Multiple chemical sensitivity

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Multiple chemical sensitivity
Classification and external resources
MeSH D018777

Multiple chemical sensitivity (MCS) is a chronic medical condition characterized by symptoms that the affected person attributes to low-level chemical exposure. Commonly attributed substances include scented products, pesticides, plastics, synthetic fabrics, smoke, petroleum products, and paint fumes. Symptoms are often vague and non-specific, such as nausea, fatigue, dizziness and headaches, but also commonly include inflammation of skin, joints, gastrointestinal tract and airways.

The National Institute of Environmental Health Sciences defines MCS as a "chronic, recurring disease caused by a person's inability to tolerate an environmental chemical or class of foreign chemicals".[1]

MCS is not recognized as an organic, chemical-caused illness by the World Health Organization, but is recognized by numerous government agencies in the USA and elsewhere including the EPA, American Lung Association,Consumer Product Safety Commission, and the American Medical Association. <43> [2][3] Blinded clinical trials have shown MCS patients react as often and as strongly to placebos as they do to chemical stimuli; existence and severity of symptoms is related to perception that a chemical stimulus is present.[4][5] Depression, anxiety, somatoform disorder, and similar mental health conditions are commonly associated with reports of MCS.[6][7] Regardless of the etiology, some people with severe symptoms are disabled as a result.

Signs and symptoms[edit]

Symptoms of MCS may be mild to disabling and may be physical or psychological in nature. They include any symptom disruptive to mental or physical wellness that the affected individual attributes to exposure to a chemical or scent.

By far the most common symptoms are vague, non-specific complaints: feeling tired, "brain fog" (short-term memory problems, difficulty concentrating) and muscle pain.[8] These complaints may be present with a wide variety of medical conditions, from psychiatric conditions, such as major depressive disorder, to neurological conditions, such as orthostatic intolerance, to sleep disorders, 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, hives or other forms of skin rash, headaches, neurological symptoms (nerve pain, pins and needles feelings, weakness, trembling, restless leg syndrome), 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 (hyperosmia), sensitivity to natural plant fragrance or natural pine terpenes, dry mouth, dry eyes, and an overactive bladder.[8][9][10][11]

Causes[edit]

There is no clear consensus for the cause or causes of the symptoms of MCS. In addition to extreme sensitivity to low concentrations of certain chemicals, several hypotheses have been proposed. The distinction between physiological and psychological causes is often difficult to test,[4] and it is particularly challenging for MCS because many substances used to test for sensitivity have a strong odor. Odor cues make double blind studies of MCS patients difficult, as scents can provoke a psychosomatic response or recall expectations and prior beliefs.[4] People with an MCS diagnosis show no differences in symptom severity, blood pressure, or heart rate when exposed to clean air or to solvents at a concentration too low to smell.[5]

Chemical triggers[edit]

Many chemicals have been reported to trigger MCS symptoms.[12] Substances with strong scents are the most common reported triggers. These include a variety of cleaning agents, pesticides, perfumes, vehicle exhaust, the products used in barber shops and beauty salons, new carpeting, new furniture, chlorine in drinking water, fresh ink, and less commonly wood smoke and secondhand tobacco smoke.[13] Food items reported as triggers include tartrazine (a.k.a. FD&C Yellow #5 or E102), and other azo dyes[14] (in the absence of an allergy), caffeine, and monosodium glutamate[15] Gasoline, asphalt, agricultural chemicals, dry cleaning fluid, formaldehyde, air fresheners, and highlighters are also sometimes reported.[citation needed]

Psychological[edit]

Several mechanisms for psychological etiology have been proposed, including theories based on misdiagnoses of an underlying mental illness, stress, or classical conditioning. Many people with MCS meet the criteria for major depressive disorder or anxiety disorder.[6] Other proposed explanations include somatoform disorder,[7] panic disorder.,[16] migraine, chronic fatigue syndrome, or fibromyalgia, where symptoms such as brain fog and headaches can be triggered by chemicals or inhalants. Sufferers may also have a tendency to "catastrophically misinterpret benign physical symptoms"[17] or simply have a disturbingly acute sense of smell.[18] The personality trait absorption, in which individuals are predisposed to becoming deeply immersed in sensory experiences, may be stronger in individuals reporting symptoms of MCS.[19] Behaviors exhibited by MCS sufferers may reflect broader sociological fears about industrial pollution and broader societal trends of technophobia and chemophobia.[3][20]

Neurological[edit]

People who suffer from MCS may have a neurological dysfunction in the odor-processing areas of the brain[21] or otherwise have an exaggerated response to scents.[22]

Genetic differences in metabolism[edit]

Genetic differences relating to toxicant metabolism pathways, such as polymorphisms and differences in expression in CYP2D6, NAT2, GSTM1, and PON1 and PON2, have been proposed as a cause for differences in susceptibility to MCS.[23][24] Elevated nitric oxide and peroxynitrite (NO/ONOO-) could then cause the symptoms of MCS and several related conditions, including fibromyalgia, posttraumatic stress disorder, Gulf War syndrome, and chronic fatigue syndrome.[25][26] British Gulf War syndrome sufferers who used personal organophosphate pesticides may be more likely to report the symptoms of MCS.[27]

Diagnosis[edit]

No characteristically unique signs, laboratory test abnormalities, tissue pathology, or course of illness have been identified, and it remains unclear whether symptoms are physiologically or psychologically generated.[28][29] 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.[2] The Australian Department of Health recognizes that sometimes debilitating symptoms are attributed to MCS but notes that diagnosis, treatment, and any underlying mechanism remain uncertain.[30] The American Medical Association does not recognize MCS as an organic disease because of the lack of scientific evidence supporting a cause-and-effect relationship between very low level exposure and the symptoms of MCS. The American Academy of Allergy, Asthma, and Immunology, the California Medical Association, the American College of Physicians, and the International Society of Regulatory Toxicology and Pharmacology also do not recognize MCS.[3][12][31] The US Occupational Safety and Health Administration (OSHA) indicates that MCS is highly controversial and that there is insufficient scientific evidence to explain the relationship between the suggested causes of MCS and its symptoms. OSHA recommends evaluation by a physician knowledgeable of the symptoms presented.[32]

MCS is a diagnosis of exclusion, and 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, depression, allergy, thyroid disorders, orthostatic syndromes, lupus, hypercalcemia, and anxiety need to be carefully evaluated and, if present, properly treated. The "gold standard" procedure for identifying a person who has MCS is to test response to the random introduction of chemicals the patient has self-identified as relevant. 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[33] 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.

A 1999 consensus statement recommends that MCS be diagnosed according to six standardized criteria:[2][34][35]

  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).

Treatment[edit]

In various studies, about one half of the patients who seek medical treatment for symptoms of MCS meet the criteria for depressive and anxiety disorders, and these conditions must be treated when present.[6] While patients may resist the potentially stigmatizing diagnosis of a mental health disorder, many MCS sufferers benefit strongly from lifestyle changes.[citation needed] 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.[36]

Epidemiology[edit]

Epidemiological data from three states puts the prevalence of chemical sensitivity at 16 to 33% of the general population, 2 to 6% of whom have already been diagnosed with MCS.[37] Women complain of MCS significantly more often than men, and most patients are 30 to 50 years old at time of diagnosis.

Relationship to Gulf War syndrome[edit]

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.[38]

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.[39] After adjusting for potentially confounding factors (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.[40]

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.[41]

History[edit]

MCS was first proposed as a distinct disease by Theron G. Randolph in 1950. In 1965, Randolph founded the Society for Clinical Ecology as an organization to promote his ideas about symptoms reported by his patients. As a consequence, clinical ecology emerged as a non-recognized medical specialty.[42] In 1984, the Society for Clinical Ecology changed its name to American Academy of Environmental Medicine (AAEM). In the 1990s, an association was noted with chronic fatigue syndrome, fibromyalgia, and Gulf War syndrome.[37]

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. The booklet further states that a pathogenesis of MCS has not been definitively proven, and that symptoms that have been self-diagnosed by a patient as related to MCS could actually be related to allergies or have a psychological basis, and recommends that physicians should counsel patients seeking relief from their symptoms that they may benefit from consultation with specialists in these fields.[43]

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 that it was unlikely that MCS would receive extensive financial resources from federal agencies because of budgetary constraints 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.[44]

In 1997, U.S. Social Security Administration Commissioner John Callahan issued a court memorandum officially recognizing MCS "as a medically determinable impairment" on an agency-wide basis.[45] That is, without making any statement about the cause of MCS or the role of chemicals in MCS, the Social Security administration agrees that some MCS patients are too disabled to be meaningfully employed.[46]

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.[47] Furthermore, accommodations sought for MCS are sometimes denied as being unreasonable as a matter of law.[48]

See also[edit]

References[edit]

  1. ^ MCSS factsheet — United States National Institute of Environmental Health Sciences
  2. ^ a b c 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.
  3. ^ a b c 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." 
  4. ^ 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)
  5. ^ 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. 
  6. ^ a b c Lax MB, Henneberger PK (1995). "Patients with multiple chemical sensitivities in an occupational health clinic: presentation and follow-up". Arch. Environ. Health 50 (6): 425–31. doi:10.1080/00039896.1995.9935978. PMID 8572720. 
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  8. ^ a b Understanding and Accommodating People With MCS, Pamela Reed Gibson, Ph.D.
  9. ^ Gibson, P. R.; Elms, A. N.; Ruding, L. A. (2003). "Perceived treatment efficacy for conventional and alternative therapies reported by persons with multiple chemical sensitivity". Environmental health perspectives 111 (12): 1498–1504. doi:10.1289/ehp.5936. PMC 1241653. PMID 12948890.  edit
  10. ^ Ross PM, Whysner J, Covello VT, Kuschner M, Rifkind AB, Sedler MJ, Trichopoulos D, Williams GM (1999). "Olfaction and Symptoms in the Multiple Chemical Sensitivities Syndrome". Preventative Medicine 28: 467–480. doi:10.1006/pmed.1998.0469. PMID 10329337. 
  11. ^ Graveling RA, Pilkington A, George JPK, Butler MP, Tannahill SN (1999). "A review of multiple chemical sensitivity". Occupational and Environmental Medicine 56 (2): 73–85. doi:10.1136/oem.56.2.73. PMC 1757696. PMID 10448311. 
  12. ^ a b Magill MK, Suruda A (September 1998). "Multiple chemical sensitivity syndrome". Am Fam Physician 58 (3): 721–8. PMID 9750540. 
  13. ^ Caress SM, and Steinemann, AC (September 2003). "A review of a two-phase population study of multiple chemical sensitivities." "Environmental Health Perspectives. 111(12):1490-1497.
  14. ^ Inomata, N; Osuna, H; Fujita, H; Ogawa, T; Ikezawa, Z (2006). "Multiple chemical sensitivities following intolerance to azo dye in sweets in a 5-year-old girl". Allergology International 55 (2): 203–5. doi:10.2332/allergolint.55.203. PMID 17075259.  edit
  15. ^ Pall ML (September 2002). "NMDA sensitization and stimulation by peroxynitrite, nitric oxide, and organic solvents as the mechanism of chemical sensitivity in multiple chemical sensitivity". FASEB J. 16 (11): 1407–17. doi:10.1096/fj.01-0861hyp. PMID 12205032. 
  16. ^ Binkley KE, Kutcher S. Panic response to sodium lactate infusion in patients with multiple chemical sensitivity syndrome. J Allergy Clin Immunol 1997;99:570-4.
  17. ^ "Idiopathic Environmental Intolerance May Have Psychological Component". Retrieved 2008-01-13. 
  18. ^ "stoppingSmell". Archived from the original on December 12, 2007. Retrieved 2008-01-13. 
  19. ^ Witthöft M, Rist F, Bailer J (2008). "Evidence for a specific link between the personality trait of absorption and idiopathic environmental intolerance". J. Toxicol. Environ. Health Part A 71 (11-12): 795–802. doi:10.1080/15287390801985687. PMID 18569578. 
  20. ^ E. Shorter, Multiple chemical sensitivity: pseudodisease in historical perspective, Scand J Work Environ Health 23 (1997) (suppl 3), pp. 35–42
  21. ^ Orriols R, Costa R, Cuberas G, Jacas C, Castell J, Sunyer J (October 2009). "Brain dysfunction in multiple chemical sensitivity". J. Neurol. Sci. 287 (1-2): 72–8. doi:10.1016/j.jns.2009.09.003. PMID 19801154. 
  22. ^ van Thriel C, Kiesswetter E, Schäper M, Juran SA, Blaszkewicz M, Kleinbeck S (2008). "Odor annoyance of environmental chemicals: sensory and cognitive influences". J. Toxicol. Environ. Health Part A 71 (11-12): 776–85. doi:10.1080/15287390801985596. PMID 18569576. 
  23. ^ McKeown-Eyssen G, Baines C, Cole DE, Riley N, Tyndale RF, Marshall L, Jazmaji V. (2004). "Case-control study of genotypes in multiple chemical sensitivity: CYP2D6, NAT1, NAT2, PON1, PON2 and MTHFR". Psychosomatic Medicine 33 (5): 971–8. doi:10.1093/ije/dyh251. PMID 15256524. 
  24. ^ Schnackenberg,E. et al. (2007).A cross-sectional study of self-reported chemical-related sensitivity is associated with gene variants of drug-metabolizing enzymes. Environmental Health.
  25. ^ Pall ML (September 2003). "Elevated nitric oxide/peroxynitrite theory of multiple chemical sensitivity: central role of N-methyl-D-aspartate receptors in the sensitivity mechanism". Environ. Health Perspect. 111 (12): 1461–4. doi:10.1289/ehp.5935. PMC 1241647. PMID 12948884. 
  26. ^ De Luca, C; Scordo, M. G.; Cesareo, E; Pastore, S; Mariani, S; Maiani, G; Stancato, A; Loreti, B; Valacchi, G; Lubrano, C; Raskovic, D; De Padova, L; Genovesi, G; Korkina, L. G. (2010). "Biological definition of multiple chemical sensitivity from redox state and cytokine profiling and not from polymorphisms of xenobiotic-metabolizing enzymes". Toxicology and Applied Pharmacology 248 (3): 285–92. doi:10.1016/j.taap.2010.04.017. PMID 20430047.  edit
  27. ^ Reid, S et al. (2001) Multiple Chemical Sensitivity and Chronic Fatigue Syndrome in British Gulf War Veterans. American Journal of Epidemiology Vol.153, No.6, pp604-9.
  28. ^ Staudenmayer H, Selner JC (June 1995). "Failure to assess psychopathology in patients presenting with chemical sensitivities". J. Occup. Environ. Med. 37 (6): 704–9; discussion 710. doi:10.1097/00043764-199506000-00012. PMID 7670917. 
  29. ^ S. Barrett, A close look at "Multiple Chemical Sensitivity", 1998
  30. ^ "Multiple chemical sensitivity review FactSheet - NICNAS". Retrieved 2014-04-02. "The pathogenic mechanisms involved in MCS have not been established." 
  31. ^ 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." 
  32. ^ "Safety and Health Topics | Multiple Chemical Sensitivities". Osha.gov. Retrieved 2014-06-08. 
  33. ^ 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. Retrieved 2007-03-04. 
  34. ^ "Multiple chemical sensitivity: a 1999 consensus". Arch. Environ. Health 54 (3): 147–9. 1999. doi:10.1080/00039899909602251. PMID 10444033. 
  35. ^ Sears, Margaret E. 2007. "The Medical Perspective on Environmental Sensitivities.".
  36. ^ Sanders, Lisa (2006-02-26). "On Her Last Legs - New York Times". The New York Times. Retrieved 2008-01-25. 
  37. ^ a b Donnay, Albert H. (1999), "On the Recognition of Multiple Chemical Sensitivity in Medical Literature and Government Policy" 'International Journal of Toxicology', November 1999 18.6:383-392, doi:10.1080/109158199225099
  38. ^ Gray GC, Gackstetter GD, Kang HK, Graham JT, Scott KC (2004). "After more than 10 years of Gulf War Veteran medical evaluations, what have we learned?". American Journal of Preventative Medicine 26 (5): 443–452. doi:10.1016/j.amepre.2004.02.006. 
  39. ^ Black DW, Doebbeling BN, Voelker MD, Clarke WR, Woolson RF, Barrett DH, Schwartz DA (2000). "Multiple Chemical Sensitivity Syndrome. Symptom prevalence and the risk factors in a military population". Archive of Internal Medicine 160: 1169–1176. doi:10.1001/archinte.160.8.1169. 
  40. ^ Thomas HV, Stimpson NJ, Weightman AL, Dunstan F, Lewis G (2006). "Systematic review of multi-symptom conditions in Gulf War veterans." Multi-symptom illnesses, unexplained illness, and Gulf War Syndrome"". Psychological Medicine 36: 735–747. doi:10.1017/s0033291705006975. 
  41. ^ Ismail K, Lewis G (2006). "Multi-symptom illnesses, unexplained illness, and Gulf War Syndrome". Philosophical Transactions of the Royal Society B 361: 543–551. doi:10.1098/rstb.2006.1815. 
  42. ^ ACOEM position statement. Multiple chemical sensitivities: idiopathic environmental intolerance. College of Occupational and Environmental Medicine. J Occup Environ Med. 1999 Nov;41(11):940-2.
  43. ^ 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. 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." 
  44. ^ "A Report on Multiple Chemical Sensitivity (MCS)". Web.health.gov. 1998-08-24. Retrieved 2014-06-08. 
  45. ^ October 31, 1997, R-164, Creamer v. Callahan
  46. ^ "DI 24515.064 Evaluation Of Specific Issues — Environmental Illness". Social Security Administration. 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." 
  47. ^ Frank v. New York, 972 F. Supp. 130 (N.D.N.Y. 1997)
  48. ^ 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/

49. Recognition of MCS as a Legitimate Disease and Disability, Albert Donnay,MHS http://www.mcsrr.org/factsheets/mcsrecog.html

External links[edit]