Environmental allergies may be psychosomatic
Environmental allergies may be psychosomatic
Case managers must pinpoint cause of disability
Imagine being allergic to everything in your environment. You can’t go outside without experiencing a wide range of uncomfortable, even disabling, symptoms. You certainly aren’t able to work an eight-hour day. Yet your physician can find little or no evidence of pathology or physiologic dysfunctions.
That’s idiopathic environmental intolerance (IEI). The condition was first described in the 1950s. Early researchers suggested that the illness was caused by a failure of human adaptation to modern synthetic chemicals in the environment, including chemical additives in the food supply. It’s been called "20th century disease," "multiple chemical sensitivity," and "total allergy" syndrome. No matter what term is used to describe the condition, it is one of a growing number of vague diagnoses that are particularly challenging for case managers.
"There are a number of diagnoses, and this is one of them, that are vague and troubling for case managers," says Scott M. Yarosh, MD, medical director of Behavioral Management, a disability management company in Minneapolis. "I am of the opinion that these patients primarily suffer from a psychiatric disorder that is hard to pin down."
Medical researchers have been unable to prove any underlying allergic or toxic basis for IEI. Some research indicates IEI patients have increased psychiatric morbidity and share many features with patients with panic disorder, including chest tightness, breathlessness, palpitations, apprehension, and avoidance of situations that cause those symptoms. (See box at right for IEI studies.)
"People who get themselves labeled with this diagnosis seem to have some common underlying personality characteristics," notes Yarosh, who is board-certified in both internal medicine and psychiatry. "They are often fearful and suggestible. When faced with stressors, they have intense experiences. Saying that they are allergic’ is a way of saying, I can’t do anything.’ These patients are essentially psychiatric patients who cannot admit that they are psychiatric patients. IEI is one of several physical exhaustion syndromes, like fibro myalgia and chronic fatigue syndrome."
In fact, research now supports the opinion of many physicians and disability case managers that IEI has a psychological component. Patients with IEI display high anxiety sensitivity similar to patients with panic disorder under controlled circumstances, according to a recent study by Canadian researchers in the Journal of Allergy and Clinical Immunology.1
Researchers asked 36 patients with IEI and 37 healthy patients to inhale differing concentrations of oxygen and CO2 through a flow spirometer, an instrument that measures air entering and leaving the lungs. After each inhalation, patients were asked to rate each panic symptom and their sensations of panic and fear on an objective diagnostic symptom questionnaire.
Researchers found that 71% of IEI patients fulfilled panic disorder criteria after inhaling CO2, compared with 26% of control subjects. There were no significant differences between IEI patients and control groups in terms of actual breathing rate, heart rate, and other physical measures.
Investigators concluded that the high rate of anxiety response to inhaled CO2 in IEI patients shows a tendency to overreport and misinterpret benign physical symptoms, a finding common in patients with panic disorder, and suggest that all patients with IEI receive psychological assessment.
"Case managers working with IEI patients have to begin thinking about this as a psychiatric disorder without telling their clients," says Yarosh. "You have to first develop a rapport with your client. If there is any suggestion on your part that you believe this to be more of a psychiatric disorder than a medical condition, it will be impossible for you to achieve a positive outcome and return your client successfully to the workplace."
"You have a client who gives you a history which basically makes little sense," says Joram Seggev, MD, an allergy, asthma, and immunology specialist and a clinical professor of medicine at the University of Nevada School of Medicine in Las Vegas. "The recent study suggests that physicians can find evidence of panic disorder in these patients. The problem is these patients are so convinced that they have a real disease, they will not accept counseling."
Seggev recalls a 30-year-old patient complaining of IEI. "She clearly had allergic rhinitis and mild asthma. She also had a range of complaints that clinically made no sense."
He placed her in a small room attached to a spirometer and deliberately sprayed a highly aromatic cleaning product into the air before closing the door. "She had a violent attack of hyperventilation even though the spirometer registered normal internal and external flow. My next step was to stop her hyperventilation, which was very difficult."
Yarosh suggests case managers adopt a "tough love" approach when working with IEI clients. "These patients will not willingly accept psychological counseling. You have to find a round-about way to address the possibility of therapy."
He suggests case managers try the following arguments:
• "I know this is uncomfortable for you. Don’t you think it would help to be able to talk to someone about how hard this is?"
• "Work is therapeutic. Our goal is to help you get better so that you can go back to work."
• "Wouldn’t it be helpful to work with someone who can help you cope with all the disabling symptoms you have?"
"You must initiate a process that allows the client to be validated," Seggev says. "These are often very needy people. You can’t challenge their belief system, but rather you enable the belief system. You collude with their delusion that their environment is making them sick in order to encourage them to seek counseling."
Of course, an initial thorough history of the disability and a thorough medical assessment to rule out all other causes of the client’s symptoms are essential, say physicians and case managers. "You’ll want a real comprehensive assessment, including a pulmonary work-up and dermatologic allergy testing. Along with the medical assessment, there must be a psychosocial assessment," says Christine E. Shanahan, RN, CCM, a clinical disability consultant in Portland, ME.
"[For] a case manager, these patients can be very frustrating," she explains. "Much of the information you gather is not looking for a specific treatment plan so much as looking for a sense of the clinician’s judgment of the client’s ability to function and how much the client’s symptoms are impacting all aspects of their life. And, of course, you don’t want to miss the possibility that there is something readily treatable to relieve their symptoms."
Yarosh agrees. "You will find some patients who are hypothyroid. You will find some patients who are anemic. You have to rule out those possibilities before you begin counseling and a work-hardening program."
Protecting your patients’ best interests
However, case managers should be wary of clinics willing to take advantage of patients with soft diagnoses such as IEI. "There are lots of labs in this country who will perform a wide range of poorly standardized tests on these patients. These tests have no good clinical controls or clinical evidence to back them up," notes Seggev.
"These same groups often convince IEI patients to exclude everything under the sun from their environment. There are several physicians who even place IEI patients on expensive and complicated regimens of food supplements," he says. "Some IEI patients move from one physician to another looking for a clinician who will reinforce their belief that the environment is making them sick."
It doesn’t matter whether you as the disability or workers’ compensation case manager believe the client has a medical disorder or a psychiatric disorder, the steps you take to pinpoint the cause of the disability are the same, says Shanahan. "The client has stopped working. You have to get a complete picture of exactly when and why they felt they were no longer able to work."
Questions she suggests you ask IEI clients include:
• When did symptoms first occur? "It is always possible that there is a stimulant, a trigger in the workplace that can be minimized or eliminated," she notes. "This is a bit like detective work. You have to help the client think back to when they first noticed symptoms and identify any triggers present at that time."
Seggev adds that case managers also should identify whether any other employees have experienced adverse reactions to the workplace. "There is such a thing as sick building syndrome.’ If your client is the only employee to complain of symptoms, it’s likely you are dealing with IEI. However, if other employees in the same workplace have also complained of symptoms, you are probably dealing with a stimulant that can be removed from the work environment."
• Can you identify any specific triggers in your environment?
• When did symptoms first cause an inability to function? "These symptoms are rarely of extremely sudden onset," says Shanahan. "The client may have had some symptoms for a period of time before they became disabling. Your job is to try to pinpoint the moment when the symptoms moved from being unpleasant to being unbearable."
• Could any other factors in your life have affected your ability to function? "Often, you will find that in addition to a trigger or stimulant in the environment, the client can identify other issues which, when combined with symptoms associated with the client’s IEI, caused the client to stop being able to function," says Shanahan. "You must find out what changed in their life just prior to the disability."
• How long do symptoms last? "As a disability case manager, it’s important to identify the duration as well as the existence of the symptoms," notes Shanahan. "Maybe the symptoms are disabling for only a few minutes after exposure to a trigger. In those cases, even if the trigger can’t be eliminated from the environment, you can often persuade the client to work through the symptoms."
• How frequently do symptoms occur? "You also have to establish whether IEI symptoms are impairing all aspects of your clients’ life or only in the workplace. Are they still able to go out socially? Can they still enjoy hobbies and recreational activities?"
• What treatments have been tried?
• Did those treatments alleviate symptoms?
• If so, for how long did treatments alleviate symptoms?
"Returning these clients to the workplace requires that the case manager build partnerships with the primary provider and the employer," says Shanahan. "You must develop a relationship with the treating provider. Sometimes with managed care, the provider is a family practitioner or a general internist with no special experience or knowledge of IEI. It’s your job to explain to the provider that removing the client from normal activities often adds to the difficulties the client is experiencing."
It doesn’t matter what the diagnosis is, as a disability case manager your main concern is that your client has an impaired ability to function, notes Shanahan. "Your job is to keep that as active as possible in all aspects of their life and gradually return them to work."
Although Yarosh and Seggev agree that most IEI patients benefit from psychological counseling, many of those clients steadfastly refuse to accept counseling. "The most positive step case managers can take in those circumstances is to continuously reassure their clients and encourage them to try returning to the workplace a few hours at a time," says Seggev. "If you offer positive reassurance, you may successfully return the client to work even without formal counseling."
Case managers who are able to get IEI clients into counseling should work with a therapist who is goal-oriented, notes Yarosh. "You want a therapist who is more cognitively oriented who will help the client cope with their symptoms with time limited goals," he says. "There is little benefit gained from these patients being in therapy forever. You want a therapist who will move your client forward, not validate their disability."
Some IEI patients benefit from a mild antidepressant with good anti-anxiety characteristics, he adds. "These drugs help reduce the severity of their reaction to triggers and so reduce their symptoms."
Reference
1. Poonai N, Antony MM, Binkley KE, et al. Carbon dioxide inhalation challenges in idiopathic environmental intolerance. J Allergy Clin Immunol 2000; 105:358-363.]
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