ABSTRACT
BACKGROUND: Exercise-induced laryngeal obstruction (EILO) causes exertional dyspnea and is important for its effect on quality of life, diagnostic confusion with exercise-induced asthma, and health care resource utilization. There is no validated patient-reported outcome measure specific to EILO. OBJECTIVE: We sought to develop, validate, and define a minimal clinically important difference for a patient-reported outcome measure to be used with adolescents and young adults with EILO. METHODS: A multidisciplinary group created a preliminary measure, modified by a 10-member participant focus group, with 20 items scored along a 5-point Likert scale. A subsequent cohort of participants recruited from a clinic, aged 12 to 21 years, with confirmed EILO by continuous laryngoscopy during exercise testing (1) completed the measure at 3 points in time over 28 days and (2) provided anchoring data in the form of a daily exercise log and categorical self-assessments of clinical improvement. Thirty additional participants without exertional dyspnea served as controls. RESULTS: Two hundred nineteen subjects with mild to severe EILO participated in the exploratory factor analysis, which identified 7 factors within the preliminary outcome measure. After a process of item reduction, a 12-item metric with a total score ranging from 0 to 48 was developed. Mean scores of patients with EILO and healthy controls at baseline were 28.8 ± 7.4 and 4.5 ± 7.4, respectively. A minimal clinically important difference of 6 was determined by comparison of index change with changes in categorical self-assessments of improvement. CONCLUSIONS: This is the first patient-reported outcome measure specifically designed for adolescents and young adults with EILO.
Subject(s)
Airway Obstruction , Asthma, Exercise-Induced , Laryngeal Diseases , Adolescent , Airway Obstruction/diagnosis , Airway Obstruction/etiology , Asthma, Exercise-Induced/diagnosis , Dyspnea/diagnosis , Dyspnea/etiology , Exercise , Humans , Quality of Life , Young AdultABSTRACT
Exercise as an important part of life for the health and wellness of children and adults. Inducible laryngeal obstruction (ILO) is a consensus term used to describe a group of disorders previously called vocal cord dysfunction, paradoxical vocal fold motion, and numerous other terms. Exercise-ILO can impair one's ability to exercise, can be confused with asthma, leading to unnecessary prescription of asthma controller and rescue medication, and results in increased healthcare resource utilization including (rarely) emergency care. It is characterized by episodic shortness of breath and noisy breathing that generally occurs at high work rates. The present diagnostic gold standard for all types of ILO is laryngoscopic visualization of inappropriate glottic or supraglottic movement resulting in airway narrowing during a spontaneous event or provocation challenge. A number of different behavioral techniques, including speech therapy, biofeedback, and cognitive-behavioral psychotherapy, may be appropriate to treat individual patients. A consensus nomenclature, which will allow for better characterization of patients, coupled with new diagnostic techniques, may further define the epidemiology and etiology of ILO as well as enable objective evaluation of therapeutic modalities.
Subject(s)
Airway Obstruction/diagnosis , Dyspnea/diagnosis , Exercise/physiology , Laryngeal Diseases/diagnosis , Larynx/pathology , Adult , Airway Obstruction/etiology , Airway Obstruction/therapy , Child , Dyspnea/etiology , Dyspnea/therapy , Female , Humans , Laryngeal Diseases/complications , Laryngeal Diseases/therapy , Vocal Cord Dysfunction/diagnosis , Vocal CordsABSTRACT
A multidisciplinary team assessed five patients who alleged chronic medically unexplained multiorgan system symptoms described by idiopathic environmental intolerance allegedly triggered by exposure to solvents used in membrane roofing repair work on an office building. The event precipitated an incident of mass psychogenic illness (MPI). Treating physicians diagnosed irritant-associated vocal cord dysfunction (IVCD) and reactive airways disease syndrome (RADS) resulting from exposure. The authors conducted medical, psychological, and industrial hygiene evaluations. Air monitoring data for total volatile organic compounds obtained during the 2-day exposure period, measurements of emissions during membrane roofing repair at a similar site, mathematical modeling of air contaminant concentrations, and injection of tracer gas into the incident building revealed exposure levels well below those doses anticipated to cause clinical symptoms. There was no objective medical evidence validating symptoms. Review of the medical records indicated that the video laryngoscopy data, pulmonary function tests, and medical examinations relied upon by the treating physicians were inconsistent with published criteria for IVCD and RADS. Psychological evaluation identified defensiveness and self-serving misrepresentations of exaggerated health concerns associated with somatization and malingering. Each case had personality traits associated with at least one personality disorder. Social histories identified premorbid life events and stressors associated with distress. This is the first study to assess psychological predisposition, social interaction among the plaintiffs, and iatrogenic reinforcement of beliefs by diagnoses of pseudo-disorders associated with patient misrepresentation of exaggerated health concerns in an incident of MPI.
Subject(s)
Asthma/psychology , Disease Susceptibility/psychology , Dyspnea/psychology , Laryngeal Diseases/psychology , Psychophysiologic Disorders/psychology , Vocal Cords/physiopathology , Adult , Asthma/diagnosis , Disease Susceptibility/diagnosis , Dyspnea/diagnosis , Female , Humans , Irritants/adverse effects , Laryngeal Diseases/diagnosis , Male , Middle Aged , Occupational Exposure/adverse effects , Psychophysiologic Disorders/diagnosis , Reinforcement, Psychology , SyndromeABSTRACT
BACKGROUND: Idiopathic environmental intolerance (IEI) is a descriptor for nonspecific complaints that are attributed to environmental exposure. METHODS: The Minnesota Multiphasic Personality Inventory 2 (MMPI-2) was administered to 50 female and 20 male personal injury litigants alleging IEI. RESULTS: The validity scales indicated no overreporting of psychopathology. Half of the cases had elevated scores on validity scales suggesting defensiveness, and a large number had elevations on Fake Bad Scale (FBS) suggesting overreporting of unauthenticated symptoms. The average T-score profile for females was defined by the two-point code type 3-1 (Hysteria-Hypochondriasis), and the average T-score profile for males was defined by the three-point code type 3-1-2 (Hysteria, Hypochondriasis-Depression). On the content scales, Health Concerns (HEA) scale was significantly elevated. CONCLUSION: Idiopathic environmental intolerance litigants (a) are more defensive about expressing psychopathology, (b) express distress through somatization, (c) use a self-serving misrepresentation of exaggerated health concerns, and (d) may exaggerate unauthenticated symptoms suggesting malingering.
Subject(s)
Compensation and Redress/legislation & jurisprudence , MMPI/statistics & numerical data , Malingering/diagnosis , Multiple Chemical Sensitivity/diagnosis , Adult , Aged , Defense Mechanisms , Depression/diagnosis , Depression/psychology , Diagnosis, Differential , Female , Humans , Hypochondriasis/diagnosis , Hypochondriasis/psychology , Hysteria/diagnosis , Hysteria/psychology , Male , Malingering/psychology , Middle Aged , Multiple Chemical Sensitivity/psychology , Psychometrics/statistics & numerical data , Reproducibility of Results , Sick Role , Somatoform Disorders/diagnosis , Somatoform Disorders/psychologyABSTRACT
Idiopathic environmental intolerance (IEI) is a descriptor for a phenomenon that has many names including environmental illness, multiple chemical sensitivity and chemical intolerance. Toxicogenic and psychogenic theories have been proposed to explain IEI. This paper presents a causality analysis of the toxicogenic theory using Bradford Hill's nine criteria (strength, consistency, specificity, temporality, biological gradient, biological plausibility, coherence, experimental intervention and analogy) and an additional criteria (reversibility) and reviews critically the scientific literature on the topic. The results of this analysis indicate that the toxicogenic theory fails all of these criteria. There is no convincing evidence to support the fundamental postulate that IEI has a toxic aetiology; the hypothesised biological processes and mechanisms are implausible.
Subject(s)
Environmental Exposure/adverse effects , Multiple Chemical Sensitivity , Pharmacoepidemiology/methods , Toxicology/methods , Animals , Causality , Evidence-Based Medicine , Humans , Multiple Chemical Sensitivity/epidemiology , Multiple Chemical Sensitivity/etiologyABSTRACT
Toxicogenic and psychogenic theories have been proposed to explain idiopathic environmental intolerance (IEI). Part 2 of this article is an evidence-based causality analysis of the psychogenic theory using an extended version of Bradford Hill's criteria. The psychogenic theory meets all of the criteria directly or indirectly and is characterised by a progressive research programme including double-blind, placebo-controlled provocation challenge studies. We conclude that IEI is a belief characterised by an overvalued idea of toxic attribution of symptoms and disability, fulfilling criteria for a somatoform disorder and a functional somatic syndrome. A neurobiological diathesis similar to anxiety, specifically panic disorder, is a neurobiologically plausible mechanism to explain triggered reactions to ambient doses of environmental agents, real or perceived. In addition, there is a cognitively mediated fear response mechanism characterised by vigilance for perceived exposures and bodily sensations that are subsequently amplified in the process of learned sensitivity. Implications for the assessment and treatment of patients are presented.