Functional symptoms in dermatology: Part 1.

Functional - or somatoform - symptoms are those that arise with no proven organic pathology. Also known as 'medically unexplained' symptoms, they can present in any medical speciality, including dermatology. Mucocutaneous pain syndromes and functional pruritus are two examples of functional disorders encountered by dermatologists. Patients presenting with somatoform symptoms have paradoxically complex and often subjectively severe symptomatology, yet minimal abnormalities on clinical examination or investigation. Such disparity can be frustrating and distressing for patients and clinicians alike, and there are many pitfalls regarding overinvestigation and misleading communication. However, with an honest and open approach - sometimes requiring collaboration with psychological services - management of functional symptoms can be effective, and patients can be successfully rehabilitated.

Neurotransmitters and Behavioral Alterations Induced by Nickel Exposure.

BACKGROUND: Nickel ions (Ni2+) are a heavy metal with wide industrial uses. Environmental and occupational exposures to Ni are potential risk factors for brain dysfunction and behavioral and neurological symptoms in humans. METHODS: We reviewed the current evidence about neurochemical and behavioral alterations associated with Ni exposure in laboratory animals and humans. RESULTS: Ni2+ exposure can alter (both inhibition and stimulation) dopamine release and inhibit glutamate NMDA receptors. Few reports claim an effect of Ni2+ at the level of GBA and serotonin neurotransmission. At behavioral levels, exposure to Ni2+ in rodents alters motor activity, learning and memory as well as anxiety and depressive-like symptoms. However, no analysis of the dose-dependent relationship has been carried out regarding these effects and the levels of the Ni2+ in the brain, in blood or urine. CONCLUSION: Further research is needed to correlate the concentration of Ni2+ in biological fluids with specific symptoms/deficits. Future studies addressing the impact of Ni2+ under environmental or occupational exposure should consider the administration protocols to find Ni2+ levels similar in the general population or occupationally exposed workers.

[One or more functional somatic syndromes? Comparison of the health status of fibromyalgia and electro-hypersensitive people]. / Un ou plusieurs syndromes somatiques fonctionnels ? Comparaison de l'état de santé de personnes fibromyalgiques et électro-hypersensibles.

INTRODUCTION: Functional somatic syndromes, grouping somatic symptoms without an organic explanation, are defined either by their predominant symptoms or by an attribution to an, often hypothetical, cause. Due to many similarities, some authors consider that there is only one FSS due to a general phenomenon of "somatization". The objective of this work was to compare two functional somatic syndromes, one defined by its symptoms, fibromyalgia, and the other by a specific contested attribution, electro-hypersensitivity. METHOD: Fibromyalgia or electro-hypersensitive participants (EHS) were recruited from September 2016 to April 2017 through associations of patients in Auvergne-Rhône-Alpes. Home interviews included the collection of medical, psychopathological, and symptom histories. The assessment of psychological distress, quality of life and the search for other functional somatic syndromes was performed through structured questionnaires, self-administrated scales, and clinical examination. RESULTS: Sixteen fibromyalgia subjects and sixteen EHS subjects were included. There are differences in symptomatology, although many symptoms are common to both conditions. Lifetime history of psychiatric disorders and current psychological distress and psychopathology are frequent in both groups but more prevalent in fibromyalgia subjects. The experience of the symptoms, their interpretation, the diagnostic itineraries and the therapeutic behaviours differ radically according to the group, even if for all socio-professional impact is high and quality of life are altered. CONCLUSION: The health status of fibromyalgia persons is overall worse than the health status of electro-hypersensitive individuals in this small sample. Despite the overlap in symptoms and a similar impact on daily functioning, this exploratory study suggests that heterogeneous mechanisms of "somatization" may be at stake in functional somatic syndromes.

Putting Sex Into Context in Later Life: Environmental Disorder and Sexual Interest Among Partnered Seniors.

Background and Objectives: This study examines whether neighborhood and household disorder is associated with sexual interest among partnered seniors. Research Design and Methods: Analyses use dyadic data from Wave 2 of the National Social Life, Health, and Aging Project (NSHAP), a nationally representative sample of community-dwelling older adults (2010-2011). Measures of environmental disorder were conducted by trained interviewers. Survey data were also linked to census tract information from the 2009 American Community Survey. We used actor-partner interdependence models to estimate the likelihood of reporting low sexual interest. Results: There was no observed association between neighborhood context (physical disorder or census tract socioeconomic disadvantage) and sexual interest, but husbands were more likely to report low sexual interest if they lived in more disorderly households. High marital quality protected against low sexual interest, but these evaluations did not mediate or moderate the putative effect of household disorder. Discussion and Implications: Regardless of the broader neighborhood context, helping older adults maintain an orderly home space may help sustain sexual functioning. Future research should consider how various features of the environment matter for additional aspects of late-life sexuality.

Neighborhood Disorder and Sleep Problems in Older Adults: Subjective Social Power as Mediator and Moderator.

BACKGROUND AND OBJECTIVES: Contextual contributors to sleep problems are important to examine among older adults because sleep problems are associated with a number of adverse outcomes in late life. We examine whether disordered neighborhoods are a key contextual determinant of sleep problems in late life, as well as how subjective social power-a sense of personal control and subjective social status-mediates and moderates this association. Central to this contribution is the use of econometric techniques that holistically control for time-stable factors that may bias estimated associations. RESEARCH DESIGN AND METHODS: Three waves (2006, 2010, 2014) of the psychosocial subsample of the Health and Retirement Study (N = 7,130) are analyzed with random-effects models that adjust for repeated observations, as well as fixed-effects models that additionally control for all time-stable confounders. RESULTS: Neighborhood disorder is associated with greater sleep problems in random-effects models, but this association is substantially weakened in a fixed-effects model. Personal control mediates this association, but does not moderate it. Subjective social status does not mediate the association, but does moderate it. DISCUSSION AND IMPLICATIONS: Although neighborhood disorder is associated with sleep problems in older adults, this association is likely to be overestimated in analyses that do not compressively control for time-stable confounders. Rather than acting as dual mediators and moderators, perceived control and subjective social status play distinct roles in this association, with seniors at lower levels of subjective social status especially at risk for sleep problems due to neighborhood disorder.

Monitoring SO2emission trends and residents' perceived health risks from PGM smelting at Selous Metallurgical Complex in Zimbabwe.

BACKGROUND: Persistently high sulphur dioxide (SO2) emissions from platinum group metal (PGM) smelting pose a major threat to communities located around smelters. This paper examined SO2 emission trends, emission regulations and residents' perceived health risks from exposures to such emissions at Selous Metallurgical Complex (SMC) PGM smelting facility in Zimbabwe. METHODS: SO2 data from roof monitoring sites at the smelter furnace were aggregated into annual, quarterly and monthly emission trends from 2008 to 2015. The regulatory regime's ability to protect human health from SO2 pollution in communities located around the smelter was examined. Questionnaire responses to perceived health risks from SO2exposure from 40 purposively sampled residents were assessed. The relationships between SO2 emission trends and residents' self-reported health risks from exposure to SO2emissions were explored using STATA version 11. Descriptive statistics were used to illustrate SO2 emission trends and residents' self-reported health risks from exposure to SO2. RESULTS: Between 2008 and 2015, annual SO2emissions increased from 7951 to 2500 tonnes. Emissions exceeded the recommended standard limit of 50 mg/Nm3, presenting considerable adverse health risks to local residents. Concerns relating to inefficient environmental impact assessment (EIA) licensing system, poor monitoring and auditing by the environmental management agency, as well as non-deterring SO2emission exceedance penalties were identified as major drivers of emission increase. Thirty-two (80%) of the forty respondents perceived exposure to SO2 emissions as adverse and the cause of their illnesses, with coughing, nasal congestion and shortness of breath the most frequently self-reported symptoms. CONCLUSION: A set of legally-binding SO2emission standards supported by stringent EIA licensing arrangements for smelting industries are suggested for development and enforcement to reduce the SO2emission problem. Community participation in SO2emissions monitoring is also proposed as a core part of sustainable environmental management in communities located around smelters.

[Environmental medical syndromes]. / Umweltmedizinische Syndrome.

Environmental medical syndromes comprise sick building syndrome (SBS), multiple chemical sensitivity (MCS)/idiopathic environmental intolerances (IEI), electromagnetic hypersensitivity, chronic fatigue syndrome (CFS), burnout, fibromyalgia, and the candida syndrome. There is also some overlap described in the literature. There is still no established knowledge of etiology, pathology, pathophysiology, diagnostics, therapy, prevention and prognosis. These syndromes are thought to result from a complex interaction of physical, chemical and/or (micro)biological environmental stresses, individual dispositions, psychological influencing factors, perceptual and processing processes, variants of somatization disorders, culturally or socially caused distress, or simply iatrogenic causation. Examination and treatment methods must be developed or existing ones scientifically validated. However, all uncertainties in the assessment of these syndromes do not absolve the physician from taking patients seriously and helping them as best as possible.

Comparing cognitive-behavioural psychotherapy and psychoeducation for non-specific symptoms associated with indoor air: a randomised control trial protocol.

INTRODUCTION: Indoor air-related conditions share similarities with other conditions that are characterised by medically unexplained symptoms (MUS)-a combination of non-specific symptoms that cannot be fully explained by structural bodily pathology. In cases of indoor air-related conditions, these symptoms are not fully explained by either medical conditions or the immunological-toxicological effects of environmental factors. The condition may be disabling, including a non-adaptive health behaviour. In this multifaceted phenomenon, psychosocial factors influence the experienced symptoms. Currently, there is no evidence of clinical management of symptoms, which are associated with the indoor environment and cannot be resolved by removing the triggering environmental factors. The aim of this study is to compare the effect of treatment-as-usual (TAU) and two psychosocial interventions on the quality of life, and the work ability of employees with non-specific indoor air-related symptomatology. METHODS AND ANALYSES: The aim of this ongoing randomised controlled trial is to recruit 60 participants, in collaboration with 5 occupational health service units. The main inclusion criterion is the presence of indoor air-related recurrent symptoms in ≥2 organ systems, which have no pathophysiological explanation. After baseline clinical investigations, participants are randomised into interventions, which all include TAU: cognitive-behavioural psychotherapy, psychoeducation and TAU (control condition). Health-related quality of life, measured using the 15D-scale, is the primary outcome. Secondary outcomes include somatic and psychiatric symptoms, occupational factors, and related underlying mechanisms (ie, cognitive functioning). Questionnaires are completed at baseline, at 3, 6 and 12-month follow-ups. Data collection will continue until 2017. The study will provide new information on the individual factors related to indoor air-associated symptoms, and on ways in which to support work ability. ETHICS AND DISSEMINATION: The Coordinating Ethics Committee of the Hospital District of Helsinki and Uusimaa, Finland, has granted approval for the study. The results will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT02069002; Pre-results.

Does electromagnetic hypersensitivity originate from nocebo responses? Indications from a qualitative study.

Idiopathic Environmental Intolerance attributed to Electromagnetic Fields (IEI-EMF) is a condition in which symptoms are attributed to electromagnetic field (EMF) exposure. As electro-hypersensitive (EHS) people have repeatedly been observed, during provocation trials, to report symptoms following perceived rather than actual exposure, the hypothesis has been put forward that IEI-EMF originates from psychological mechanisms, especially nocebo responses. This paper examines this hypothesis, using data from a qualitative study aimed at understanding how EHS people come to regard themselves as such. Forty self-diagnosed EHS people were interviewed. A typified model of their attribution process was then elaborated, inductively, from their narratives. This model is linear and composed of seven stages: (1) onset of symptoms; (2) failure to find a solution; (3) discovery of EHS; (4) gathering of information about EHS; (5) implicit appearance of conviction; (6) experimentation; (7) conscious acceptance of conviction. Overall, symptoms appear before subjects start questioning effects of EMF on their health, which is not consistent with the hypothesis that IEI-EMF originates from nocebo responses to perceived EMF exposure. However, such responses might occur at the sixth stage of the process, potentially reinforcing the attribution. It remains possible that some cases of IEI-EMF originate from other psychological mechanisms.

The relationship of modern health worries to non-specific physical symptoms and perceived environmental sensitivity: A study combining self-reported and general practice data.

OBJECTIVE: The present study investigates the association of modern health worries (MHW) with self-reported as well as general practitioner (GP)-registered non-specific physical symptoms (NSPS), medication use, alternative therapy consultations, sleep quality and quality of life. The interrelation between MHW, general environmental sensitivity and the aforementioned outcomes is also explored. METHODS: Self-reported questionnaires and data from electronic medical records from 21 general practices in The Netherlands were combined in a sample of 5933 adult participants. RESULTS: The majority of the participants reported increased worries about potential health effects from environmental exposures. The highest worry scores were reported by people who perceived themselves as more vulnerable to environmental stressors. After adjustment for socio-demographic characteristics and diagnosed psychiatric morbidity, higher MHW were significantly associated with increased self-reported prevalence and duration of NSPS, symptom-related healthcare utilization, GP-registered NSPS, alternative therapy consultations and lower sleep quality and quality of life. These associations were statistically mediated by perceived environmental sensitivity. No association was observed between worries and GP-registered medication prescriptions. CONCLUSION: Modern health worries are very common in the general population. They are associated with self-reported as well as clinically defined NSPS and as such might play a key role in the process of developing and maintaining environmental sensitivities and related symptoms. A large cross-cultural longitudinal study would help to determine important aspects such as temporal precedence and stability of MHW and the relevant psychosocial context within which symptomatic conditions occur.

Actual and perceived exposure to electromagnetic fields and non-specific physical symptoms: an epidemiological study based on self-reported data and electronic medical records.

BACKGROUND: There is continuing scientific debate and increasing public concern regarding the possible effects of electromagnetic fields (EMF) on general population's health. To date, no epidemiological study has investigated the possible association between actual and perceived EMF exposure and non-specific physical symptoms (NSPS) and sleep quality, using both self-reported and general practice (GP)-registered data. METHODS: A health survey of adult (≥ 18) participants (n=5933) in the Netherlands was combined with the electronic medical records (EMRs) of NSPS as registered by general practitioners. Characterization of actual exposure was based on several proxies, such as prediction models of radiofrequency (RF)-EMF exposure, geo-coded distance to high-voltage overhead power lines and self-reported use/distance of/to indoor electrical appliances. Perceived exposure and the role of psychological variables were also examined. RESULTS: Perceived exposure had a poor correlation with the actual exposure estimates. No significant association was found between modeled RF-EMF exposure and the investigated outcomes. Associations with NSPS were observed for use of an electric blanket and close distance to an electric charger during sleep. Perceived exposure, perceived control and avoidance behavior were associated with the examined outcomes. The association between perceived exposure was stronger for self-reported than for GP-registered NSPS. There was some indication, but no consistent pattern for an interaction between idiopathic environmental intolerance (IEI-EMF) and the association between actual exposure and NSPS. CONCLUSIONS: In conclusion, there is no convincing evidence for an association between everyday life RF-EMF exposure and NSPS and sleep quality in the population. Better exposure characterization, in particular with respect to sources of extremely low frequency magnetic fields (ELF-MF) is needed to draw more solid conclusions. We argue that perceived exposure is an independent determinant of NSPS.

Community exposure to asbestos in Casale Monferrato: from research on psychological impact to a community needs-centered healthcare organization.

INTRODUCTION: Asbestos exposure has a negative impact on both the physical health of the population, and on its psychological and community components. Usually such issues are addressed via top-down strategies, but this approach is unable to address the interpersonal processes connected to living in a specific context. METHOD: The work carried on in Casale Monferrato since 2006 proceeds in the opposite direction: promoting a different interaction between health system policy-makers and administrators, field actions, and system thinking. Our goal was to create a reliable model that could fit into other contexts, while being flexible and adapting to specific backgrounds. Starting from the results obtained during a first assessment phase, a psychoanalytic group was arranged, aimed at promoting the symbolization and signification of the emotions related to the ill-fated prognosis. RESULTS: The clinical work offers a space for handling the illness and its psychological impact, in order to achieve: 1) a subjective perception of themselves as not impotent and alone; 2) improved abilities of caregivers to manage the disease; 3) enhanced quality of residual life. CONCLUSIONS: An integrated multidimensional intervention promotes resilience in the community, but it requires time, for patients, relatives, and the professionals involved. Only with the combined support of oncologists and the entire ward staff will an internal trust be free to grow within a somato-psychic space able to accommodate and sustain the participants during the final stages of their own life, or that of someone close to them.

Use of psychology and behavioral economics to promote healthy eating.

Understanding the psychology of how people make decisions can shed light on important factors contributing to the cause and maintenance of public health problems like obesity. This knowledge can and should inform the design of government and private-sector public health interventions. Several insights from psychology and behavioral economics that help explain why people are particularly vulnerable to the current food environment are discussed. These insights fall into the following categories: the influence of starting points (status quo bias and anchoring effects); communicating health information (simplicity and framing); and unintended consequences of policy interventions (compensation, substitution, and the peanuts effect). The paper discusses opportunities for improving the design of food policies and interventions by altering default options, providing the public with simple and meaningful nutrition information, carefully constructing the framing of public health messages, and designing food policies to minimize unintended consequences, such as compensation and substitution.

Comparing non-specific physical symptoms in environmentally sensitive patients: prevalence, duration, functional status and illness behavior.

OBJECTIVE: Little is known about the potential clinical relevance of non-specific physical symptoms (NSPS) reported by patients with self-reported environmental sensitivities. This study aimed to assess NSPS in people with general environmental sensitivity (GES) and idiopathic environmental intolerance attributed to electromagnetic fields (IEI-EMF) and to determine differences in functional status and illness behavior. METHODS: An epidemiological study was conducted in the Netherlands, combining self-administered questionnaires with the electronic medical records of the respondents as registered by general practitioners. Analyses included n=5789 registered adult (≥18 years) patients, comprising 5073 non-sensitive (NS) individuals, 514 in the GES group and 202 in the IEI-EMF group. RESULTS: Participants with GES were about twice as likely to consult alternative therapy compared to non-sensitive individuals; those with IEI-EMF were more than three times as likely. Moreover, there was a higher prevalence of symptoms and medication prescriptions and longer symptom duration among people with sensitivities. Increasing number and duration of self-reported NSPS were associated with functional impairment, illness behavior, negative symptom perceptions and prevalence of GP-registered NSPS in the examined groups. CONCLUSION: Even after adjustment for medical and psychiatric morbidity, environmentally sensitive individuals experience poorer health, increased illness behavior and more severe NSPS. The number and duration of self-reported NSPS are important components of symptom severity and are associated with characteristics similar to those of NSPS in primary care. The substantial overlap between the sensitive groups strengthens the notion that different types of sensitivities might be part of one, broader environmental illness.

[Life quality parameters in prenosologic evaluation of health state in residents of protective measures area near objects of storage and destruction of chemical weapons].

The article presents results of life quality assessment and subjective evaluation data on health state, used for prenosologic evaluation of health state in residents of protective measures area near objects of storage and destruction of chemical weapons. Considering specific features of residence near potentially dangerous objects, the authors conducted qualitative evaluation of satisfaction with various life facets, with taking into account the objects specificity, established correlation between life quality and self-evaluation of health with factors influencing public health state.

Symptoms in response to controlled diesel exhaust more closely reflect exposure perception than true exposure.

BACKGROUND: Diesel exhaust (DE) exposures are very common, yet exposure-related symptoms haven't been rigorously examined. OBJECTIVE: Describe symptomatic responses to freshly generated and diluted DE and filtered air (FA) in a controlled human exposure setting; assess whether such responses are altered by perception of exposure. METHODS: 43 subjects participated within three double-blind crossover experiments to order-randomized DE exposure levels (FA and DE calibrated at 100 and/or 200 micrograms/m(3) particulate matter of diameter less than 2.5 microns), and completed questionnaires regarding symptoms and dose perception. RESULTS: For a given symptom cluster, the majority of those exposed to moderate concentrations of diesel exhaust do not report such symptoms. The most commonly reported symptom cluster was of the nose (29%). Blinding to exposure is generally effective. Perceived exposure, rather than true exposure, is the dominant modifier of symptom reporting. CONCLUSION: Controlled human exposure to moderate-dose diesel exhaust is associated with a range of mild symptoms, though the majority of individuals will not experience any given symptom. Blinding to DE exposure is generally effective. Perceived DE exposure, rather than true DE exposure, is the dominant modifier of symptom reporting.

Quality of life of patients with asthma related to damp and moldy work environments.

OBJECTIVE: Long-term outcomes of asthma related to exposure to workplace dampness are not well known. The aim of this study was to evaluate the quality of life (QOL) of patients with asthma related to damp and moldy workplaces and characterize factors influencing QOL. METHODS: Using a questionnaire, we followed 1267 patients previously examined for suspected occupational respiratory disease related to exposure to damp and moldy indoor environments. In addition to demographic and other background data, the questionnaire included sections on current employment status, QOL, anxiety and depression, somatization, hypochondria, and asthma medication. We compared the QOL of patients with occupational asthma (OA) with that of patients with work-exacerbated asthma (WEA) or symptoms without asthma. RESULTS: Impaired QOL was found among patients diagnosed with OA when they were compared with patients in corresponding environments with WEA or symptoms only. Not working and greater use of asthma medication were major determinants of worse QOL. Psychological factors did not explain the differences between the groups. CONCLUSIONS: OA induced by exposure to workplace moisture and molds is associated with QOL deterioration. The impairment is related to being unemployed (due to disability, retirement, job loss or other reasons) and the need for medication.

Prevalence and psychiatric comorbidity of self-reported electromagnetic field sensitivity in Taiwan: a population-based study.

BACKGROUND/PURPOSE: Psychological factors have been implicated in the etiology of idiopathic environmental illness in many studies. Few studies have ever reported psychiatric morbidity among individuals with electromagnetic hypersensitivity. We aimed to estimate the prevalence and identify the associated factors of self-reported electromagnetic field sensitivity (SREMFS) in adults of Taiwan. METHODS: A total of 1251 adults selected from a nationwide Computer-Assisted Telephone Interviewing system received a telephone survey about the perception of risk from various environmental agents and their effects on health and well-being. RESULTS: The estimated prevalence of people with SREMFS was 13.3 % (95% confidence interval: 11.2-15.3). People aged >65 years were associated with a lower risk of reporting sensitivity to electromagnetic fields, whereas people with a very poor self-reported health status, those who were unable to work, and those who had psychiatric morbidity were associated with a higher risk of having SREMFS. CONCLUSION: The prevalence of SREMFS in the general population of Taiwan is higher than that reported in western countries. People with psychiatric morbidity are more likely to report sensitivity to electromagnetic fields. The cross-sectional design precludes the causal inference of all identified correlates and electromagnetic field sensitivity.

Life styles, anxiety, expertise: the perception of risk from electromagnetic fields.

INTRODUCTION: This study analyzed the effect of expertise, by comparing the opinions of groups of "experts" and "non-experts" on the so-called "classic" risks and on the risks from exposure to electromagnetic fields. METHODS: A protocol comprising personal history questionnaires, including lifestyle details, STAI-Y, and two rating scales based on the "psychometric paradigm" was administered to 48 people, 22 experts on these risks and 26 non-experts. The findings were analyzed by one-way analysis of variance, exploratory factor, correlational and bivariate regression analysis. RESULTS: Significant differences emerged between the perceptions of the two groups, though the underlying qualitative dimensions were similar. Bivariate regression analysis showed that both state and trait anxiety exert a statistically significant effect on some risks, both classic and related to electromagnetic fields exposure. CONCLUSIONS: This study displayed the role of expertise in risk perception processes, giving indications on the relationships between anxiety and risk perception. On the basis of the available data it is concluded that people prone to anxiety and individual emotional states filter the perception of risk arising from activities, technologies, substances etc. included in the present study.