Clinical ecology: Environmentat unsubstantiated theory?
A concept known by several terms, including “environmental illness,” “multiple chemical sensitivities,” “ environmental hypersensitivity disorder,” “20th century disease,” and “total allergy syndrome” has recently attracted public attention and generated considerable controversy. The concept was developed by physicians known as clinical ecologists who now call themselves practitioners of “environmental medicine.” These physicians believe that certain persons are adversely affected by synthetic chemicals in the environment at doses far lower than can be explained by accepted pathophysiologic mechanisms. They believe that such low-level exposure can damage the immune system and make these persons hypersensitive to all or most synthetic chemicals. The symptoms attributed to this hypersensitivity are not the ordinary manifestations of toxicity or allergy, nor are they accompanied by any specific laboratory abnormalities or demonstrable pathologic lesions. The symptoms may involve every organ system, but central nervous system and behavioral symptoms seem to predominate; these symptoms include fatigue, depression, headache, dizziness, irritability, anxiety, mood swings, memory lapses, and periods of confusion. Some of the other symptoms reported include nausea, palpitations, constipation, muscle and joint pain, and vaginal burning. In this issue, a position paper by the American College of Physicians provides a thorough review of the theories and practices of clinical ecology.’ Elsewhere,’ the principal author of this paper has pointed out that there is no clear definition of the disease and
The views expressed arc not necessarily
by the authors are their personal opinion and those of the California Department of Health
Services or the State Compensation Insurance fund. Reprint requests: Ephraim Kahn, MD, MPH, Hazard Evaluation Section, California Department of Health Services. 2151 Berkeley Way, Room 619, Berkeley. CA 94704.
l/l/17048
Medicine
or
that the vagueness and multiplicity of symptoms argue against their constituting a single disease process, especially in the absence of immunologic, biochemical or histologic abnormalities. To the patient, of course, purely subjective symptoms are fully as real as symptoms attributable to variable pathologic processes. These patients are sick and sometimes tndy disabled. The underlying question is: What makes them ill and how should they be treated? There have been three systematic evaluations of clinical ecology by health and medical organizations. The California Medical Association appointed, at the request of clinical ecologists, a task force with members chosen from nine specialties to review over many months the literature presented by the clinical ecologists and to listen to oral presentations. In Canada. the Ontario Ministry of Health appointed a Committee on Environmental Hypersensitivity, and the American Academy of Allergy and Immunology conducted its own review. Separate reports issued by all three organizations3“ in 1986 found no convincing evidence to support the concepts underlying clinical ecology or its methods of diagnosis and treatment. Three clinical reports, two of them by psychiatrists, have reviewed the findings in groups of clinical ecology patients. The patients are described as middle class, generally intelligent and well educated. and predominantly female. B&sky6 described eight patients who had filed workers’ compensation claims on the basis of environmental illness diagnosed by clinical ecologists. Because the cases were in litigation. Brodsky had access to extensive medical and other records on each claimant. He found that all patients had had psychiatric symptoms for many years before their “exposure” at work and had gone from one doctor to another until they found one who provided them with a physical explanation for their symptoms, an explanation acceptable to them and fulfilling many psychological needs. Stewart and Raskin’ examined 18 patients referred 437
438 Kahn and Leb
by physicians or lawyers to a university psychiatric service. They found that 7 patients had somatoform disorders, 10 patients suffered from a psychosisor an affective or anxiety disorder, and 1 patient had a personality disorder. Ter?’ reviewed 50 clinical ecology cases, 46 of which were involved in workers’ compensationclaims or other litigation. Although 3 1 patients in thesecases had multiple subjective symptoms, there were no abnormal physical findings or laboratory results. The clinical ecology treatments they had received had failed in every case to produce a remission. In most patients the number of symptoms significantly increased after such therapy, implying a strong iatrogenie factor. It can be arguedthat the patients examined by Ter? and by B&sky6 were not typical becausethey were involved in litigation and that Stewart and Raskin’s’ findings may be biasedbecausetheir patientshad been referred for psychiatric evaluation. Their findings indicate, however, that a psychiatric diagnosis should be consideredin thesepatients and that the symptoms of 20th century diseasehave much in common with other conditions known to physicians for centuries under various names such as hysteria, neurasthenia, and neurocircualtory asthenia,all of which were unexplained by the conventional medicine of the time.’ In this regard it is revealing that the founders of clinical ecology dedicate their work to “all patients who have ever been called neurotic, hypochondriac, hysterical or starved for attention while suffering from environmentally induced illness.‘* Another review of the subject, which clearly applies only to a limited subsetof patients, is the collection of papers on “workers with multiple chemical sensitivities,” edited by Cullen.” This collection dealswith casesoccurring in the occupational setting where exposuresto toxic materials may be substantial. Cullen’O provides his own definition of the syndrome, which is far more limited than the wide-ranging descriptions usedby clinical ecologists. Many of the casesinvolve chronic exposure to solvents with known central nervous system toxicity. Cullen concedesthat some of these cases may represent true toxicity, the posttraumatic stresssyndrome, or somatoform disorders. The collection also contains a paper by Levin and Byers,” leading proponentsof the practice of clinical ecology. Characteristically, their discussion mixes their theories concerning a new type of environmentally induced immune system dysfunction with referencesto known toxic mechanismsin a manner that tends to blur the distinction between the two. Perhaps the most important paper in the Cullen collection is that by Schottenfeld.‘2He points out the high incidenceof depressionin the generalpopulation,
J. ALLERGY
CLIN. IMMUNOL. FEBRUARY 1990
the frequency with which its manifestationsare atypical and resemble those of patients with “multiple chemical sensitivity,” and that the diagnosisof depression is routinely missed by primary care physicians. Examining the sociocultural aspectsof the clinical ecology movement may be more illuminating than looking at its scientific foundation or lack thereof. That it constitutes a movement rather than merely a new medical theory seemsobvious. Brodsky” refers to it as a “medical subculture” and suggestsstudy by social and behavioral scientists. Support groups for clinical ecology patients have sprung up in several areas.They publish newsletters, lobby for legislation recognizing their disabilities, and try to persuadethe media to carry stories about personsallergic to everything who are so disabled they must live in total isolation, avoiding exposuresto everything from newsprint and detergents to plastics and perfumes. They have attracted an aggressive group of lawyers who litigate their claimsI and even threaten legal action against those who criticize the practice of clinical ecology. There is a fertile social environment for a crusade of this sort-a result of the strong environmental movementof the past two decadesand the widespread concern it has engenderedabout environmental contamination. With analytic methodsnow able to show the presenceof environmental contaminantsat levels in the part-per-trillion range, the public seesitself as exposed to toxic materials on all sides. Not surprisingly, some people are receptive to the rhetoric of a group that claims to show how harmful environmental chemicals can be, not just as potential carcinogensor mutagensbut as agentsof immediate disabling illness acting through the mysterious mechanismsof the immune system.Is When does a movement take on the characteristics of a cult? Accusationsmadeby clinical ecologiststhat organized medicine is prejudiced against them certainly represent one such feature. Another is selfportrayal as embattled fighters for new truths against an entrenched establishment. Most characteristic is reliance on testimonials and anecdotesasevidenceand the lack of training in scientific methodology among the chief proponentsof clinical ecology. To back their claims, clinical ecologists frequently quote the scientific literature. When it is pointed out that they are either misquoting or misinterpreting the data or are citing seriously flawed reports, they may then attack the “limitations of the scientific method” that cannot confirm their newly discovered disease.16.” Clinical ecologists may also point to their successin various court casesand even claim that the courtroom is the best place to validate scientific hypotheses.IR.I9
VOLUME NUMBER
a5
Clinical
ec-oiocjv
439
2
As in any science, modem medicine must be open to new conceptsand theories. But as we approachthe last decadeof the twentieth century, it should be obvious that new theories and methods of diagnosis or treatmentcan be acceptedas valid only after they have been subjected to properly done and reproducible, controlled clinical trials. In the history of medicine, including modem medicine, many theories and practices have had to be discarded under the impact of properly controlled investigation: for example, the abandonmentof prolonged bed rest after childbirth or surgery; the discarding of childhood tonsillectomy as a routine procedure, the realization that radical mastectomy is not the treatment of choice for all breast cancer; and the rejection of Wangensteenfreezing of the gastric mucosaas therapy for peptic ulcer. Clinical ecology lacks scientific validation, and the practice of “environmental medicine” cannot be considered harmless. Severe constraints are placed on patients’ lives, and, in many cases,invalidism is reinforced as patients develop increasing iatrogenic disability. Treatmentby clinical ecologistsfrequently createsa severefinancial burden for patientsand imposes significant costson health insurers and workers’ compensation systems. Terr hascorrectly statedthat acceptanceof the concepts and practices of clinical ecology must be based on standardsof evidenceas rigorous asthosecurrently being applied in other areas of medicine.’ He has described in detail the nature of the studies required to test the theories and methods of clinical ecology and the mannerin which thesestudiesshould be done. At present, serious ethical problems are raised by the use of treatmentsbefore they have been proved safe and effective. Ephraim Kahn, MD, MPH California Department of Health Services Berkeley, California Gideon Letz, MD, MPH State Compensation Insurance Fund San Francisco, California Ann Intern Med 1989;111:104-106.
REFERENCES Ann lnrcrn I. American College of Physicians. Clinical ecolq! Med 1989;l Il:168-78. 2. Terr AI. “Multiple chemical sensitivities”: irnmurrohrlzic errtique of ciinical ecology theories and practice State An Rev Occup Med 1987;2:683-94. 3. California Medical Association Scientitic Board ‘I‘& lorce on Clinical Ecology. Clinical ecology -a critical appraisal. Wc\t J Med 1986;144:239-45. 4. Report of the Advisory Panel on Environmental Hypersensitivity. 1986. Toronto. Ontario: Ministry of Her.lth. I’rovmce of Ontario, 1986. 5. Clinical Ecology. Executive Committee of the American Academy of Allergy and Immunology. J AI.I.EKC;Y (‘I IU IhtMt.Nor 1986;78:269-71. 6. B&sky CM. “Allergic to everything”: a medical subculture. Psychosomatics 1983;24:731-2. 734-6, ?4O-2. 7. Stewart DE, Raskin J. Psychiatric assessment of patients with “2Oth-century disease” (“total allergy syndrome” 1 Can Mcd Assoc J 1985;l33:1001-6. 8. Tert AI. Environmental illness: a clinical revtew 01 51) case, Arch Intern Med 1986;146: 145-9. 9. Randolph TG. Mass RW. An alternative approach to allergic\: the new tield of climcal ecology unravels the environmental causes of mental and physical ills. New Yurk: lrppincott & Cromwell, 1980. 10. Cullen MR. The worker with multiple chemical scnsitivitie\: an overview. State Art Rev Occup Med 19872 65.5-61. II. Levin AS, Byers VS. Environmental illness: drsorder ot immune regulation. State Art Rev Occup Mcd 19Xi.2:669-81. 12. Schottenfeld RS. Workers with multiple chemical sensitivities: a psychiatric approach to diagnosis and treatment. State Art Rev Occup Med 1987;2:739-53. 13. Brodsky CM. Multiple chemical sensitivities and other “environmental illness”: a psychiatrist’s view,. State Art Rev Oocup Med 1987;2:695-704 14. Marshall E. Wobum case may spark explosun ot lawsuits [news]. Science 1986:234:418-20. 1.5. Kahn E. Chemical sensitivity: a non-believer‘s \ icw J ~&IItide Reform 1987;7:33-6. 16. Nikiforuk C. Nikiforuk M. Evidence for the “hyperscnsrtivity syndrome.” Can Med Assoc J 1986; 134.13434 17. Levin AS. In: Legro W. Under siege. Crganrc Gardening 1988(AprilJ:66. 18. Levin AS. Science in court. Lancer 1987;: 1529 science and standards of proof. 19. Miller DR. Courtroom 1987~2: 1283-j. 01989 American College of Physicians
Lancct
A concept known by several terms, including “environmental illness,” “multiple chemical sensitivities,” “ environmental hypersensitivity disorder,” “20th century disease,” and “total allergy syndrome” has recently attracted public attention and generated considerable controversy. The concept was developed by physicians known as clinical ecologists who now call themselves practitioners of “environmental medicine.” These physicians believe that certain persons are adversely affected by synthetic chemicals in the environment at doses far lower than can be explained by accepted pathophysiologic mechanisms. They believe that such low-level exposure can damage the immune system and make these persons hypersensitive to all or most synthetic chemicals. The symptoms attributed to this hypersensitivity are not the ordinary manifestations of toxicity or allergy, nor are they accompanied by any specific laboratory abnormalities or demonstrable pathologic lesions. The symptoms may involve every organ system, but central nervous system and behavioral symptoms seem to predominate; these symptoms include fatigue, depression, headache, dizziness, irritability, anxiety, mood swings, memory lapses, and periods of confusion. Some of the other symptoms reported include nausea, palpitations, constipation, muscle and joint pain, and vaginal burning. In this issue, a position paper by the American College of Physicians provides a thorough review of the theories and practices of clinical ecology.’ Elsewhere,’ the principal author of this paper has pointed out that there is no clear definition of the disease and
The views expressed arc not necessarily
by the authors are their personal opinion and those of the California Department of Health
Services or the State Compensation Insurance fund. Reprint requests: Ephraim Kahn, MD, MPH, Hazard Evaluation Section, California Department of Health Services. 2151 Berkeley Way, Room 619, Berkeley. CA 94704.
l/l/17048
Medicine
or
that the vagueness and multiplicity of symptoms argue against their constituting a single disease process, especially in the absence of immunologic, biochemical or histologic abnormalities. To the patient, of course, purely subjective symptoms are fully as real as symptoms attributable to variable pathologic processes. These patients are sick and sometimes tndy disabled. The underlying question is: What makes them ill and how should they be treated? There have been three systematic evaluations of clinical ecology by health and medical organizations. The California Medical Association appointed, at the request of clinical ecologists, a task force with members chosen from nine specialties to review over many months the literature presented by the clinical ecologists and to listen to oral presentations. In Canada. the Ontario Ministry of Health appointed a Committee on Environmental Hypersensitivity, and the American Academy of Allergy and Immunology conducted its own review. Separate reports issued by all three organizations3“ in 1986 found no convincing evidence to support the concepts underlying clinical ecology or its methods of diagnosis and treatment. Three clinical reports, two of them by psychiatrists, have reviewed the findings in groups of clinical ecology patients. The patients are described as middle class, generally intelligent and well educated. and predominantly female. B&sky6 described eight patients who had filed workers’ compensation claims on the basis of environmental illness diagnosed by clinical ecologists. Because the cases were in litigation. Brodsky had access to extensive medical and other records on each claimant. He found that all patients had had psychiatric symptoms for many years before their “exposure” at work and had gone from one doctor to another until they found one who provided them with a physical explanation for their symptoms, an explanation acceptable to them and fulfilling many psychological needs. Stewart and Raskin’ examined 18 patients referred 437
438 Kahn and Leb
by physicians or lawyers to a university psychiatric service. They found that 7 patients had somatoform disorders, 10 patients suffered from a psychosisor an affective or anxiety disorder, and 1 patient had a personality disorder. Ter?’ reviewed 50 clinical ecology cases, 46 of which were involved in workers’ compensationclaims or other litigation. Although 3 1 patients in thesecases had multiple subjective symptoms, there were no abnormal physical findings or laboratory results. The clinical ecology treatments they had received had failed in every case to produce a remission. In most patients the number of symptoms significantly increased after such therapy, implying a strong iatrogenie factor. It can be arguedthat the patients examined by Ter? and by B&sky6 were not typical becausethey were involved in litigation and that Stewart and Raskin’s’ findings may be biasedbecausetheir patientshad been referred for psychiatric evaluation. Their findings indicate, however, that a psychiatric diagnosis should be consideredin thesepatients and that the symptoms of 20th century diseasehave much in common with other conditions known to physicians for centuries under various names such as hysteria, neurasthenia, and neurocircualtory asthenia,all of which were unexplained by the conventional medicine of the time.’ In this regard it is revealing that the founders of clinical ecology dedicate their work to “all patients who have ever been called neurotic, hypochondriac, hysterical or starved for attention while suffering from environmentally induced illness.‘* Another review of the subject, which clearly applies only to a limited subsetof patients, is the collection of papers on “workers with multiple chemical sensitivities,” edited by Cullen.” This collection dealswith casesoccurring in the occupational setting where exposuresto toxic materials may be substantial. Cullen’O provides his own definition of the syndrome, which is far more limited than the wide-ranging descriptions usedby clinical ecologists. Many of the casesinvolve chronic exposure to solvents with known central nervous system toxicity. Cullen concedesthat some of these cases may represent true toxicity, the posttraumatic stresssyndrome, or somatoform disorders. The collection also contains a paper by Levin and Byers,” leading proponentsof the practice of clinical ecology. Characteristically, their discussion mixes their theories concerning a new type of environmentally induced immune system dysfunction with referencesto known toxic mechanismsin a manner that tends to blur the distinction between the two. Perhaps the most important paper in the Cullen collection is that by Schottenfeld.‘2He points out the high incidenceof depressionin the generalpopulation,
J. ALLERGY
CLIN. IMMUNOL. FEBRUARY 1990
the frequency with which its manifestationsare atypical and resemble those of patients with “multiple chemical sensitivity,” and that the diagnosisof depression is routinely missed by primary care physicians. Examining the sociocultural aspectsof the clinical ecology movement may be more illuminating than looking at its scientific foundation or lack thereof. That it constitutes a movement rather than merely a new medical theory seemsobvious. Brodsky” refers to it as a “medical subculture” and suggestsstudy by social and behavioral scientists. Support groups for clinical ecology patients have sprung up in several areas.They publish newsletters, lobby for legislation recognizing their disabilities, and try to persuadethe media to carry stories about personsallergic to everything who are so disabled they must live in total isolation, avoiding exposuresto everything from newsprint and detergents to plastics and perfumes. They have attracted an aggressive group of lawyers who litigate their claimsI and even threaten legal action against those who criticize the practice of clinical ecology. There is a fertile social environment for a crusade of this sort-a result of the strong environmental movementof the past two decadesand the widespread concern it has engenderedabout environmental contamination. With analytic methodsnow able to show the presenceof environmental contaminantsat levels in the part-per-trillion range, the public seesitself as exposed to toxic materials on all sides. Not surprisingly, some people are receptive to the rhetoric of a group that claims to show how harmful environmental chemicals can be, not just as potential carcinogensor mutagensbut as agentsof immediate disabling illness acting through the mysterious mechanismsof the immune system.Is When does a movement take on the characteristics of a cult? Accusationsmadeby clinical ecologiststhat organized medicine is prejudiced against them certainly represent one such feature. Another is selfportrayal as embattled fighters for new truths against an entrenched establishment. Most characteristic is reliance on testimonials and anecdotesasevidenceand the lack of training in scientific methodology among the chief proponentsof clinical ecology. To back their claims, clinical ecologists frequently quote the scientific literature. When it is pointed out that they are either misquoting or misinterpreting the data or are citing seriously flawed reports, they may then attack the “limitations of the scientific method” that cannot confirm their newly discovered disease.16.” Clinical ecologists may also point to their successin various court casesand even claim that the courtroom is the best place to validate scientific hypotheses.IR.I9
VOLUME NUMBER
a5
Clinical
ec-oiocjv
439
2
As in any science, modem medicine must be open to new conceptsand theories. But as we approachthe last decadeof the twentieth century, it should be obvious that new theories and methods of diagnosis or treatmentcan be acceptedas valid only after they have been subjected to properly done and reproducible, controlled clinical trials. In the history of medicine, including modem medicine, many theories and practices have had to be discarded under the impact of properly controlled investigation: for example, the abandonmentof prolonged bed rest after childbirth or surgery; the discarding of childhood tonsillectomy as a routine procedure, the realization that radical mastectomy is not the treatment of choice for all breast cancer; and the rejection of Wangensteenfreezing of the gastric mucosaas therapy for peptic ulcer. Clinical ecology lacks scientific validation, and the practice of “environmental medicine” cannot be considered harmless. Severe constraints are placed on patients’ lives, and, in many cases,invalidism is reinforced as patients develop increasing iatrogenic disability. Treatmentby clinical ecologistsfrequently createsa severefinancial burden for patientsand imposes significant costson health insurers and workers’ compensation systems. Terr hascorrectly statedthat acceptanceof the concepts and practices of clinical ecology must be based on standardsof evidenceas rigorous asthosecurrently being applied in other areas of medicine.’ He has described in detail the nature of the studies required to test the theories and methods of clinical ecology and the mannerin which thesestudiesshould be done. At present, serious ethical problems are raised by the use of treatmentsbefore they have been proved safe and effective. Ephraim Kahn, MD, MPH California Department of Health Services Berkeley, California Gideon Letz, MD, MPH State Compensation Insurance Fund San Francisco, California Ann Intern Med 1989;111:104-106.
REFERENCES Ann lnrcrn I. American College of Physicians. Clinical ecolq! Med 1989;l Il:168-78. 2. Terr AI. “Multiple chemical sensitivities”: irnmurrohrlzic errtique of ciinical ecology theories and practice State An Rev Occup Med 1987;2:683-94. 3. California Medical Association Scientitic Board ‘I‘& lorce on Clinical Ecology. Clinical ecology -a critical appraisal. Wc\t J Med 1986;144:239-45. 4. Report of the Advisory Panel on Environmental Hypersensitivity. 1986. Toronto. Ontario: Ministry of Her.lth. I’rovmce of Ontario, 1986. 5. Clinical Ecology. Executive Committee of the American Academy of Allergy and Immunology. J AI.I.EKC;Y (‘I IU IhtMt.Nor 1986;78:269-71. 6. B&sky CM. “Allergic to everything”: a medical subculture. Psychosomatics 1983;24:731-2. 734-6, ?4O-2. 7. Stewart DE, Raskin J. Psychiatric assessment of patients with “2Oth-century disease” (“total allergy syndrome” 1 Can Mcd Assoc J 1985;l33:1001-6. 8. Tert AI. Environmental illness: a clinical revtew 01 51) case, Arch Intern Med 1986;146: 145-9. 9. Randolph TG. Mass RW. An alternative approach to allergic\: the new tield of climcal ecology unravels the environmental causes of mental and physical ills. New Yurk: lrppincott & Cromwell, 1980. 10. Cullen MR. The worker with multiple chemical scnsitivitie\: an overview. State Art Rev Occup Med 19872 65.5-61. II. Levin AS, Byers VS. Environmental illness: drsorder ot immune regulation. State Art Rev Occup Mcd 19Xi.2:669-81. 12. Schottenfeld RS. Workers with multiple chemical sensitivities: a psychiatric approach to diagnosis and treatment. State Art Rev Occup Med 1987;2:739-53. 13. Brodsky CM. Multiple chemical sensitivities and other “environmental illness”: a psychiatrist’s view,. State Art Rev Oocup Med 1987;2:695-704 14. Marshall E. Wobum case may spark explosun ot lawsuits [news]. Science 1986:234:418-20. 1.5. Kahn E. Chemical sensitivity: a non-believer‘s \ icw J ~&IItide Reform 1987;7:33-6. 16. Nikiforuk C. Nikiforuk M. Evidence for the “hyperscnsrtivity syndrome.” Can Med Assoc J 1986; 134.13434 17. Levin AS. In: Legro W. Under siege. Crganrc Gardening 1988(AprilJ:66. 18. Levin AS. Science in court. Lancer 1987;: 1529 science and standards of proof. 19. Miller DR. Courtroom 1987~2: 1283-j. 01989 American College of Physicians
Lancct
