Talk:Multiple chemical sensitivity

Turning back time with the intro

@TylerDurden8823: I see that you've taken the introduction back to some version of what it was before, without consultation, when it had been carefully updated, over several months, by several people, in line with 2017-2019 reviews.

I feel disappointed that the good work that was done has been undone. I'm also confused about why this has happened without any discussion or consultation here.

I propose that the old introduction be put back–for now—and that any contentious issues about it be discussed here, and that changes be made in line with the consensus reached and in line with WP policies.

Previously, we had two verbatim definitions of MCS, both from the two most recent large scale reviews. Now, instead we have Tyler's own creative definition, which is transparently biased in favour of the psychogenic cause arguments.

This is not an improvement, it's a step back to the nineties. Can we please bring this page forward to 2019.

I'd like to invite other editors to give their opinions on this, and for that, here's the old intro for you to compare with what is there now. Leobenite (talk) 04:58, 14 December 2019 (UTC)Leobenite

Multiple Chemical Sensitivity (MCS), also known as Idiopathic Environmental Intolerances (IEI) and Environmental Sensitivities/Multiple Chemical Sensitivities (ES/MCS), was defined in a 2017 scientific review as "a complex syndrome that manifests as a result of exposure to a low level of various common contaminants."[1]

A 2019 review described the condition as an "acquired disorder characterized by recurrent symptoms, affecting multiple organs and systems, which arise in response to a demonstrable exposure to chemicals, even at low doses, much lower than those that would cause a reaction in the general population."[2]

Chemicals that are common triggers for MCS symptoms include pesticides, petrochemicals, formaldehyde, and perfumed products.[3] Natural irritants like mold and woodfire smoke are also common incitants.[4]

The etiology, diagnosis, and treatment of MCS are still debated among researchers.[1] MCS is not recognized as a separate, discrete disease by the World Health Organization (WHO), but a 2017 scientific review said that it can be codified as a clinical condition using disease codes in WHO's 2010 International Classification of Diseases (ICD10).[5] It also said that the condition is recognized as a discrete pathology in some countries' disease codes and by some governmental agencies.[6][7][8]

I totally agree with Leobenite. Tyler's edits have just brought back tired old narratives, which have been discredited. Martin Kempf (talk) 05:29, 14 December 2019 (UTC)Martin Kempf

Discredited source

It appears from this review [1] that the dismissive quotations from writings of Ronald Gots should not be cited as authoritative. The abstract of his tendentious 1995 editorial is quoted in its entirety, with three references to that footnote in this article. A mere citation would suffice, and should be contextualized with his conflict of interest as one whose principle livelihood appears to have been as an expert witness in legal defense of corporations accused in court of wrongdoing. Bn (talk) 13:48, 29 January 2019 (UTC)

As of today (2019-12-13), this article relies on a number of WP:FRINGE individuals such as William Rea, Martin L. Pall and dubious working groups ("Italian Workgroup on MCS", and a Canadian Task Force on Environmental Health) that have produced unscientific documents. MCS is not a recognized condition by mainstream medicine. This article is in need of a rewrite. ScienceFlyer (talk) 01:47, 14 December 2019 (UTC)

@ScienceFlyer: The Italian consensus is probably the largest collaborative review of MCS literature to date. It was funded by the Italian health department—hardly fringe.

And re the Canadian Taskforce, how are the conclusions of a large-scale, three-year government inquiry, set up by the health department, fringe?@ScienceFlyer:

Using labels like "fringe" on here seem to be a way to maintain old narratives and ignore new research and what seems to be a new emerging consensus.

Also @ScienceFlyer: note the paras on recognition in the 2017 Rossi & Pitidis review. Is that review too fringe too?

MCS clearly has some degree of recognition or there wouldn't be this abundance of academic activity around it, nor would formal representatives of college of physicians be talking about it as a disease, nor would the CDC be talking about it in their policies.Leobenite (talk) 05:49, 14 December 2019 (UTC)Leobenite

To the group of new editors

I assume you all know each other from some off-wiki site dedicated to discussing this syndrome. Anyway, I noticed in your edits the claim that some medical associations eg in Denmark and Germany recognise this disorder. The question is what do they recognise it as? Do they really believe and accept that short exposure to micro doses of perfume, petrol fumes etc causes a syndrome of severe symptoms? Or do they say yes this is a real disorder caused by psychological factors? Or real symptoms wrongly attributed by the individual to smells in the environment?--Literaturegeek | T@1k? 08:36, 16 December 2018 (UTC)

I think this article's probably due for a refresh.

I've just started into the latest papers, but the overall tenor seems to have moved from "we've got no clue what makes these people sick" to "neurological problems plus personality quirks means that smelling things is distressing". This seems to explain a lot, from why SSRIs work (because they mitigate some kinds of neurological problems) to why unscented toxins produce no symptoms.

Are you up for helping with a re-write? WhatamIdoing (talk) 20:04, 16 December 2018 (UTC)

The Germany-and-Austria thing is nonsense. It says what the ICD code medical services are usually billed under. It does not say that it's "physical". That is merely the self-serving interpretation of an advocacy group. WhatamIdoing (talk) 20:05, 16 December 2018 (UTC)

Well yes, the article did need to be updated re. the personality traits and hypersensitive limbic and sensory systems - but that has been done now. I am not seeing a major problem with the article in it’s present format. I mean, sourcing could aim to use higher quality sources but is it really worth the effort to replace or lose non-controversial unchallenged content when there are other more important articles? I guess the treatment section could do with being updated. I might try doing some work there but it is a busy time of year.

Good job with removing the misrepresentation of the Germany-Austria thing.

I think the main thing to do is watch list this article and help avoid the single purpose accounts skewing and biasing the article.--Literaturegeek | T@1k? 20:51, 16 December 2018 (UTC)

I'm thinking that the article needs to be updated primarily on the grounds that about a third of the sources are from the previous century, and we'd usually like to have everything from the last five years, or perhaps stretch it as far back as ten years for a rare disease. The stuff from twenty-plus years ago really should be replaced. For example, my quick search (feel free to prove me wrong) indicates that a connection between MCS and the Gulf War hasn't been discussed in the medical literature for over a decade now, so all of that ought to be either removed or at least significantly minimized. WhatamIdoing (talk) 01:14, 17 December 2018 (UTC)

Well, one reason is because the Gulf War happened in 1991, it (Gulf War Syndrome) was researched to death. It is no longer and likely never again will be an area of active research. That was why I was not motivated to remove that primary source. But I do understand your reasoning and am not strongly motivated one way or the other about that reference.--Literaturegeek | T@1k? 02:43, 17 December 2018 (UTC)

Page protection

@AndersBirzulis, Literaturegeek, MKarlsssson, Natureium, SamuelBurckhalter, ToveK65, and WhatamIdoing: I would like to alert involved parties to a conversation on my talk page regarding my temporary semi-protection of this page. Hopefully we can centralize further discussion on the article here on its own talk page. Best, Airplaneman ✈ 21:41, 16 December 2018 (UTC)

Response to page protection

Thanks for directing me here, Airplaneman.

I didn't know this conversation was happening. My mistake; am still finding my way around talk, and thought it only happened on user pages. So from my perspective, things were being deleted without discussion, despite invitations to discuss.

I do understand your concern about multiple new editors appearing and making a lot of controversial changes in a short space of time. That's fair. And Literaturegeek explained that big changes quickly wasn't the way to go about it. Understood. It was a rookie mistake.

So I'm glad some of the suggested amendments have been being discussed.

If the input from new editors is considered here and responded to in a meaningful (and respectful) way, then I think the protected status (temporarily anyway) is a reasonable measure. MKarlsssson (talk) 22:36, 16 December 2018 (UTC)MKarlssssonMKarlsssson (talk) 22:36, 16 December 2018 (UTC)

Welcome to Wikipedia. It's an almost impossibly complicated place. But you're here now, and I'd be happy to hear what you think, about anything, really, but especially if you have any overall impressions of this article or goals for fixing it. WhatamIdoing (talk) 00:57, 17 December 2018 (UTC)

MCS involving chemicals without odors

WhatamIdoing, re your comment about reacting to odors above and, this was addressed in one of the edits in the past few days, which was deleted, several secondary sources that have been cited (including the NICNAS2010 report by the Australian government) reinforce that people with MCS don't just react to smells (they also react to certain chemicals topically, intravenously (eg. anaesthetics) and by ingesting them eg. tartrazine and MSG -- this is even in the existing entry). They react to toxins without smells or no perceptible smell at low concentrations in the air (eg. pesticides). There are also documented cases of people with MCS without a sense of smell. This fact is important.

Saying MCS is an odor sensitivity isn't accurate at least not relevant for all types of this condition (and it's not clear if MCS one condition or several disorders -- I'd say several). This was also put in one of the recent edits and was removed.

With chemicals with odors, a Pavlovian sensory mechanism may sometimes be involved -- sure; but the research shows that this isn't always involved in the mechanism. MKarlsssson (talk) 22:36, 16 December 2018 (UTC)MKarlssssonMKarlsssson (talk) 22:36, 16 December 2018 (UTC)

Further to my comment below (in nocebo section), these are relevant paragraphs from the recent Milan review on hyperosmia and role of smell in MCS:

“It should be specified, however, that hyperosmia is not a unique trait of MCS because in the literature, cases of exposure to toxic substances that have led to the decrease or loss of smell are reported. Furthermore, some studies have found that the olfactory function of MCS patients does not differ from the control population. Other research has found comparable levels of olfactory sensitivity, despite the stimulation producing symptoms of sensitivity:

The research group of Prof. Marco Alessandrini, of the University of Tor Vergata in Rome, clarified this aspect, emphasizing that several studies on MCS have found an association between mucosal irritation and the triggering of symptoms, probably through mediators of the inflammation.

This phenomenon is compatible with the hypothesis of neurogenic inflammation of MCS, and activation of an immune reaction with the release of neuropeptides, chemokines and cytokines in peripheral tissues.

In the experience of Prof. Andrea Mazzatenta, exposure to natural odors does not generate any variation in the test pattern Olfactory Real Time - Volatile Organic Compounds, which is currently being tested in relation to MCS, while sensitizing substances cause hyperosmic pathological responses.” --Leobenite | T@1k? —Preceding undated comment added 05:23, 19 October 2019 (UTC)

Further implications of this are the neurological section in causes needs to be rewritten. It's currently wrong and breaches WP:MEDRS--Leobenite | T@1k? —Preceding undated comment added 10:42, 19 October 2019 (UTC)

Suggestions for improving the Intro

Thanks for the welcome and for asking of my overall impression of the article. I had a think and put down some thoughts on the intro. MKarlsssson (talk) 13:07, 20 December 2018 (UTC)MKarlssssonMKarlsssson (talk) 13:07, 20 December 2018 (UTC)

Bias up top

The intro is now a bit more up to date and a few notches less biased than it was (thank you to the editors who helped with that). In my view, it didn't, and still doesn't, adhere to a neutral point of view WP:NPOV. It gives the psychogenic theory of MCS undue weight, well above the toxicological theory and all other theories. This is bias. Recent reviews we cite say the etiology and causes of MCS aren’t understood. Therefore one postulated cause shouldn’t be elevated above another.

I’d like to see the intro edited so that it reflects a neutral point of view. This is how I think that could be done. MKarlssssonMKarlsssson (talk) 13:07, 20 December 2018 (UTC)

Just because a source says there may be or are abnormalities in the limbic system and increased sensory sensitivity does not mean it is not a psychiatric or psychogenic disorder since the limbic system could just explain the anxiety part of the disorder. It is biologically implausible that scents of say perfume could wreak havoc on someone’s mental of physical wellbeing.--Literaturegeek | T@1k? 20:11, 20 December 2018 (UTC)

I agree that the lines between "psychological", "psychiatric", and "neurological" are very blurry. But I think it's important to write the body of the article first. WhatamIdoing (talk) 21:53, 20 December 2018 (UTC)

Recommended edits

1. Ditch “pseudomedical diagnosis” and “nocebo” from the box on the top right.

2. Move the provocation/nocebo studies sentence into causes or into its own section under causes

3. Move the “depression, somatoform, anxiety” sentence into “causes”

4. Change “peculiar” to “particular”MKarlssssonMKarlsssson (talk) 13:07, 20 December 2018 (UTC)

Top-right box playing favourites

“Nocebo” here suggests MCS is all nocebo and that’s absolutely not the consensus, nor was it the finding of the review of the provocation studies cited (it’s also not the most important thing about MCS). And “pseudomedical diagnosis” isn't consistent with the current scientific consensus, nor is it mentioned in the academic reviews we’ve included from 2018. This is biased and misleading. The psychogenic camp is clearly the teacher's pet. MKarlssssonMKarlsssson (talk) 13:07, 20 December 2018 (UTC)

Until such time that multiple chemical sensitivity is accepted by the world health organisation and similar it will be a pseudodiagnosis.--Literaturegeek | T@1k? 20:11, 20 December 2018 (UTC)

Position of provocation studies and nocebo

Provocation/nocebo studies are not generic information about what MCS is. That’s why several editors tried to move the sentence about provocation studies in the intro to “causes”/“psychological” (and each time it was moved back). This reference is clearly there to support the psychogenic theory. It’s giving it undue weight having it in the intro. Does it have a place on the page? Sure it does. But if you put it in the intro, you’re giving it elevated importance above other research. Also, it’s from 2006. Hardly current. You could just as easily mention limbic system abnormalities. But, no, doing that in the intro would be biased too. So, please, put research about possible causes under “causes”.

And on nocebo, asthma sufferers have repeatedly been shown in clinical studies to have asthma attacks in response to nocebo provocations. Here’s one https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5814540/. Does this prove asthma is a psychogenic condition or a pseudomedical diagnosis? Nup. Does asthma have reference to nocebo trials in its WK intro? Nup. Because it’s not the most important thing you need to know about asthma. Same goes here.

If you’re interested in nocebo, you might like this 2018 study: https://www.ncbi.nlm.nih.gov/pubmed/30146057 of nocebo in neurological diseases. It concludes that “nocebo responses have been found to be very prevalent in various neurological conditions, in particular, in many brain disorders including headache, Parkinson's disease, Alzheimer's disease, depression, epilepsy, multiple sclerosis and motor neuron disease.”

On the basis of recent research like this, I’d argue that the subject of nocebo responses should have its own section, below causes. It is interesting and it is important, but when researchers don’t understand the relationship between nocebo and causes of a condition, it’s misleading to elevate it as key to our understanding of MCS. It isn’t. MKarlssssonMKarlsssson (talk) 13:07, 20 December 2018 (UTC)

Yea, but asthma has an enormous amount of scientific evidence determining it to be a real physical disorder whereas MCS works on biologically unlikely theories, and nocebo is necessary to explain why some people think they react to microscopic amounts of perfume or solvent in the air etc. I accept newer sources should be sought.--Literaturegeek | T@1k? 20:11, 20 December 2018 (UTC)

I don't think that's true. Tiny amounts of some smells can have truly surprising results. The situation with average MCS seems to be less Hyperosmia (which can have neurological causes, and which some MCS people do report) and more like Parosmia – you can smell something, but you can't quite place it, so the brain decides that it's probably dangerous. Add a little natural tendency towards anxiety, and you can easily imagine how that could quickly spiral downwards. Anyway, my point isn't that I've got it figured out, but that it's not necessary to reach for a nocebo effect to explain anything here. That's one option, but it's not the only option. WhatamIdoing (talk) 22:03, 20 December 2018 (UTC)

One mistake throughout this page (and it's an important one) is that people with MCS don't only react to odours, as MKarlssson has raised above.

This is well documented in the literature, including in the recent review from Milan University.--Leobenite | T@1k? —Preceding undated comment added 05:05, 16 October 2019 (UTC)

Position of line on mental illness being the cause of MCS

This sentence also has no place being in the intro: “Some experts attribute the symptoms to depression, somatoform disorders, or anxiety disorders”. Why is this up top when other, I'd argue, more current and accepted theories aren't? You could equally put: “Many experts think MCS is caused by chemical injury or limbic system impairment”. Also, this reference is from 2001. Outdated studies don’t belong in the intro. This line goes under “causes”, “psychological’, where it was moved to several times in recent edits, only to be moved back.

The broad context here that's worth considering, too, is that historically a lot of diseases, where the aetiology of symptoms wasn’t understood and the subjective experience of sufferers wasn’t considered important, were labelled psychogenic. A good example is multiple sclerosis, formerly known as “hysterical paralysis”[2] prior to MRIs -- ouch!!

Automatically giving conditions that aren’t understood yet a psychogenic explanation is a questionable habit that still enjoys unjustified currency, and this habit is a recurring theme in this article.

Is MCS an anxiety disorder? Nup. Is it correlated with them? Yep. And on this, please consider that social isolation is stressful for humans and it’s one of the biggest risk factors for mental illness (MCS can be profoundly socially isolating). Being chronically ill also isn’t fun (understatement). Barriers to accessing public spaces, employment and social participation are a hard gig for MCS sufferers (perfumed personal-care products being the main barrier there). I would argue that being psychologically stressed out would be an understandable response to the psychosocial and physical stresses that people with MCS tend to live with. And several studies (eg. this one[3]) have found that mental health symptoms tended to arrive post onset of MCS.

Why am I going down this road? Because the intro doesn't even mention that MCS can be associated with high levels of disability. I mention above that nocebo studies aren't the most important thing you need to know about MCS. I'd argue that the way sufferers are disabled by MCS is (regardless of the cause/s of the condition). I think this subject not getting proper coverage is a major weakness of the article. And I'll come back to this later.MKarlssssonMKarlsssson (talk) 13:07, 20 December 2018 (UTC)

There is little doubt that many people claiming to have MCS are sick with symptoms. The question is their eitiology, which could be mental illness (depression, anxiety, somatoform etc), chronic fatigue syndrome, IBS, side effect of a medication, celiac disease, thyroid disorders etc - really a laundry list of a thousand and one different possible reasons for feeling terrible. But then for MCS sufferers to say their health and wellbeing is horrific and are house bound because they’re sensitive to perfume smells, solvent smells, is really just biologically implausible self-misdiagnosis of real symtoms with a different cause. You need sources to say they are housebound because of MCS. Do you have any? Just because a hundred or so years ago some doctor misdiagnosed MS as a hysterical disorder does not prove the biologically unlikely disorder of MCS is real.--Literaturegeek | T@1k? 20:11, 20 December 2018 (UTC)

“Peculiar personality traits” ableist

Re the Viziano reference and the line about “peculiar” personality traits being associated with MCS, this is a subjective judgment (after all, one person’s peculiar, could be another’s charming), it’s certainly negative and it’s moderately denigrating of sufferers. Yes, it is the language used in the translation of the review, but that doesn’t mean we should republish ableist[4] language.

The days of labelling people with lesser-understood disabilities or atypical behaviours or appearances “peculiar” are gone. It’s offensive. I suggest changing it to “particular personality traits”. This would give readers the concept minus the negative subjective judgment.

If you got this far, thanks for reading. I’d be interested to hear your thoughts on any of this.

MKarlsssson (talk) 13:07, 20 December 2018 (UTC)MKarlssssonMKarlsssson (talk) 13:07, 20 December 2018 (UTC)

Your signature seems to get duplicated. Just type four tildes, one time, and nothing else. It should add your user name, a link to your talk page, and the date automatically. (If you're already doing that, and not typing four tildes, then your name, and then four more tildes, then let me know, and we'll go de-bug your account.)

I think that the "psychogenic" thing is built into the definition of MCS, which says that you have MCS if you say you do. What's to stop a person with depression or anxiety from saying "No, doc, really, I don't have anxiety. Anxiety is for weak people. I have physical problems with those nasty chemicals"? Well – nothing. Unlike a true allergy (which is also over-reported in self-diagnoses), there's no requirement that the problems be proven in an objective fashion. So from the POV of the general-practice clinician, a third of patients have an anxiety disorder, and a tiny fraction have problems with multiple chemicals, so statistically, if someone shows up in a doctor's office claiming that dryer sheets (which I hate without reservation) causes panic attacks, the doc is realistically going to think anxiety first, and "chemicals" only much later.

Overall, I see a self-contradiction in the current first paragraph (it is the "result of low-level exposures" to chemicals, but the etiology is not agreed upon – either we know that it's the result of these chemicals, or the etiology is still being debated, but it's not possible for both of these claims to be true), but I don't think we should try to fix the lead first. The best process is usually to find a couple of good sources, and to build the body of the article first, and then to summarize the body into a lead.

So let's pretend this was a game. The first step in the game is to find the last two or three review articles on this subject. The most recent three that I see are:

• Rossi, Sabrina; Pitidis, Alessio (February 2018). "Multiple Chemical Sensitivity". Journal of Occupational and Environmental Medicine. 60 (2): 138–146. doi:10.1097/JOM.0000000000001215. ISSN 1076-2752. PMC 5794238. PMID 29111991.{{cite journal}}: CS1 maint: PMC format (link)
• Alessandrini, Marco; Della-Morte, David; Pasquantonio, Guido; Micarelli, Alessandro; Viziano, Andrea (2018-11-01). "Perspectives on multisensory perception disruption in idiopathic environmental intolerance: a systematic review". International Archives of Occupational and Environmental Health. 91 (8): 923–935. doi:10.1007/s00420-018-1346-z. ISSN 1432-1246.
• Dantoft, Thomas M.; Andersson, Linus; Nordin, Steven; Skovbjerg, Sine (2015). "Chemical intolerance". Current Rheumatology Reviews. 11 (2): 167–184. ISSN 1875-6360. PMID 26088215.

They seem to describe a range of viewpoints on the question of "chemicals", from skeptical to supportive, which is exactly what we need for that part of the article. Do those look like decent journals to you? Are there any more recent reviews that you think would be better? WhatamIdoing (talk) 17:29, 20 December 2018 (UTC)

Infobox

User:Natureium, the infobox – or the "disinfobox", as some might call it – does not seem to display most of the codes. It displays alternate names in a monospace font (why?!), and then says "Pseudomedical diagnosis", "Risks Nocebo", and "MeSH D018777". That's it. The ICD codes are ignored. There's no useful information for the reader in the box, to the point that the infobox doesn't really even manage to be redundant. The implicit claim that MCS is a "pseudomedical diagnosis" – which I assume was someone's prime goal in switching the template from the usual one – appears to be unverifiable in reliable sources (zero hits in PubMed and Google Scholar). I can't even find a solid source that says this is an altmed subject, which is what that link leads to. For example, the highly skeptical Science-Based Medicine blog doesn't believe that; they say it's real suffering with an unproven cause, and that these suffering people at risk of becoming victims of the altmed industry – not that the diagnosis itself is specific to the altmed.[5]

I think we should remove this, and have no infobox on this article. WhatamIdoing (talk) 21:51, 20 December 2018 (UTC)

Yes that font is awful. SBM doesn't use the words altmed, and sort of says that it's a real condition, but what they actually say is that while people do experience symptoms that they blame on exposure to "chemicals", there has been no link found, and no scientific evidence whatsoever that exposure to chemicals is the cause of the symptoms people are experiencing. If you want a direct quote: "Chemical sensitivities have been ruled out owing to chemical challenges that cause symptoms only in the absence of proper blinding." It also says that "MCS is not recognized as a distinct clinical entity in any country (with the exception of Germany and Austria) given the lack of confirmed physical effects and the lack of clear diagnostic criteria." So while they are not saying the symptoms are invented, they aren't due to chemical exposure, which makes this a pseudoscientific condition. I am concerned that this article seems to be moving away from the scientific consensus on this condition by cherry-picking sources to support a specific point of view. Natureium (talk) 22:38, 20 December 2018 (UTC)

And they're wrong about Austria and Germany, for that matter, as the ultimate source for that is a letter about billing codes, rather than any actual recognition by medical or scientific people.

I think that the scientific position has shifted in the last decade (which is good for all concerned), and I think that we need to make some significant changes to the article. But it's not good enough for an editor to say "Well, the etiology originally proposed by some folks is X, and X isn't the pure cause, so I say that the whole thing is pseudoscientific." You actually have to have a reliable source for that claim – a rock-solid one, given that this is at least an uncommon understanding of MCS, even by researchers who reject the "chemicals" thing outright. Do you have sources to back up that claim? WhatamIdoing (talk) 00:35, 21 December 2018 (UTC)

Semi-protected edit request on 23 October 2019

Current wording: Many people with MCS meet the criteria for major depressive disorder or anxiety disorder.[27]

Suggested wording: Many people with MCS meet the criteria for major depressive disorder or anxiety disorder.[27] However, multiple studies have found a higher prevalence of depression and anxiety in individuals with chronic physical disease.[28,29]

28. DeJean, D, Giacomini, M, Vanstone, M, Brundisini, F. 2016. “Patient experiences of depression and anxiety with chronic disease: a systematic review and qualitative meta-synthesis”, Brain and Behavior 6:e00497. doi:10.1002/brb3.497.

29.Clarke, DM, Currie, KC. 2009. “Depression, anxiety and their relationship with chronic diseases: a review of the epidemiology, risk and treatment evidence”, Med J Aust 190:54-60. doi:10.5694/j.1326-5377.2009.tb02471.x. Greenved (talk) 01:14, 23 October 2019 (UTC)

 Not done because MCS is not recognised as a physical disease and you are synthesising conclusions that don’t exist by using sources that do not even mention MCS. Please see WP:SYN.--Literaturegeek | T@1k? 12:36, 23 October 2019 (UTC)