicts by displacing somatization to their children, holding them hostage to the EI/MCS phenomenon. This resembles a form of child abuse called Munchausen syndrome by proxy (Meadow, 1977) which has been labeled ‘‘multiple chemical sensitivity by proxy’’ (Robertson, 1994). In the first historical account of Munchausen’s syndrome by proxy, Meadow (1977) noted that mothers had a history of falsifying their own medical records and treatment, and had been labeled as hysterical personalities who also tended to be depressed. Mothers who victimize their children often have previous and ongoing physical and sexual abuse in their own history, and their children who have suffered Munchausen syndrome by proxy show increased psychologic morbidity as they become older (McGuire and Feldman, 1989).

TAKING A COMPANION

Erasing history by cultivating denial is essential to the brainwashing that is an inevitable part of psychic murder, resulting all too often in what Nietzsche called the worst form of slavery: That of the slave who has lost the knowledge of being a slave. Shengold, Soul Murder

In the psychological literature induced psychotic disorders and communicated emotional illness between two people is called ‘‘folie a deux,’’ or double insanity. The shared distorted beliefs that occur in couples also occur in larger groups and form the basis for group cohesion, as is the case with the medical cult associated with the EI/MCS phenomenon. The psychopathology of folie a deux is characterized by an induced disorder in which the distorted beliefs are transferred from one person to another. Typically, both persons have been intimately associated for a long time and live in relative social isolation. In my experiences with EI/MCS patients, the most common occurrence of folie a deux involved spouses. The dyad usually consists of a dominant, controlling person who establishes the distorted belief, and a secondary person who is less intelligent, more gullible and suggestible, passive, and has lowself esteem. The submissive person is compliant and uncritically obedient to an idea or the influence of the dominant party. The motive for the controlling party often reflects the dynamics of borderline/narcissistic personality structure. The motive for such submissiveness of the passive party often emanates from a dependent personality, characterized by fear of abandonment and the need to be taken care of. In a folie a deux, the dependent partner may also harbor deep-seated resentment and hostility toward the controlling party. There is some question as to whether patients who are the passive partner in a folie a deux are truly delusional rather than highly impressionable, because frequently there is merely passive acceptance of the delusional beliefs of the more dominant person in the relationship until they are separated, at which point the distorted belief may remit spontaneously. One particularly distressing manifestation of folie a deux involves mothers who express their psychological

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NO EXIT

The further one travels down this path, the further one is removed from contact with the real world, and the more elaborate become the distorted beliefs in the possible world of the EI/MCS phenomenon. Physical isolation can result, forcing one to seek shelter in the confines of a room that has walls covered with aluminum foil, or a porcelain-lined trailer parked in the wilderness. Social isolation is also at the end of the path, such that contacts are limited to other travelers along the path. Under such isolation the need for human contact and support can distort judgment even further. Identification with advocacy/victim groups may provide a sense of affiliation, a sense of acceptance and importance, which counteracts feelings of isolation, vulnerability, emptiness, and sadness. Alternatively, this affiliation may provide an expression of deep-seated hostility, projected onto the purveyors of foods, household products, and industrial chemicals who are accused of having created an ‘‘unsafe world.’’ In the extreme, this hostility can be displayed with acts of aggression by misguided zealots who profess political radicalism. One such example is the disruption of an academic seminar in 1990 at the annual meeting of the College of Allergy and Immunology in San Francisco by the AIDS advocacy group Act Up, at a time when ‘‘chemical AIDS’’ was a popular label for the phenomenon. When the overvalued ideas take on the extreme form of a delusion, there often is no exit from this fantasy world. The advocates of this phenomenon have indicated that there have been deaths caused either by ‘‘multiple chemical sensitivities’’ or by suicide (Rea,

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TABLE 1 Deposition by a Clinical Ecologist on the Use of Imprinted Water Q. [by the attorney] And then you have in your note which is Exhibit 7, ‘‘Put her imprinted water in a cup and drank it and felt better.’’ What does that mean? A. Well, we were on an experiment with [a colleague] from England on electromagnetics and he was trying some stuff about imprinting water with electromagnetic frequencies. Q. What does ‘‘imprinting water with electromagnetic frequencies’’ mean? A. Well, he beams different frequencies into the water and holds it, apparently holds it. Q. The water holds electromagnetic frequencies? A. Yeah. Q. Add what about her imprinted water, is there something about— A. Well, it would be for her pattern that he worked out on her. Q. Explain to me a little bit more what this means, what patterns is he working out? A. Well, he has them imprint water and then he has a measuring device that he uses to read the different frequencies on it, and then he uses other balancing frequencies for these. Like I say, it’s just an experiment on this yet, it’s nothing proven. Q. And how much water did she drink? A. Well, it says a cup. Q. Okay. And then you also say in your note of November 25th, 1992, Exhibit 7, ‘‘Also slept on top of imprinted water vials last night and felt better.’’ What does that mean? A. Just what it says. Q. Well, what’s the procedure when you say you sleep on top of imprinted water vials? A. Oh, I don’t know why she was sleeping on top of them. Probably she was given some vials with her imprint on it and had them in her bed clothes or whatever. Q. And is that something that this doctor who is working with you recommends that people do? A. Well, it’s some of the experiments he’s carrying on, yeah. Q. That people sleep on top of vials of water and they feel better? A. No, I don’t think it was sleeping on top of any vials, they just put them in their pocket. Q. Okay. And describe for me the process. A. I just did. Q. Could you give me a little more detail? A. Well, he takes a frequency generator, you know what a frequency generator is? Q. No, I don’t. A. Well, that probably is the problem then. In physics there’s a generator that generates frequencies through the spectrum, for example, like one-tenth hertz, one hertz, two hertz, twenty hertz, 50 hertz, a hundred hertz, five megahertz, you’ve heard of the different frequencies? Q. Right. A. Okay. Well, it will generate those, okay? And his experiment is that he feels that he can take different frequencies and that water will hold them, and he’s not alone in this, there are a lot of people in the world that have done that, and it’s been observed that some people get a mild clinical benefit out of that if they hold it or if they keep it next to their skin. Q. Okay. And is this procedure approved by the Food and Drug Administration as an experimental protocol? A. I don’t know whether it is or not. Q. Okay. Is it done only in your clinic? A. No. Q. Where else is it done? A. Well, he’s done it in several clinics across the country. Q. Where else? A. I can’t really tell you. Q. All right. Have you obtained any approval from the FDA to test people with this imprinted water? A. No. Q. Did she tell you— A. Why would we? Q. I don’t know, sir. A. Well, you asked the question. Q. Did she tell you in what ways she felt better after sleeping on top of imprinted water vials? A. It just says she felt better, I don’t know. Q. Have you recommended that she continue sleeping on top of vials of imprinted water? A. I don’t really recall. As I say, we were running an experiment. She complained to be a little sensitive to electricity, so we thought we’d try it and see. Q. Was it your notion or belief or idea that drinking imprinted water would help her sensitivity to electromagnetic field? A. I didn’t know. Like I say, it was an experiment. We try it on some of these people so we can get a feeling to whether it’s worthwhile pursuing or not. Q. And given her response, do you think it’s worthwhile pursuing? A. I don’t really know.

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TABLE 1—Continued Q. You have her diagnosed as ‘‘Electromagnetic Field sensitivity, chemical sensitivity.’’ How did you decide that she had electromagnetic sensitivity? A. Well, apparently just from the testing. It wasn’t a thing, if you notice, we didn’t put that down on any of our diagnosis or anything except for in this progress note here, we didn’t put it on any of the front sheets or anything. Q. Okay. But my question is how did you decide she had electromagnetic field sensitivity. A. Well, I said, from the testing. Q. Of her? A. Yeah. Q. And what testing did you do on her? A. I just told you. Q. Did he hook up electrodes to her or did he beam frequencies at her? A. He beamed frequencies at her. Q. He beamed frequencies at her? A. Yeah. Q. And how did she respond? A. I don’t recall. Q. Is there any record made of the test? A. No. He’s got it in his research book I’m sure.

1994), a sobering thought in light of Theron Randolph’s alluring dedication that often initiates access to this path. THE PATH OUT

Long is the way and hard, that out of hell leads up to the light. John Milton, Paradise Lost To help a EI/MCS patient out of the depths of his/her distorted beliefs, it is helpful to have an appreciation of why they were susceptible to such illusion and suggestion. In many EI/MCS patients with personality disorders, the distorted beliefs in the EI/MCS phenomenon serve as a psychological defense against awareness of deep-seated anxiety. It is these anxieties that the therapist must constantly be vigilant for and invariably treat, the patient willing, before there is much chance of restructuring the distorted beliefs. PRIMARY AND SECONDARY GAIN

Projections of harmful appraisals onto the environment that have associated alterations in life-style are usually motivated by primary and secondary gain, mixed with infrequent cases of factitious malingering. Preoccupation with beliefs about the EI/MCS phenomenon serves to distract attention away from underlying conflicts, often associated with recalling trauma-inducing experiences from the past and coping with stressors in current life. For individuals with character disorders, such experiences are often perceived to be incriminating of self. Those with a history of childhood trauma or deprivation often resist entertaining the possibility that their personalities have been disrupted by these experiences. Some also suffer the physical and psychological sequelae of posttraumatic stress disorder

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(PTSD) and acute anxiety, for which they have found a target of projection. For other EI/MCS patients the PTSD results from adult trauma associated with war or assault which is also displaced onto the physical environment. Individuals suffering the sequelae of trauma may be afraid of any label which triggers their primal fear of being or going insane. Surviving the horrors of trauma can certainly drive one to the edge of insanity, if not beyond. Any individual so severely traumatized in childhood, or adulthood, often has a vested interest in keeping the secret of the trauma. In the most severe cases of dissociative identity disorder, where the trauma occurs in early childhood, dissociative processes create introjected schema representations of the perpetrators which act as internal messages that reinforce the fear of being killed if they were to reveal the secret. This is one reason that some EI/MCS patients with a history of trauma and deprivation resist rational explanations of their symptoms that suggest somatization and conversion of intrapsychic conflicts. HOW TO DIRECT A PATIENT TO THE PATH OF PSYCHOTHERAPY

The physician often finds that certain EI/MCS patients are poorly responsive to usual methods of medical therapy, especially those individuals with somatic symptoms in whom psychosocial factors are a major, if not the sole, determinant of the illness. These patients are generally reluctant to accept psychiatric referral, and if they do, it often backfires because the only treatment offered is polypsychopharmaceutical (Ducatman, 1993; Selner and Staudenmayer, 1991). When there is no objective disease, and no medication or medical procedure indicated, the healing quality of the doctor– patient relation becomes essential to bring out the self-

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healing potential of the patient. First and foremost, the treatment of EI/MCS patients requires a complementary relationship between the medical and mental health care professionals. Psychotherapeutic methods are vehicles to facilitate healing. No one psychotherapeutic method has ever been shown to be more effective than any other as a general approach to a broad spectrum of psychological disorders. This implies that the effectiveness of a plethora of psychotherapies lies in the essential characteristics shared by all of them (Frank and Frank, 1991). Psychotherapy is viewed to be a safe haven in which to learn about self-defeating personality characteristics, to face primal fears of being rejected or harmed, to restructure false beliefs and overvalued ideas, to selfregulate stress physiology and somatization, to talk about explosive affect and feelings of overwhelming rage, to weigh the facilitating effects of psychotropic medication, to reveal secrets about childhood trauma, and to convert false defenses into effective coping styles. These are noble sentiments, and admirable aspirations. But can they be achieved with the most guarded and difficult patients? Many EI/MCS patients have reason not to trust, to be vigilant and suspicious. Some qualify as difficult or ‘‘hated’’ patients who would try the patience of the mythical Job. It has been my clinical experience that a history of childhood trauma is invariably associated with the most severely disturbed of EI/MCS patients (Staudenmayer et al., 1993b). The interaction between a physician or therapist and an adult EI/MCS patient who has a history of childhood trauma or deprivation may be influenced by attitudes and fears that come from another source, having nothing to do with the immediate interaction. Within the context of the past when the original trauma occurred, the family was usually in overt denial or actively threatened the child not to reveal the intrafamilial abuse. For the patient to risk revealing the abuse in the context of the present, the physician/therapist needs to be open, nonjudgmental, and supportive. For many who have not told their secret, they may never have had anyone to listen. My physician colleague, John C. Selner, has coined a phrase that may be used to introduce this most sensitive topic: ‘‘Has anyone ever made any mistakes with you.’’ The responses many abused patients expect from others based on their childhood experiences are disbelief, rejection, judgment, withdrawal, or banishment (Saporta and Gans, 1995). Others have long overcome their inhibitions to disclosure, but lack insight about the sequelae of abuse, especially somatization. It is with a sense of embarrassment and humility that the guardians of psychiatric and psychological theories of psychopathology are acknowledging an historical error. An account of childhood abuse related in adulthood may well be more than a fantasy. Until recently, many

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therapists have treated patients who present such a history in line with the self-fulfilling prophecy of their perpetrators, ‘‘If you mention it, they’ll think your crazy.’’ If any perceived hostility is inferred from the language or actions of the physician that can link a transference association to the perpetrator, the patient is unlikely to risk revealing aspects of his/her underlying trauma, much less be willing to discuss how it might be related to the current complaints. Instead, the patient is more likely to revert to his/her false defenses, which in the case of EI/MCS patients is often the repetition of rationalizations about overvalued ideas of chemical sensitivities. If confronted about the error of that logic, the patient is likely to go elsewhere for treatment. In working with these patients, the one thing to keep in mind is that ‘‘It is not always rational to be logical.’’ Antidepressant medications and insight-oriented psychotherapy are usually contraindicated in many EI/ MCS patients, at least initially. There are several reasons for this, but suffice it to say that psychiatrists/ psychologists experienced in working with somatoform disorders and personality disorders do have other modes of treatment. But before we access the path of psychotherapy, the most effective treatment to escort EI/MCS patients there is educational. Focusing on the physiology and psychophysiology of the presenting symptoms is one option. THE STRESS RESPONSE

The neuroendocrinology and the psychoneuroimmunology of stress and the stress disorders that result from dysregulation of homeostasis have been extensively reviewed (Chrousos, 1995; Chrousos and Gold, 1992). The biological mechanisms proposed for the toxicogenic explanations of the EI/MCS phenomenon are the same as those employed to explain the stress response. They focus on the limbic, catecholamine, autonomic, and immune systems, as well as the pathways of the hypothalamic–pituitary–adrenal axis. The only difference in the toxicogenic explanations is the hardcore postulate that environmental agents play a necessary, and sometimes sufficient, role. Psychophysiological stress-profiling is a diagnostic technique for psychophysiological disorders which measures several of these systems under baseline conditions. The physiologic measures are objective and include spectral patterns of brain waves which are associated with attentional difficulty, muscle tension associated with headaches, and constricted peripheral blood vessels and elevated galvanic skin response often associated with symptoms of autonomic arousal. Psychophysiologic stress-profiling is usually psychologically nonthreatening to the patient because it does not challenge their belief about environmental causation of symptoms, nor does it activate defenses against ‘‘They think it’s all in my head.’’ In fact, the psychophysiologi-

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cal data are often the only objective indication that there is something out of homeostasis. Certainly these measures should not be construed to be diagnostic tests for medical diseases, much less chemical sensitivities. However, objective evidence of stress physiology is sometimes enough for the patient to consider treatment. Carefully titrated explanations of learned sensitivity, the placebo response, and the physiology of the stress response may overcome the resistance to enter psychotherapy and explore psychogenic factors, where a great deal of the etiology for these psychophysiological abnormalities may be found. The scientific literature on the psychophysiological effects of childhood and adult trauma is extensive. In cohort-controlled studies, combat veterans diagnosed with PTSD have been shown to manifest significantly greater long-term effects of sympathetic ANS arousal, e.g., higher resting heart rate, elevated systolic blood pressure, and increased conditioned physiological and emotional startle responses (Blanchard et al., 1982; Pitman et al., 1987). Many Vietnam veterans with combatrelated PTSD also show increased and prolonged startle responses, an abnormality that appears to be unique to PTSD in comparison to other psychiatric disorders like depression (Butler et al., 1990). TRAUMA AS PREDISPOSITION TO EMOTIONAL DISORDERS

The long-term sequelae of childhood abuse can have profound effects on mood and affect, cognitive processing, beliefs and attitudes, and behavior (Silk, 1994). There are psychological effects in disruption of normal personality development and social functioning. There are physiologic and biochemical response dysregulations that resemble a chronic stress response and are associated with a spectrum of neuropsychiatric disturbances and psychopathological consequences as well as problems of living (Green, 1989). Cognitive dysfunction including deficits in attention, executive conceptual processes, and memory is consistent with neurobiological hyperarousal (Sutker et al., 1995) which has been linked to the etiology and maintenance of PTSD (van der Kolk, 1987) and associated severe personality disorder (Teicher et al., 1994). THE TRAUMA PARADIGM: A NEUROGENIC HYPOTHESIS

The trauma paradigm is a bold and provocative theory postulating that repeated traumatization, particularly in childhood abuse, may disrupt normal development of the brain, thereby contributing to dysregulation of cognitive processes and psychiatric sequelae (Kolb, 1987; van der Kolk and Greenberg, 1987). The limbic system, and particularly the amygdala, which mediates emotional responses, and the hippocampus,

which mediates memory processes, are especially susceptible to the disruptive effects of stress and trauma. Anatomical changes in hippocampal volume have been identified in veterans suffering combat-related PTSD using magnetic resonance imaging (MRI) measurements, with associated deficits in short-term memory (Bremner et al., 1995). These findings have been replicated by Bremner’s group at Yale in girls with a history of childhood sexual abuse, as well as by Murray Stein’s group at University of California, San Diego, reported at the 1995 annual meeting of the American Psychiatric Association in Miami. The link to memory difficulty is consistent with clinical reports from combat veterans who demonstrate alterations in memory, including flashbacks, nightmares, intrusive memories, and amnesia for traumatic experiences. Some severe EI/MCS patients present with similar symptoms, but displaced onto environmental causes. The effects in Bremner’s study were also found to be specific sequelae of trauma because control subjects were matched for alcohol use and depression. These findings have two relevant implications. First, trauma offers an alternative explanation to the toxicogenic hypothesis that EI/MCS patients are unlike ‘‘typical psychiatric patients’’ because they have a lower incidence of alcohol abuse. Second, the implications to the treatment of EI/MCS patients with antidepressant medications, and their resistance to taking them seem obvious — depression is only a symptom for patients who suffer PTSD. Furthermore, antidepressant medications can exacerbate some of the symptoms of PTSD. The amygdala has been linked to fearful responses which are characteristically associated with sensory memory. Numerous studies have shown that simple sensory memories such as tastes and odors which have prior associations with a traumatic event may serve to trigger PTSD responses (van der Kolk, 1994). A neural model has been suggested to explain memory of trauma and related behaviors (Charney et al., 1993). Neural mechanisms of fear conditioning, extinction, and sensitization involve certain brain regions and neurochemical systems which contribute to the persistence of traumatic memories and associated symptoms. The amygdala plays a key role in these processes because of its extensive connections to all of the sensory systems in the cortex where memories of each sensory system are stored. The amygdala may be necessary in the complex neural pathways to elicit traumatic memories. These pathways may also help to explain how neutral stimuli come to be associated with fear, anger, pain, and other negative emotions and experiences associated with trauma (Pincus and Tucker, 1985). NEUROPHYSIOLOGICAL EFFECTS OF PTSD

Recently, Teicher and his colleagues at Harvard presented self-report data from the limbic system Check-

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list (LSCL-33) to corroborate the hypothesis that psychopathology sequelae seen in adults is related to traumatic abuse in childhood (Teicher et al., 1993). Teicher’s group also conducted comprehensive assessment for neurologic abnormalities including neuroimaging, neuropsychological testing, and electrophysiological measurements (Ito et al., 1993). Spectral EEG analysis showed the most dramatic differences between the nonabused patients (10% abnormalities) and the severe physical/sexual abuse subgroup (47.8% abnormalities). The greatest differences were observed in the prefrontal cortex, implicating abnormalities in dopamine projections to the prefrontal cortex which are specifically activated by mild stress (Kalivas and Duffy, 1989), and could explain the low threshold for stress tolerance among individuals so affected. These investigators suggested that repeated activation may adversely affect the development of this brain region, noting that it is the last region of the central nervous system to mature, making it more vulnerable to early childhood abuse. In another QEEG study by Teicher’s group, 15 hospitalized children with a history of intense physical or sexual abuse were compared to a group of controls on measures of right and left hemisphere coherence (Ito et al., submitted). Coherence is a parameter that indicates the degree of synchrony between two EEG recording leads, and can be used to assess cortical connectivity and differentiation. The abused children had higher levels of left hemisphere coherence compared to controls, but there were no differences in right hemisphere coherence. The investigators concluded that their findings supported the hypothesis that early severe abuse may exert a deleterious effect on brain development that may enhance our understanding of associated psychiatric vulnerabilities. The most sobering conclusion suggested is the possibility that early abuse may produce enduring neurobiological abnormalities. QEEG abnormalities correlating with psychiatric conditions have also been reported in EI/MCS patients. In a cohort study comparing EI/MCS patients to normal controls and outpatients with psychological disorders, the EI/MCS patients showed abnormalities on several QEEG measures similar to those of the psychiatric positive control group. The results for both groups were significantly different from that of the asymptomatic control group, which had fewer subjects classified with abnormal EEG spectral patterns (Staudenmayer and Selner, 1990). Certainly, more research in neuroscience is needed before we can begin to understand the complexity of these systems and explain the associated psychiatric effects. For the purposes of our discussion, these studies have demonstrated that there are measurable longterm effects of childhood trauma on the CNS, and indicate that the trauma paradigm is supported by a progressive research program in neurophysiology.

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TRAUMA: NEUROBIOLOGIC EFFECTS

There is ever-increasing evidence that the emotional and psychophysiologic sequelae associated with severe stress and trauma have neuroendocrine and neurotransmitter biomarkers (Chrousos and Gold, 1992). Two studies of young girls with prior history of sexual abuse (defined as genital contact) have shown longterm, residual sequelae of catecholamine abnormalities (De Bellis et al., 1994b) and abnormalities in the neuroendocrine system (De Bellis et al., 1994a). These girls also showed symptoms of psychopathology including depression and suicidal ideation. Lowered basal urinary-free cortisol levels associated with PTSD has been observed in combat veterans (Mason et al., 1990) and elderly holocaust survivors (Yehuda et al., 1995). PROVOCATION CHALLENGES AND ALTERNATIVE EXPLANATIONS

When alternative medical diagnoses have been ruled out through comprehensive assessment (Selner, 1989), it is the validity of the patient’s belief about appraisal of symptoms caused by putative chemical agents that remains to be tested. Despite all of the theoretically illusive formulations about mechanisms of action, despite all of the ‘‘yin–yang’’ postulates that may be invoked post hoc by advocates of the EI/MCS phenomenon, each individual EI/MCS patient invariably presents a testable hypothesis about the specific aspects of his or her unique chemical sensitivities that is usually held with conviction. Before undertaking such testing, the alternative predictions are explained to the patient, delineating the conditions under which the hypothesis is rejected or not. A presupposition of this approach is that consistency of appraisal of a reaction across a series of challenges with putative active agent and placebo controls is required to establish a toxicodynamic effect. The approach can be employed even when the dependent variables may be limited to symptom report (Jewett et al., 1990; Staudenmayer et al., 1993a). THE SIGNAL-DETECTION DECISION MODEL

Certain hypotheses about the putative effects of an environmental agent predict state changes in objective measures. Biomarkers from laboratory assays include neurotransmitters, immune parameters, and neurohumoral markers. Measures of central nervous system function include brain imaging, functional neurophysiology such as QEEG, and psychometric measures of task performance. Peripheral measures of the autonomic nervous systems may also be employed, as well as subjective symptom ratings. The advantage gained in decision making from having objective measures is that the dependent variable may be assessed independently of the subject’s appraisal of exposure, which

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FIG. 1. A signal detection model for the appraisal of reaction to a putative chemical agent under double-blind, placebo-controlled provocation challenges.

tends to be confounded with subjective symptom report. The combination of two challenge conditions, putative active agent and placebo, and the two outcomes based on the subject’s appraisal, reaction or not, creates a 2 1 2 contingency table that characterizes the signal detection paradigm, as illustrated in Fig. 1. For purposes of discussion, the hypothesized effect of a putative toxic agent is illustrated with a hypothetical dependent variable that shows either a response or not. The pattern of provocation challenge results expected according the null hypothesis, two toxicogenic explanations (toxicologic and interaction), and the cognitive/ belief psychogenic explanation are presented in Fig. 2. The null hypothesis (upper right panel, Fig. 2) assumes that the spontaneous or cognitively mediated responses are equally likely to occur in any of the four contingencies, and there are no differences in the dependent variable among the four contingencies of the signal detection paradigm. The toxicologic explanation (upper left panel, Fig. 2) predicts outcomes according to basic postulates of toxicology and neurotoxicology. All psychologic and psychophysiologic symptoms (including conditioning effects) are postulated to be toxicodynamic effects, that is, consequences of chemical activation of the underlying physiologic mechanisms. Premorbid psychological or psychophysiological effects are irrelevant. The interactive explanation (lower left panel, Fig. 2)

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presupposes that toxicodynamic effects are observable only when they are paired with a second factor which creates an additive or synergistic dysregulation effect in a susceptible host. According to the interactive explanation presented by proponents of the EI/MCS phenomenon, psychologic and psychophysiologic factors underlying the stress response create physiologic dysregulations that lower the sensitivity threshold for individuals predisposed to chemical sensitivities, cacosmia, or both, all in good time with aging or time-dependent sensitization (Bell, 1994). In my opinion, this represents a reformulation of the core clinical ecology postulate that all symptoms are caused by environmental chemicals irrespective of the psychological status of the host, necessitated by ample evidence that preexisting and comorbid psychological factors are common in EI/MCS patients (reviewed in Sparks et al., 1994). The cognitive/belief explanation (lower right panel, Fig. 2) does not require any form of precipitating or eliciting toxic exposure associated with a response. Symptoms and psychophysiologic responses are associated only with perception or belief of exposure and harmful effects. The physiologic responses are mediated through central activation of the pathways and systems of the stress response. Clinically, the effort required to conduct doubleblind, placebo-controlled provocation challenges is usually expended only if the patient agrees to the methods

FIG. 2. A signal detection model for appraisal of reaction (effect or no effect) and challenge agent (active or placebo) and predicted effects on a hypothetical dependent variable for the null hypothesis and competing explanations of the EI/MCS phenomenon.

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that will be employed in the study and accepts the implications of all of the different possible outcomes. When a patient’s own hypothesis about chemical sensitivities is not confirmed, be that by a failure to react to an open challenge conducted as a baseline condition to determine the symptoms associated with the alleged offending agent or under double-blind, placebo-controlled challenge conditions (Selner, 1996), the implications of a psychogenic explanation can be broached with the patient. For some, empirical evidence to refute their personal hypothesis is often enough for them to consider alternative explanations and the path of psychotherapy which they imply. THE ENVIRONMENTAL CARE UNIT AS A SANCTUARY

In the early 1980s, John Selner and I worked with EI/MCS patients in an inpatient setting, with the environmental restrictions that define an environmental care unit (ECU). The ECU provides a sanctuary from an unsafe world. While these patients perceived the ECU as a haven from environmental contamination, it also protected them from the social environment that often was exacerbating their conditions. In the safety of the sanctuary and the caring from the staff, many could stop their obsessive thought processes centered on their distorted beliefs. If properly handled, this period of time-out and caring may allow the patient to restructure distorted beliefs and establish adequate coping mechanisms to return to the outside world (Selner and Staudenmayer, 1986). On the other hand, if unsubstantiated diagnostic and treatment methods are employed, as is the case in the ECU facilities run by clinical ecologists, the hospitalization facilitates avoidance of reality and instills and reinforces distorted beliefs about chemical sensitivities. ON THE PATH OF PSYCHOTHERAPY

Once the EI/MCS patient steps on this path, it leads him/her through many well established principles and practices. An argument can be made that there is nothing new along this path uniquely set aside for EI/MCS patients. The essence of therapy with these patients may lie in finding the right road map for each of them. Part of the art of therapy with EI/MCS patients is knowing the facts that remain to be discovered, having the patience to fend off their psychological defenses and distorted beliefs, and waiting for the information to emerge. The success of this process often lies in the use of persuasion, to gently broach likely topics, leading the patients to discover the insight themselves. The ideal time to offer explanations founded in fact is when the EI/MCS patient begins to question their own reactions, or the lack thereof, when exposed to a putative chemical agent. Later in therapy, after an alliance has been established, being confronted about false reac-

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TABLE 2 General Guidelines for Short-Term Therapy with EI/MCS Patients 1. Confidence To facilitate confidence in the technique, begin with an elaborated, well-planned rationale that provides an initial structure. 2. Relevance Provide training in meaningful skills that the patient can utilize to feel more effective in handling daily life. 3. Generalization Emphasize independent use of these skills outside of the therapist’s office. 4. Success and reinforcement The training should provide enough structure and explanation so that the skill can be mastered in the office and generalized to at least some real-world situations. 5. Self-reliance Encourage the patient’s attribution that improvement is caused by the patient’s increased skillfulness, not by the therapist’s skillfulness or the magical aspects of a therapeutic ritual.

tions is not as threatening to them since they realize they are not the object of scrutiny or criticism. The point of entry onto the path of psychotherapy is often with a short-term therapy. Behavioral, cognitivebehavioral, and self-regulation therapies tend to be short-term, goal-oriented, and structured to provide reinforcement (Frank and Frank, 1991). Some suggested guidelines to structure the initial interventions with EI/MCS patients are presented in Table 2. For many EI/MCS patients, these therapies are sufficient for a successful resolution of their complaints and lead to an exit from psychotherapy to wellness. For others, these serve as bridges to the more arduous path of long-term cognitive therapy, crossed by many EI/MCS patients, even by some of those who are the most severely disturbed and most difficult to treat. There is hope at the end of this path. For many EI/ MCS patients who have been able to process their childhood traumas in therapy, the emotionally disruptive sequelae have become manageable. As the psychological and psychophysiological sequelae of the trauma subside, symptoms become more manageable and controllable, more effective coping styles replace false defenses, the overvalued beliefs about the EI/MCS phenomenon are displaced by more realistic concepts about health and the environment, and life becomes more functional and productive. As the person-environment is perceived to be less threatening, projection of fears and anxieties onto the physical environment are no longer necessary. BIOFEEDBACK AND SELF-REGULATION

Clinically, self-regulation and biofeedback training are often an effective first step in the treatment of

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EI/MCS patients (Selner and Staudenmayer, 1986). By recognizing partial successes or accomplishments in regulating their body and symptoms with biofeedback, and experiencing small degrees of pleasure from the sense of accomplishment, the patient is helped to reevaluate his/her feelings of inadequacy and incompetence. Consumer warning: Biofeedback is not validated as a procedure for depuration of chemical sensitivities. SYSTEMATIC DESENSITIZATION

Wolpe’s (1958) application of systematic desensitization to overcome simple phobias, such as animal phobias, work especially well if the fears have been acquired in response to a frightening experience with the animal. The same holds for conditioned responses associated with a toxic exposure, where there is a well-defined unconditioned stimulus, the toxic event (Bolla-Wilson et al., 1988). In applying desensitization, studies have shown that the approach to the phobic stimulus does not need to be progressive or systematic. Those aspects of the procedure are structural in the sense that order and precision of a ritual give it a greater semblance of credibility. Frank and Frank (1991) have suggested that Wolpe’s technique succeeds because its ritual persuades patients to remain in actual or imagined contact with the phobic situation long enough for the fear to subside. The success of this and other therapies for phobias depends to a considerable degree on their persuasiveness, to which the scientific rationale, valid or not, contributes. Desensitization does not work well with agoraphobia because there is no specific unconditioned stimulus. In that respect agoraphobia is similar to the phobia of multiple environmental agents professed by EI/MCS patients where no triggering toxic event can be identified. When there is no identifiable unconditioned stimulus, classical Pavlovian conditioning does not apply as a model of learning. However, higher-order cognitive mechanisms that incorporate belief of exposure and appraisal of a harmful stimulus do apply. Learned sensitivity, which incorporates beliefs and psychophysiological explanations, is an alternative mechanism to explain the EI/MCS phenomenon. For example, expectation of danger or harm from exposure to a chemical appraised to be harmful initiates anxiety and the stress response, which can even manifest as a panic attack (Shusterman and Dager, 1991). COGNITIVE–BEHAVIORAL AND RATIONAL COGNITIVE THERAPIES

The focus of these short-term therapies is analysis of thinking and identifying cognitive distortions, which

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works well in patients who are motivated to identify such distortions. However, these techniques are best held in reserve with EI/MCS patients until they develop insight about their distorted beliefs, at which time analyzing how their cognitive styles are manifested in these beliefs is often less threatening. Some of these patients feel the burden of defending the distorted beliefs for fear of being seen as crazy for holding them. This burden needs to be lifted before cognitive restructuring can begin effectively. If logical analysis and factual data alone were an effective treatment for distorted beliefs, toxicologists and industrial hygienists would make the best therapists for EI/MCS patients. No amount of engineering data about HVAC systems, no amount of industrial hygienist sampling data can convince EI/MCS patients complaining of ‘‘sick building syndrome’’ that they were not harmed. The linguistic techniques of rational, cognitive–behavioral therapies were not designed to address the unconscious motivations of primary and secondary gain, much less the conscious malingering seen in factitious disorders. In working with EI/MCS patients, it has been my experience that fundamental changes occur in therapy only when there is a substantial change in irrational beliefs, which usually occurs only after motivational issues are addressed, even though not resolved. COGNITIVE THERAPY

One could argue that all forms of psychotherapy are cognitive at some level. As used here, cognitive therapy is usually long-term, and includes a panoply of techniques, all aimed at facilitating the patient’s perception and acceptance of reality. In cognitive therapy, the technique of restructuring is employed, the objective of which is to unstructure the schema networks representing false defenses and to elaborate or restructure the conceptualizations of reality. The therapeutic techniques of interpretation and confrontation direct the attention of the patient and therapist toward new information that challenges the validity of the presuppositions, assumptions, and postulates on which their beliefs are founded. The same techniques are used to confirm the validity of the therapist’s alternative theory, formulated as a model of reality, for better or for worse. The sensory, emotional, cognitive, and action schema in a memory network are closely linked or integrated. If all goes well, a change in one type of schema facilitates awareness and change in the others. In patients with a history of trauma, restructuring may also disarm some of the emotional impact of the anxiety of exploring the secrets of their trauma. As a new conceptual system evolves it offers some semblance of safety and security to counteract the destructive primal fears of separation or abandonment, being killed, or going insane, which

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TABLE 3 Four Essential Psychodynamic Principles on Which Psychodynamic Treatment Rests 1. During treatment unconscious material becomes conscious. 2. The mobilization of unconscious material is achieved mainly through the interpretation of information presented during free association and the patient’s emotional interpersonal experience (transference). 3. The patient shows resistance against recognizing unconscious content. 4. Through the transference relation with the therapist resistance is overcome and childhood experiences are reenacted to be better understood with insight, and resolved. Source. Alexander (1963).

are three pillars on which their beliefs about an unsafe world were built. The last cognitive therapy I shall mention is psychodynamic psychotherapy, also called ego psychology. Shortly before his death, Franz Alexander, the psychoanalyst best known for his work with psychosomatic illness, summarized what he considered to be the essential psychodynamic principles presented in Table 3. Both the psychoanalytic tradition and the cognitive tradition within psychology are undergoing a paradigm shift with the recognition of psychiatric sequelae associated with childhood abuse and adult trauma. This paradigm shift will require a reconsideration and modification of many therapeutic principles and techniques, as implied by Franz Alexander’s guidelines. CONCLUSION

The procedures and techniques of psychotherapy can be used for good or evil. To work with EI/MCS patients, one must understand the dynamics of brainwashing, including the effects of iatrogenic influence and the individual’s predisposition and susceptibility to it. Giving up psychological defenses is often threatening to an individual who has relied on them to protect against a personal reality of trauma and inability to cope. One can only guide these patients along this precarious and painful journey, accepting that ultimately their destination is their own choosing. They cannot be rescued from the journey described by John Milton, nor be transported to a rational world by the proclamation that their false world is scientifically unproved. Knowing the answer is only the beginning for the mentor. The patient/student needs to learn to incorporate the integrated conceptual networks that represent reality into their own knowledge. This entails correcting not only the false propositions, but also the associated emotional and behavioral schema networks that often manifest as panic reactions, appraised as chemical reactions. The journey in search of self and reality is fraught with pitfalls, hardship, and suffering. For some

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EI/MCS patients, the journey is too threatening to undertake and they remain prisoner to their distorted beliefs. Others may undertake this journey reluctantly, but never complete it. Of these, some will return to the EI/MCS phenomenon, and some will find another possible world of beliefs to escape into. But some will perserve and complete the journey to wellness, as evidenced by one sample of EI/MCS patients who underwent psychotherapy, 75% of whom had a successful outcome (Staudenmayer et al., 1993b). I have learned from those whom I have treated. This dedication was inspired by them, and hopefully can help others: To all patients who have ever been labeled with EI/MCS, subjected to unfounded diagnostic and treatment practices, and deprived of overcoming the psychological and physical symptoms associated with psychological defenses resulting from fears justifiable.

From a psychological perspective, societies rise and fall in relation to how antisocial and psychopathic elements are constrained. Institutional systems of government, jurisprudence, economics, science, commerce, industry, individual rights and personal freedoms, the welfare of the unfortunate, and the morality of the collective consciousness function in proportion to how well the constructive elements can curtail the destructive ones. The enlightened and free society ruled by rational and compassionate philosopher–kings envisioned by Socrates is perpetually threatened by forces of intrapersonal darkness and psychopathic destain, anarchistic irrationality, bureaucratic complacency, political expediency, and egocentric hedonism and greed. One need not look to macrocosmic world tragedies to see these forces battle; they can be observed readily in the microcosm that has come to be called the EI/MCS phenomenon. REFERENCES Alexander, F. (1963). The dynamics of psychotherapy in the light of learning theory. Am. J. Psychiat. 120, 440–448. [Reproduced in Creative Developments in Psychotherapy (A. R. Mahrer and L. Pearson, Eds.), pp. 330–344. Case Western Reserve University Press, Cleveland, OH.] Bell, I. R. (1994). Neuropsychiatric aspects of sensitivity to low-level chemicals: A neural sensitization model. Presented at the Conference on Low Level Exposure to Chemicals and Neurobilogic Sensitivity, sponsored by ATSDR, Baltimore, MD, April 6–7, 1994. Proceedings published in Toxicol. Ind. Health 10, 277–312. Benton, A. L. (1994). Neuropsychological assessment. Annu. Rev. Psychol. 45, 1–23. Blanchard, E. B., Kolb, L. C., Pallmeyer, T. P., and Gerardi, R. J. (1982). A psychophysiological study of post traumatic stress disorder in Vietnam veterans. Psychiat. Q. 54, 220–229. Bolla-Wilson, K., Wilson, R. J., and Bleeker, M. L. (1988). Conditioning of physical symptoms after neurotoxic exposure. J. Occup. Med. 30, 684–686. Bremner, J. D., Randall, P., Scott, T. M., Bronen, R. A., Seibyl, J. P., Southwick, S. M., Delaney, R. C., McCarthy, G., Charney, D. S.,

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CLINICAL CONSEQUENCES OF THE EI/MCS DIAGNOSIS and Innis, R. B. (1995). MRI-based measurement of hippocampal volume in patients with combat-related posttraumatic stress disorder. Am. J. Psychiat. 152, 973–981. Butler, R. W., Braff, D. L., Rausch, J. L., Jenkins, M. A., Sprock, J., and Geyer, M. A. (1990). Physiological evidence of exaggerated startle response in a subgroup of Vietnam veterans with combatrelated PTSD. Am. J. Psychiat. 147, 1308–1312. Charney, D. S., Deutch, A. Y., Krystal, J. H., Southwick, S. M., and Davis, M. (1993). Psychobiologic mechanisms of posttraumatic stress disorder. Arch. Gen. Psychiat. 50, 294–305. Chrousos, G. P. (1995). The hypothalamic-pituitary-adrenal axis and immune-mediated inflammation. N. Engl. J. Med. 332(20), 1351– 1362. Chrousos, G. P., and Gold, P. W. (1992). The concepts of stress and stress system disorders: Overview of physical and behavioral homeostasis. JAMA 267, 1244–1252. De Bellis, M. D., Chrousos, G. P., Dorn, L. D., Burke, L., Helmers, K., Kling, M. A., Trickett, P. K., and Putnam, F. W. (1994a). Hypothalamic–pituitary–adrenal axis dysregulation in sexually abused girls. J. Clin. Endocrinol. Metab. 78, 249–255. De Bellis, M. D., Lefter, L., Trickett, P. K., and Putnam, F. W. (1994b). Urinary catecholamine excretion in sexually abused girls. J. Am. Acad. Child Adol. Psychiat. 33, 320–326. Ducatman, A. M. (1993). MCS: Multiple negative findings—implications, history, and predictions. Occup. Environ. Med. Report 7(9), 73–75. Frank, J. D., and Frank, J. B. (1991). Persuasion and Healing: A Comparative Study of Psychotherapy, 3rd ed. Johns Hopkins Press, Baltimore, MD. Green, A. H. (1989). Physical and sexual abuse of children. In Comprehensive Textbook of Psychiatry (H. I. Kaplan and B. I. Sadeck, Eds.), 5th ed., pp. 1962–1970. Williams and Wilkins, Baltimore, MD. Hubbard, L. R. (1990). Clear Body, Clear Mind: The Effective Purification Program. Bridge Publications, Los Angeles. Ito, Y., Teicher, M. H., Glod, C. A., and Ackerman, E. Preliminary evidence for aberrant cortical development in abused children: A quantitative EEG study. Submitted. Ito, Y., Teicher, M. H., Glod, C. A., Harper, D., Magnus, E., and Gelbard, H. A. (1993). Increased prevalence of electrophysiological abnormalities in children with psychological, physical, and sexual abuse. J. Neuropsychiat. 5, 401–408. Jewett, D. L., Fein, G., and Greenberg, M. H. (1990). A double-blind study of symptom provocation to determine food sensitivity. N. Engl. J. Med. 323, 429–433. Kalivas, P. W., and Duffy, P. (1989). Similar effects of daily cocaine and stress on mesocorticolimbic dopamine neurotransmission in the rat. Biol. Psychiat. 25, 913–928. Kolb, L. C. (1987). A neuropsychological hypothesis explaining posttraumatic stress disorders. Am. J. Psychiat. 144, 989–995. Kurt, T. (1995). Sauna-depuration: Toxicokinetics. Presentation at the 2nd Aspen Environmental Medicine Conference, Aspen, CO, Sept. 7–9. Mason, J. W., Giller, E. L., Kosten, T. R., and Yehuda, R. (1990). Psychoendocrine approaches to the diagnosis and pathogenesis of post traumatic stress disorder. In Biological Assessment and Treatment of PTSD (E. Giller, Ed.), pp. 65–86. American Psychiatric Press, Washington, DC. McGuire, T. L., and Feldman, K. W. (1989). Psychologic morbidity of children subjected to Munchausen syndrome by proxy. Pediatrics 83, 289–292. Meadow, R. (1977). Munchausen syndrome by proxy: The hinterland of child abuse. Lancet 2, 343–345. Moser, F., Schaeffer, J., Waxman, A. D., Mayberg, H., and Newer,

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M. R. (1995). New modalities of brain imaging and neurocognitive assessment: Emerging areas of interest and controversy related to applications in head injury, neurotoxicology and environmental medicine. Disability 4, 1–12. Pincus, J. H., and Tucker, G. J. (1985). Behavioral Neurology, 3rd ed., pp. 70–100. Oxford University Press, New York. Pitman, R. K., Orr, S. P., Forgue, D. F., de Jong, J. B., and Clairborn, J. M. (1987). Psychophysiologic assessment of posttraumatic stress disorder imagery in Vietnam combat veterans. Arch. Gen. Psychiat. 44, 970–975. Randolph, T. G., and Moss, R. W. (1980). An Alternative Approach to Allergies. Lippincott & Crowell, New York. Rea, W. (1994). Environmental illness. Presentation to the panel on evaluating individuals reporting sensitivities to multiple chemicals. California Department of Health Services, Environmental Health Investigations Branch, May 5, 1994, Berkeley, CA. Robertson, W. O. (1994). MCS (multiple chemical sensitivity) by proxy. Veterinary Human Toxicol. 36, 579–580. Saporta, J. A., Jr., and Gans, J. S. (1995). Taking a history of childhood trauma in psychotherapy. J. Psychother. Pract. Res. 4, 194– 204. Selner, J. C. (1989). Workup of the chemically sensitive patient. Masters Allergy 1, 8–16. Selner, J. C. (1996). Chamber challenges: The necessity of objective observation. Regul. Toxicol. Pharmacol. 24(Suppl.), S87–S95, 1996. Selner, J. C., and Staudenmayer, H. (1986). The relationship of the environment and food to allergic and psychiatric illness. In Psychophysiological Aspects of Allergic Disorders (S. H. Young, J. M. Rubin, and H. R. Daman, Eds.), pp. 102–146. Praeger, New York. Selner, J. C., and Staudenmayer, H. (1991). Food allergy: Psychological considerations. In Food Allergy: Adverse Reactions to Foods and Food Additives (D. D. Metcalfe, H. A. Sampson, and R. A. Simon, Eds.), pp. 370–381. Blackwell Scientific, Boston. Shusterman, D. J., and Dager, S. R. (1991). Prevention of psychological disability after occupational respiratory exposures. Occup. Med. State Art Rev. 6, 11–27. Silk, K. R. (Ed.) (1994). Biological and Neurobehavioral Studies of Borderline Personality Disorder. American Psychiatric Press, Washington, DC. Sparks, P. J., Daniell, W., Black, D. W., Kipen, H. M., Altman, L. C., Simon, G. E., and Terr, A. I. (1994). Multiple chemical sensitivity syndrome: A clinical perspective. Parts I & II. J. Occup. Environ. Med. 36, 718–737. Staudenmayer, H., and Selner, J. C. (1990). Neuropsychophysiology during relaxation in generalized, universal ‘‘allergic’’ reactivity to the environment: A comparison study. J. Psychosomat. Res. 34, 259–270. Staudenmayer, H., Selner, J. C., and Buhr, M. P. (1993a). Doubleblind provocation chamber challenges in 20 patients presenting with ‘‘Multiple Chemical Sensitivity.’’ Regul. Toxicol. Pharmacol. 18, 44–53. Staudenmayer, H., Selner, M. E., and Selner, J. C. (1993b). Adult sequelae of childhood abuse presenting as environmental illness. Ann. Allergy 71, 538–546. Sutker, P. B., Vasterling, J. J., Brailey, K., and Allain, A. N., Jr. (1995). Memory, attention, and executive deficits in POW survivors: Contributing biological and psychological factors. Neuropsychology 9, 118–125. Teicher, M. H., Glod, C. A., Surrey, J., and Swett, C. (1993). Early childhood abuse and limbic system ratings in adult psychiatric outpatients. J. Neuropsychiat. 5, 301–306. Teicher, M. H., Ito, Y., Glod, C. A., Schiffer, F., and Gelbard, H. A. (1994). Early abuse, limbic system dysfunction, and borderline personality disorder. In Biological and Neurobehavioral Studies of

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AP: Reg Tox Pharm

S110

HERMAN STAUDENMAYER

Borderline Personality Disorder (K. R. Silk, Ed.), pp. 177–207. American Psychiatric Press, Washington, DC. van der Kolk, B. A. (1987). Psychological Trauma. American Psychiatric Press, Washington, DC. van der Kolk, B. A. (1994). The body keeps the score: Memory and the evolving psychobiology of posttraumatic stress. Harvard Rev. Psychiat. 1, 253–265. van der Kolk, B. A., and Greenberg, M. S. (1987). The psychobiology of the trauma response: Hyperarousal, constriction, and addiction

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09-23-96 23:03:24

to traumatic reexposure. In Psychological Trauma (B. A. van der Kolk, Ed.), pp. 63–87. American Psychiatric Press, Washington, DC. Wolpe, J. (1958). Psychotherapy by Reciprocal Inhibition. Stanford University Press, Stanford, CA. Yehuda, R., Kahana, B., Binder-Brynes, K., Southwick, S. M., Mason, J. W., and Giller, E. L. (1995). Low urinary cortisol excretion in holocaust survivors with posttraumatic stress disorder. Am. J. Psychiat. 152, 982–986.

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