Multiple chemical sensitivity

Multiple chemical sensitivity
Classification and external resources
MeSH	D018777

Multiple chemical sensitivity (MCS) is a chronic medical condition characterized by symptoms the affected person attributes to exposure to low levels of chemicals. Commonly suspected substances include smoke, pesticides, plastics, synthetic fabrics, scented products, petroleum products and paints.^[1] Symptoms may be vague and non-specific, such as nausea, fatigue, and headaches.

MCS is a controversial diagnosis, and is not recognised as an organic, chemical-caused illness by the American Medical Association.^[2] Blinded clinical trials have shown MCS patients react as often and as strongly to the exposure to the chemicals they say harm them as they do to placebos, including clean air.^[3][4] This has led some to believe MCS symptoms are due to odor hypersensitivity^[5] or are mainly psychological.^[2] Regardless of the etiology, some people with severe symptoms are disabled as a result.^[6]

MCS has also been termed toxic injury (TI), chemical sensitivity (CS), chemical injury syndrome (CI),^[7] 20th century syndrome, environmental illness (EI), sick building syndrome, idiopathic environmental intolerance (IEI) and toxicant-induced loss of tolerance (TILT).

Definition

Six consensus criteria were identified by researchers for the diagnosis and definition of MCS in 1989 (later edited in 1999):^[8]

1. Symptoms are reproducible with repeated (chemical) exposures.
2. The condition has persisted for a significant period of time.
3. Low levels of exposure (lower than previously or commonly tolerated) result in manifestations of the syndrome (i.e. increased sensitivity).
4. The symptoms improve or resolve completely when the triggering chemicals are removed.
5. Responses often occur to multiple chemically unrelated substances.
6. Symptoms involve multiple-organ symptoms (runny nose, itchy eyes, headache, scratchy throat, ear ache, scalp pain, mental confusion or sleepiness, palpitations of the heart, upset stomach, nausea and/or diarrhea, abdominal cramping, aching joints).^[9]

The National Institute of Environmental Health Sciences (a division of the NIH) defines MCS as a "chronic, recurring disease caused by a person's inability to tolerate an environmental chemical or class of foreign chemicals".^[10] MCS has also been described as a group of "sensitivities to extraordinarily low levels of environmental chemicals" appearing "to develop de novo in some individuals following acute or chronic exposure to a wide variety of environmental agents including various pesticides, solvents, drugs, and air contaminants", including those found in sick buildings.^[11]

Environmental medicine specialists claim MCS causes negative health effects in multiple organ systems, and respiratory distress, seizures, cognitive dysfunction, heart arrhythmia, nausea, headache, and fatigue can result from exposure to levels of common chemicals that are normally deemed as safe.^[12][13]

Lack of widespread recognition

The International Statistical Classification of Diseases and Related Health Problems (ICD), maintained by the World Health Organization, does not recognize multiple chemical sensitivity or environmental sensitivity as a valid diagnosis.^[14]

Because of the lack of scientific evidence, based on well-controlled clinical trials, that supports a cause-and-effect relationship between exposure to very low levels of chemicals and the myriad symptoms reported by clinical ecologists, MCS is not recognized as an established organic disease by the American Academy of Allergy, Asthma, and Immunology, the American Medical Association (AMA), the California Medical Association, the American College of Physicians, or the International Society of Regulatory Toxicology and Pharmacology.^[2][15][16] In 1994, the AMA, American Lung Association, US EPA and US Consumer Product Safety Commission published a booklet on indoor air pollution that discusses MCS, among other issues. Although sometimes misrepresented as evidence these groups recognize MCS as a specific disease, the booklet states a pathogenesis of MCS has not been definitively proven. The booklet further states symptoms that have been self-diagnosed by a patient as related to MCS could actually be related to allergies or have a psychological basis. Finally, the booklet recommends physicians counsel individuals seeking medical assistance to alleviate their symptoms that they may benefit from consultation with specialists in these fields.^[17]

Ronald E. Gots, M.D., an environmental toxicologist and frequent defense consultant in toxic tort litigation,^[18] describes MCS as "a label given to people who do not feel well for a variety of reasons and who share the common belief that chemical sensitivities are to blame. ... It has no consistent characteristics, no uniform cause, no objective or measurable features. It exists because a patient believes it does and a doctor validates that belief."^[19] In editorial in the Journal of Toxicology - Clinical Toxicology Gots wrote, "The phenomenon of multiple chemical sensitivities is a peculiar manifestation of our technophobic and chemophobic society. ... It may be the only ailment in existence in which the patient defines both the cause and the manifestations of his own condition."^[2]

In 1995, an Interagency Workgroup on Multiple Chemical Sensitivity was formed under the supervision of the Environmental Health Policy Committee within the United States Department of Health and Human Services to examine the body of research that had been conducted on MCS to that date. The work group included representatives from the Centers for Disease Control and Prevention, United States Environmental Protection Agency, United States Department of Energy, Agency for Toxic Substances and Disease Registry, and the National Institutes of Health. The Predecisional Draft document generated by the workgroup in 1998 recommended additional research in the basic epidemiology of MCS, the performance of case-comparison and challenge studies, and the development of a case definition for MCS. However, the workgroup also concluded it was unlikely MCS would receive extensive financial resources from federal agencies due to budgetary restraints and the allocation of funds to other, extensively overlapping syndromes with unknown etiology, such as chronic fatigue syndrome, fibromyalgia, and Gulf War syndrome. The Environmental Health Policy Committee is currently inactive, and the workgroup document has not been finalized.^[20]

Limited recognition in some situations

In 1997, Social Security Administration Commissioner John Callahan issued a court memorandum officially recognizing MCS "as a medically determinable impairment" on an agency-wide basis.^[21] With regard to the potential for exposure to chemicals in the workplace and MCS, the Occupational Safety and Health Administration (OSHA) has indicated MCS is highly controversial and there is insufficient scientific evidence to explain the relationship between the theorized causes of MCS and its symptoms. However, OSHA recommends “…an evaluation must be performed by a physician knowledgeable of the symptoms of this condition.”^[22]

A 1997 court decision held that MCS "is untested, speculative, and far from generally accepted in the medical or toxicological community," and thus cannot be used as the basis for disability claims.^[23] Furthermore, accommodations sought for MCS are sometimes denied as being unreasonable as a matter of law.^[24]

Clinical trials

Double-blind, placebo-controlled trials indicate people diagnosed with MCS do not reproducibly have symptoms when exposed to chemicals. In a 1993 study, MCS subjects could not discriminate between their chemical triggers and clean air when an olfactory masker was introduced that eliminated the ability to discriminate on the basis of odor.^[25] In a 2008 study, a variety of responses, including the subjective perception of being exposed to solvents, increases in blood pressure or heart rate, or increased symptom severity, were measured following the double-blind exposure to several solvents. People with an MCS diagnosis showed no differences in these parameters when they were exposed to clean air or to solvents at a concentration too low to smell.^[4] The trial did not support the hypothesis that MCS is directly related to the effects of chemical exposures. Since MCS sufferers seem to only have symptoms when they perceive exposure to chemicals, the syndrome is proposed to be a result of odor hypersensitivity in which individuals have an exaggerated response to scents,^[5] or psychological factors.

Symptoms

Symptoms of MCS may be mild to disabling. Symptoms may be physical or psychological in nature and are essentially those that are disruptive to the individuals’ mental or physical wellness and that the individual attributes to exposure to a chemical or scent.

By far, the most common symptoms are vague complaints: feeling tired, "brain fog" (short-term memory problems, difficulty concentrating) and muscle pain.^[26] These complaints are common to a large number of medical conditions, from psychiatric conditions, such as major depressive disorder, to neurological conditions, such as orthostatic intolerance, to high blood pressure, autoimmune diseases and cancer.

A partial list of other symptoms patients have attributed to MCS include difficulty breathing, pains in the throat, chest, or abdominal region, asthma, skin irritation, contact dermatitis, and hives or other forms of skin rash, headaches, neurological symptoms (nerve pain, pins and needles feelings, weakness, trembling, restless leg syndrome, etc.), tendonitis, seizures, visual disturbances (blurring, halo effect, inability to focus), extreme anxiety, panic and/or anger, sleep disturbance, suppression of immune system, digestive difficulties, nausea, indigestion/heartburn, vomiting, diarrhea, joint pains, vertigo/dizziness, abnormally acute sense of smell, sensitivity to natural plant fragrance or natural pine terpenes, insomnia, dry mouth, dry eyes, and an overactive bladder.^{[12][26][27][28]}

Causes

There is no clear consensus as to what causes the symptoms of MCS; there may be several.

Misdiagnosis

More than half of 56 people from one study about MCS instead had somatoform disorder^[29] or panic disorder.^[30] Other possible explanations include migraine, anxiety disorder, lupus, postural orthostatic tachycardia syndrome or other forms of orthostatic intolerance, hay fever and other allergies, hypercalcemia, hypothyroidism, chronic fatigue syndrome, or fibromyalgia. Sufferers may also have a tendency to "catastrophically misinterpret benign physical symptoms"^[31] or simply a disturbingly acute sense of smell.^[32]

Psychological

Several mechanisms for psychological etiology have been proposed, including theories based on stress, Pavlovian conditioning, or misdiagnoses of an underlying mental illness. Behavior exhibited by MCS sufferers may reflect broader sociological fears about industrial pollution.^[33]

The distinction between physiological and psychological causes is often difficult to test,^[3] and it is particularly challenging for MCS because substances used to test for sensitivity can often be detected by scent. Odor cues make double blind studies of MCS patients difficult, and scents might provoke a psychosomatic response. Research by Dr Mariko Saito et al. from the Department of Psychosomatic Medicine at the University of Tokyo in 2005 found patients only experienced symptoms when they themselves initiated the challenge tests. When they were given random prompts, there was no difference between MCS patients and controls in terms of physical and psychologic symptoms.^[34] Their conclusion was "MCS patients do not have either somatic or psychologic symptoms under chemical-free conditions, and symptoms may be provoked only when exposed to chemicals," although their results showed it was not the chemicals themselves that caused the symptoms.

A review of 37 provocation studies concluded "persons with MCS do react to chemical challenges; however, these responses occur when they can discern differences between active and sham substances, suggesting that the mechanism of action is not specific to the chemical itself and might be related to expectations and prior beliefs".^[3]

An alternative psychological cause has been suggested by a recent case-control study in which MCS was associated with a personality trait called absorption, in which individuals are predisposed to becoming deeply immersed in sensory experiences, leading to self-altered states of consciousness (see Flow). When 54 MCS sufferers were compared to 44 subjects with a somatoform disorder and 54 normal individuals, only those with MCS were related to increased absorption scores, leading the authors to suggest absorption contributes to MCS by making individuals more susceptible to harboring beliefs in MCS, and these beliefs are reinforced by conditioning.^[35]

The cause and existence of MCS are disputed. In particular, doctors disagree about whether symptoms are physiologically or psychologically generated, or both. United States courts and several medical organizations reject MCS as a physiological disease. An approach called clinical ecology attempts to treat the disease, but this work is controversial.^[36] Critics charge:

1. MCS has never been clearly defined,
2. no scientifically plausible mechanism has been proposed for it,
3. no diagnostic tests have been substantiated,^[37] and
4. not a single case has been scientifically validated.^[38]

These claims are challenged, particularly (1) and (2), insofar as both definitions^[8] and physiological pathways^[39][40] have actually been proposed. The scientific community remains divided, however, with many proponents of the psychosomatic school rejecting physiological explanations outright.

Neurological

One of the first studies on MCS (1993) focused on possible long-term potentiation in the hippocampi and neural sensitization as a central mechanism.^[41][42] Later studies examined the role of the inflammatory process, and found brain inflammation was correlated with symptoms of MCS.^[42] In 1999, Meggs proposed MCS is caused by low molecular weight-chemicals that bind to chemoreceptors on sensory nerve C-fibres, leading to the release of inflammatory mediators.^[43]

MCS people may have some neurological dysfunction in the odor-processing areas of the brain.^[44]

Genetic differences in metabolism

In 2004, McKeown-Eyssen and colleagues showed polymorphisms in the CYP2D6 allele responsible for variation in toxicant metabolism pathways may cause differences in susceptibility to MCS.^[45] Pall has suggested elevated nitric oxide and peroxynitrite (NO/ONOO-) as the etiology for MCS and several related conditions, including fibromyalgia, posttraumatic stress disorder, Gulf War syndrome, and chronic fatigue syndrome.^[42] This seems to be supported by a study by Reid et al. (2001) into the prevalence of MCS amongst British Gulf War syndrome sufferers. This study concluded veterans who had used personal organophosphate pesticides during the second Gulf War were 12 times more likely to develop MCS.^[46] Many observable and empirical, scientific facts can help identify MCS, including SPECT scans and chemical encephalopathy, vitamin deficiencies, mineral deficiencies, excess amino acid deficiency, and disturbed lipid and carbohydrate metabolism.^{[13][47][48][49]}

McKeown-Eyssen studied 203 MCS sufferers and 162 controls; blood tests revealed genetic differences relating to the body's detoxification processes were present more often in those with MCS than those without.^[45] The data showed five genetic polymorphisms have a statistically significant role in determining MCS prevalence.^[45] Each of these genes encode proteins that metabolize chemicals previously implicated in MCS, notably the organophosphate pesticides (PON1 and PON2 genes) and the organic solvents (CYP2D, NAT1 and NAT2 genes). People with a high expression of two specific genes (CYP2D6 and NAT2) were 18 times more likely to have MCS than those without. They concluded "a genetic predisposition for MCS may involve altered biotransformation of environmental chemicals." Haley found similar, confirmatory results with the PON1 gene in studies of the Gulf War syndrome veterans.^[50] A new study by Schnakenberg et al. (2006) confirmed the genetic variation previously found by McKeown-Eyssen and Haley.^[40] A total of 521 unrelated individuals participated in the study. Genetic variants of four genes were analyzed: NAT2, GSTM1, GSTT1, and GSTP1. The researchers concluded the individuals who are NAT2 slow acetylators and those with homozygously deleted GSTM1 and GSTT1 genes are significantly more likely to develop chemical sensitivity. According to the study, the glutathione S-transferases act to inactivate chemicals, so people without these GSTM1 and GSTT1 genes are less able to metabolize environmental chemicals, because "glutathione S-transferases play an important role in the detoxification of chemicals". The deletion of another gene, the GSTP1 gene, leaves individuals more susceptible to developing these diseases, as lack of these genes means a loss of protection from oxidative stress.

A specific laboratory rat, the Flinders Sensitive line, has been bred by Dr. Overstreet to be sensitive to an organophosphate, and displays "Increased sensitivity to cholinergic agents [that] has also been observed in several human populations, including individuals suffering from chemical intolerance."^[51] In particular, Flinders Sensitive rats show increased responses to nicotine, alcohol, and other chemicals known to act on acetylcholine, dopamine, and serotonin receptors. However, these rats have not reacted abnormally to other chemicals thought to trigger MCS, such as perfume, in any known studies. Study of these rats may therefore provide useful clues about the mechanisms involved in some, but not all, forms of chemical intolerance in humans.

Miscellaneous theories

Emotional stresses

People who have stronger emotional states will react more strongly to a smell.^[52] The brain's emotional regions do not discriminate well between the different odors. That discrepancy between brain regions may relate to anxiety disorders. If the olfactory region does not distinguish a dangerous odor signal from a benign smell, the brain's fight-or-flight region can overreact.^[53] Indeed, there has been some suggestion that the hypothalamic-pituitary-adrenal axis (the "stress axis") may be abnormal (blunted) in persons highly sensitive to chemicals, such as MCS, Addison's disease, chronic fatigue syndrome, and seasonal affective disorder.^[54]

Chemical triggers

Multiple chemicals have been reported to trigger MCS symptoms.^[13][16] In addition to anything which is perfumed or scented, complaints are commonly formed about everyday items:

Food

• Tartrazine (a.k.a FD&C Yellow #5 or E102), and other azo dyes^{[citation needed]} (true allergy must first be excluded)
• Caffeine
• Monosodium glutamate^[55]

Multiple food intolerances can be masked by a delayed reaction. These are not allergic reactions, and cannot be tested, only discovered by an elimination diet.

Substances with strong scents

In a review of a two-phase population study, respondents with MCS indicated cleaning agents (88.4%), pesticides (81.2%), perfumes (81.2%), vehicle exhaust (72.5%), the products used in barber shops and beauty salons (60.9%), new carpeting (53.6%), new furniture (39.1%), chlorine in drinking water (29.1%), and fresh ink (26.1%) were the products most often reported to trigger reactions in the respondents. They also indicated smoke from a fireplace, wood stove, or barbecue grill, and secondhand tobacco smoke were triggers for reactions.^[56]

Other reported^{[citation needed]} chemical triggers include:

• Gasoline (petrol) or diesel fuel
• Petroleum-based products, including petroleum jelly, tar, or asphalt
• Pesticides, herbicides, fertilizers, and other agricultural chemicals
• Industrial cleaning chemicals, such as dry cleaning fluid
• Formaldehyde
• Glues, varnishes, polishes, paints, solvents, paint thinners, and volatile organic compounds (VOCs)
• Bleach, fabric softeners, wool-wash, and laundry detergents
• Perfumes, lotion, aftershave lotion, nail polish, or skin care products
• Air fresheners, deodorizers and scented candles
• Shampoos, hairsprays and hair care products
• Dishwashing liquid and dishwasher detergent
• Marking pens, such as highlighters

Diagnosis

People who have developed symptoms of MCS have attributed a wide assortment of symptoms to chemical exposure, though symptoms are generally consistent for each individual. The first step in diagnosing a potential MCS sufferer is to identify and treat all other conditions which are present and which often explain the reported symptoms. For example, true allergy, thyroid disorders, orthostatic syndromes, anxiety, and depression need to be carefully evaluated and, if present, properly treated.

The "gold standard" procedure for identifying a person who has MCS is to test his or her response to the random introduction of chemicals the patient has self-identified as relevant, such as scented soaps or dryer sheets. This may be done in a carefully designed challenge booth to eliminate the possibility of contaminants in the room. Chemicals and controls, sometimes called prompts, are introduced in a random method, usually scent-masked. The test subject does not know when a prompt is being given. Objective and subjective responses are measured. Objective measures, such as the galvanic skin response^[8] electrodermal response, indicate psychological arousal, such as fear, anxiety, or anger. Subjective responses include patient self-reports. A diagnosis of MCS can only be justified when the subject cannot consciously distinguish between chemicals and controls, and when responses are consistently present with exposure to chemicals and consistently absent when prompted by a control.

Investigators in Japan,^[57] Spain,^[58] Germany^[59] and the United States^[60] have used the Quick Environmental Exposure and Sensitivity Inventory (QEESI) as a self-screening questionnaire in their research on MCS. The QEESI is a shortened version of the Environmental Exposure and Sensitivity Inventory developed by Dr. Claudia S. Miller.^[61] The QEESI asks individuals to rank their responses to exposures from 0 to 10 in four scales: symptom severity, chemical intolerances, other intolerances, and life impact.^[62]

Treatment

In various studies, about one half of the patients who present with symptoms of MCS meet the criteria for depressive and anxiety disorders, and these conditions must be treated when present.^[63] The use of SSRI antidepressants with a 53-year-old man with multiple chemical sensitivities showed a dramatic improvement, which suggests, as with the general population, a subgroup of MCS patients may have an atypical depression and should be evaluated for this condition.^[64]

Another study showed psychotherapy resulted in significant, long-term improvement in MCS symptoms, although there was no control group to which to compare results.^[65]

While patients typically resist the potentially stigmatizing diagnosis of an anxiety disorder, many MCS sufferers benefit strongly from lifestyle changes. A 2003 survey of 917 MCS patients revealed the two most effective treatments for MCS, in order of self-perceived harm/benefit ratio, were a chemical-free living space and chemical avoidance. Next came prayer and meditation, which presumably did no harm.^[12] By comparison, two-thirds of patients who had tried Zoloft thought it was harmful. Other treatments with perceived harm included other pharmaceutical drugs, provocative neutralization, hydrogen peroxide, Metagenics' UltraClear medical food, and microhydrin antioxidants. Overall, one or more antidepressants and anxiolytics were rated harmful by about half of survey respondents who had tried them, and as either harmless or helpful by the remaining respondents.

Other treatment modalities variably consist of the avoidance of known irritants, nutritional support to purge the body of its toxic load, sauna detoxification and autolymphycyte factor treatment.^[13]

Because many people eliminate whole categories of food in an effort to reduce symptoms, a complete review of the patient's diet may be needed to avoid nutritional deficiencies.^[66]

History

Allergist Theron G. Randolph (1906–1995) was the first to describe "the chemical intolerance phenomenon" in the mid-20th century, calling it "unwitting addiction" and comparing it to drug and alcohol addiction, with the addiction cycle being transparent to the patient as a masked intolerance.^[67] When Randolph formulated his views, the term allergy was not connected with immunology, as it has been since the late 1960s.^[67] It was then that non-immune-mediated hypersensitivities came to be called "intolerances", "idiopathic" or "idiosyncratic reactions" or "pseudoallergies". Randolph's theory was dismissed from the realm of allergology as the condition is not mediated by the humoral immune system.^[67]

Epidemiology

As Magill and Seruda report:

Most patients (85 to 90 percent) complaining of MCS syndrome are women. Most present between the ages of 30 and 50 years. Much additional basic descriptive and epidemiologic information is still unknown. The incidence and prevalence are unknown. The question of whether MCS is becoming more or less common is unanswered, as is the question of whether it is preventable. The natural history and biologic outcomes of MCS are unknown, and descriptions of MCS in primary care settings have not been reported. Selected patients from specialty settings comprise reports of the syndrome.^[16]

Relationship to Gulf War syndrome

Several clinical and epidemiological studies conducted in the United States and in the United Kingdom have investigated the occurrence of MCS in military personnel deployed to the Persian Gulf during the 1990s. Some of the health complaints and symptoms reported by veterans of the Gulf War attributed to Gulf War syndrome are similar to those reported for MCS, including headache, fatigue, muscle stiffness, joint pain, inability to concentrate, sleep problems, and gastrointestinal issues.^[68]

A population-based, cross-sectional epidemiological study involving American veterans of the Gulf War, non-Gulf War veterans, and non-deployed reservists enlisted both during Gulf War era and outside the Gulf War era concluded the prevalence of MCS-type symptoms in Gulf War veterans was somewhat higher than in non-Gulf War veterans.^[69] After adjusting for potentially confounding factors (i.e., age, sex, and military training), there was a robust association between individuals with MCS-type symptoms and psychiatric treatment (either therapy or medication) before deployment and, therefore, before any possible deployment-connected chemical exposures.

The odds of reporting MCS or chronic multiple-symptom illness was 3.5 times greater for Gulf War veterans than non-Gulf veterans.^[70]

Gulf War veterans have an increased rate of multiple-symptom conditions compared to military personnel deployed to other conflicts, and although it is unexplained, Gulf War syndrome is not considered distinct from other medically unexplained syndromes observed in civilian populations, including MCS.^[71]

In media

• John Stossel's 1994 TV special The Blame Game, which chronicles cultural victimization and lack of responsibility in American society, includes a group of four employees of Tompkins County, New York's Social Services Department who claimed to have been rendered disabled by MCS caused by the chemicals in their building.
• In the TV series Northern Exposure, the character Mike Monroe is portrayed as suffering from MCS.^{[episode needed]}
• The 1995 film "Safe," starring Julianne Moore and directed by Todd Haynes, is about a woman who develops MCS. It was voted the best film of the 1990s in the 1999 Village Voice Film Poll.
• The 2008 work Tilt, by Italian writer Caterina Serra, reports and narrates the lives of many patients affected by MCS.
• Anne Lipscomb's 2009 memoir Poisoned by Pollution: An Unexpected Spiritual Journey details the author's struggles with MCS.^[72]
• In a 2009 episode of the TV series "Bones," MCS patients are scammed and murdered.^[73]
• Thilde Jensen NY Times Multimedia piece: Everything Makes Them Sick, September 17, 2011

See also

• Salicylate sensitivity
• Chemophobia, the fear of chemicals

References

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2. ^ ^{a b c d} Gots RE (1995). "Multiple chemical sensitivities--public policy". J. Toxicol. Clin. Toxicol. 33 (2): 111–3. doi:10.3109/15563659509000459. PMID 7897748. "The phenomenon of multiple chemical sensitivities is a peculiar manifestation of our technophobic and chemophobic society. It has been rejected as an established organic disease by the American Academy of Allergy and Immunology, the American Medical Association, the California Medical Association, the American College of Physicians, and the International Society of Regulatory Toxicology and Pharmacology. It may be the only ailment in existence in which the patient defines both the cause and the manifestations of his own condition." 
3. ^ ^{a b c} J. Das-Munshi, G. J. Rubin, S. Wessely, Multiple chemical sensitivities: A systematic review of provocation studies, Journal of Allergy and Clinical Immunology, 118, pp.1257-1264 (2006)
4. ^ ^{a b} Bornschein S, Hausteiner C, Römmelt H, Nowak D, Förstl H, Zilker T. (2008). "Double-blind placebo-controlled provocation study in patients with subjective Multiple Chemical Sensitivity (MCS) and matched control subjects". Clin Toxicol (Phila). 46 (5): 443–9. doi:10.1080/15563650701742438. PMID 18568800. 
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6. ^ "DI 24515.064 Evaluation Of Specific Issues — Environmental Illness". Social Security Administration. https://secure.ssa.gov/apps10/poms.nsf/lnx/0424515064!opendocument. Retrieved 8 May 2010. "Therefore, in evaluating claims based on environmental illness, all of the claimant's symptoms, signs, and laboratory findings must be considered to determine if there is a medically determinable impairment and the impact of any impairment on the claimant's ability to work. This evaluation should be made on an individual case-by-case basis to determine if the impairment prevents substantial gainful activity." 
7. ^ Michaels, supra, states: "Some advocates refer to this disability as Chemical Injury Syndrome (CIS), which they believe more effectively communicates the severity of this disability."
8. ^ ^{a b c} Joffres MR, Sampalli T, Fox RA (2005). "Physiologic and symptomatic responses to low-level substances in individuals with and without chemical sensitivities: a randomized controlled blinded pilot booth study". Environ Health Perspect 113 (9): 1178–83. doi:10.1289/ehp.7198. PMC 1280398. PMID 16140624. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1280398. Retrieved 2007-03-04. 
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10. ^ MCSS factsheet — United States National Institute of Environmental Health Sciences
11. ^ Miller CS (1997). "Toxicant-induced Loss of Tolerance-An Emerging Theory of Disease?". Environ Health Perspect. (Brogan &#38) 105 (2): 445–53. doi:10.2307/3433351. JSTOR 3433351. PMC 1469811. PMID 9167978. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1469811. Retrieved 2007-03-04. 
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13. ^ ^{a b c d} Rea, WJ, Johnson, AR, Ross, GH, Butler, JR, Fenyves, EJ, Griffiths, B,& Laseter, J (2006). Considerations for the Diagnosis of Chemical Sensitivity. Retrieved January 1, 2007 from http://www.aehf.com/articles/A55.htm
14. ^ Sears, Margaret E. 2007. "The Medical Perspective on Environmental Sensitivities." Note: The opinions expressed in this report are those of the author and do not necessarily reflect the views of the Canadian Human Rights Commission.
15. ^ Council on Scientific Affairs, American Medical Association (1992). "Clinical ecology.". JAMA 268 (24): 3465–7. doi:10.1001/jama.268.24.3465. PMID 1460738. ""No evidence based on well-controlled clinical trials is available that supports a cause-and-effect relationship between exposure to very low levels of substances and the myriad symptoms reported by clinical ecologists to result from such exposure . . . . Until such accurate, reproducible, and well-controlled studies are available, the American Medical Association Council on Scientific Affairs believes that multiple chemical sensitivity should not be considered a recognized clinical syndrome."" 
16. ^ ^{a b c} Magill MK, Suruda A (September 1998). "Multiple chemical sensitivity syndrome". Am Fam Physician 58 (3): 721–8. PMID 9750540. http://www.aafp.org/afp/980901ap/magill.html. 
17. ^ Indoor Air Pollution: An Introduction for Health Professionals. Co-sponsored by: The American Lung Association (ALA), The Environmental Protection Agency (EPA), The Consumer Product Safety Commission (CPSC), and The American Medical Association (AMA). 1994. http://www.epa.gov/iedweb00/pubs/hpguide.html#faq1. Retrieved 2008-06-30. "[D]efinition of the phenomenon is elusive and its pathogenesis as a distinct entity is not confirmed....The current consensus is that in cases of claimed or suspected MCS, complaints should not be dismissed as psychogenic, and a thorough workup is essential. Primary care givers should determine that the individual does not have an underlying physiological problem and should consider the value of consultation with allergists and other specialists." 
18. ^ An Expert Who Has Been There - Dr. Ronald E. Gots, The Metropolitan Corporate Counsel
19. ^ Gots RE. Multiple Chemical sensitivities: What is it? North Bethesda, MD: Risk Communication International, Inc., March 31, 1993.
20. ^ http://web.health.gov/environment/mcs/
21. ^ October 31, 1997, R-164, Creamer v. Callahan
22. ^ http://www.osha.gov/SLTC/multiplechemicalsensitivities/index.html
23. ^ Frank v. New York, 972 F. Supp. 130 (N.D.N.Y. 1997)
24. ^ Andrew K. Kelley, "COMMENT: Sensitivity Training: Multiple Chemical Sensitivity and the ADA," 25 B.C. Envtl. Aff. L. Rev. 485; see, for example, Whillock v. Delta Air Lines, 926 F.Supp. 1555 (N.D.Ga. 1995) http://lawdigitalcommons.bc.edu/ealr/vol25/iss2/5/
25. ^ Staudenmayer H, Selner JC, Buhr MP., Double-blind provocation chamber challenges in 20 patients presenting with "multiple chemical sensitivity". ul Toxicol Pharmacol. 1993 Aug;18(1):44-53.
26. ^ ^{a b} Understanding and Accommodating People With MCS, Pamela Reed Gibson, Ph.D.
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External links

• Overview from the MCS support organization Chemical Injury Information Network
• "Seeking Modern Refuge From Modern Life in The New York Times (2006)
• Understanding and Accommodating People With MCS, Pamela Reed Gibson, Ph.D., James Madison University
• Multiple Chemical Sensitivity: a spurious diagnosis, Stephen Barrett, MD. — A skeptical article hosted on Quackwatch
• Position statement from the American Academy of Allergy, Asthma, and Immunology