Medically

Unexplained Illness
Gender and Biopsychosocial Implications

SUSAN K. JOHNSON

American Psychological Association

Washington, DC
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Library of Congress Cataloging-in-Publication Data
Johnson, Susan K.
Medically unexplained illness: gender and biopsychosocial implications / by Susan K.
Johnson. — 1st ed.
p. cm.
Includes bibliographical references.
ISBN-13: 978-0-9792125-8-1
ISBN-10: 0-9792125-8-8
1. Somatoform disorders. 2. Chronic fatigue syndrome—Etiology. 3. Multiple chemical
sensitivity—Etiology. 4. Fibromyalgia—Etiology. 5. Sex differences (Psychology)
I. American Psychological Association. II. Title.
[DNLM: 1. Psychophysiologic Disorders—psychology. 2. Psychophysiologic Disorders—
therapy. 3. Fatigue Syndrome, Chronic. 4- Fibromyalgia. 5. Irritable Bowel Syndrome.
6. Sex Factors. WM 90 J69m 2007]
RBI 13.J6448 2007
616'.0478—dc22 2007010292
British Library Cataloguing-in-Publication Data
A CIP record is available from the British Library.
Printed in the United States of America
First Edition
For Dennis, Elise, and Caroline
 CONTENTS

Foreword ix
Introduction 3

I. Overview of Medically Unexplained Illness 9

Chapter 1. A Brief History of Gender in Medically
Unexplained Illness 13
Chapter 2. Psychiatric Disorder in Medically Unexplained
Illness 21
Chapter 3. Psychosocial and Cognitive Factors in
Medically Unexplained Illness 31
Chapter 4. Biology of Medically Unexplained Illness . . . . 49

II. Common Medically Unexplained Illnesses 61

Chapter 5. Irritable Bowel Syndrome 67
Chapter 6. Fibromyalgia 89
Chapter 7. Chronic Fatigue Syndrome 115
Chapter 8. Multiple Chemical Sensitivity 131

III. General Treatment Issues in Medically Unexplained

Illness 145
Chapter 9. Treatment Approaches to Irritable Bowel
Syndrome 149
 Chapter 10. Treatment Approaches to Fibromyalgia 163
Chapter 11. Treatment Approaches to Chronic Fatigue
Syndrome 173
Chapter 12. Treatment Approaches to Multiple Chemical
Sensitivity 181
Chapter 13. Conclusion: Understanding Medically
Unexplained Illness 185

References 189
Author Index 247
Subject Index 261
About the Author 271

viii CONTENTS
 FOREWORD

Medical practitioners are taught fact-based medicine. They are taught

to use a patient's story of his or her illness as a path to suggest various diag-
noses confirmed in part by the physical examination and then more defini-
tively by appropriate laboratory testing. Unfortunately, the fact-based ap-
proach often is not sufficient. This is because many patients seen in the
outpatient setting have complaints or symptoms with no detectable abnor-
mality. The most common of these are fatigue, pain, or achiness—either in
localized parts of the body such as the head or abdomen or throughout the
body, problems with sleep, or feeling as if it is hard to concentrate (a com-
plaint that patients will often call "brain fog")- The practitioner has no ba-
rometer with which to gauge fatigue and has to turn to the neuropsychologist
for help in gauging brain fog. With patients who complain of pain, the prac-
titioner can often find tenderness on palpation but no hint as to why it ex-
ists. So even if the examination can elicit abnormal signs such as tenderness
or abnormalities on cognitive testing, the results often do not point to a
definitive diagnosis, which leaves the practitioner without an explanation.
This can lead to a disconnect between what the patient is expecting to hap-
pen and what actually does happen in the doctor's office. When the medical
model fails, practitioners turn to psychogenic mechanisms. If they cannot
find a physiological cause for symptoms, they believe that none exists. This
leads to the conclusion that patients are either making up their pain or that
it is "all in their heads." Some doctors actually say as much; others prefer to
tell their patients that "nothing is wrong." Patients leave the doctor's office
feeling dissatisfied and still ill. They have fallen between the cracks of classi-
cal medicine and are on their own. This is probably the biggest reason that
vitamins and health-related foods are now a billion-dollar industry in America.
Of course, this scenario represents a failure of the medical profession to
care for the patient. If a diagnosis doesn't fit, reject the patient! However,
this is the antithesis of what a doctor should be doing, and that is whatever
helps the patient feel better. Somehow, the fact-based approach to medicine,
with its need to solve the medical puzzle, has trumped the original reason for
the existence of the medical profession. In the high-tech world of modern
medicine, the patient with disabling symptoms but no definite illness is left
on his or her own. George Engel's1 biopsychosocial approach to illness has
fallen to the wayside.
The consequences of this shift are just now hitting the American medi-
cal educational system with the following questions for the near future. Who
is going to take care of all these patients? How can we increase this number
by shifting the focus from the machine back to the patient? How can we
teach doctors to deal with uncertainty when they are trained to be comfort-
able only when they know all the answers?
Answering these questions constitutes a process in education. Susan K.
Johnson's book is a clear step in this process. The book is a rarity in that it
provides one scholar's synthesis, integration, and conclusions from many
complex and often contradictory studies. To the inquisitive, the book opens
many research questions. To the practitioner, the book provides an up-to-
date review of what is known and how to apply it to the patient, and it does
this in a way in which the clinician, whether a psychologist or a physician,
can learn the biological bases for these medical problems. Thus, the person
who reads this book can understand the pathophysiological bases for the prob-
lems seen in the office. This broad background is critical for the future re-
search that is needed to improve the therapeutic armamentarium available
to the practitioner. However, the biopsychosocial component reviewed in
depth herein is also a critical factor, because it makes the point that the
practitioner can develop a prescription hand tailored to each patient that
can lead to reduced symptoms and thus better health. A careful reading of
this book plus a bit of thought will make you a better caregiver. Patients will
leave your office feeling better rather than feeling lost or rejected, as is too
often the case with classical medicine today.

Benjamin Natelson, MD

'Engel, G. (1977, April 8). The need for a new medical model: A challenge for biomedicine. Science,
196, 129-136.

X FOREWORD
Medically Unexplained Illness
 INTRODUCTION

Interest in medically unexplained illnesses (MUIs) is on the rise, not

surprising considering that they constitute the most common disorders seen
in primary care (Kroenke et al, 1997). MUIs are syndromes characterized by
multiple symptoms, significant suffering, and disability that fail to show con-
sistent pathophysiology (Barsky & Borus, 1999). MUIs present a conundrum
for conventional biomedical approaches. Their high degree of prevalence,
together with chronicity, attendant disability, and skyrocketing costs to the
health care system, have fed this interest. Undoubtedly, some of the recent
fascination with MUIs is related to the clues they offer to the mind-body
relationship. Research in the physiology of these illnesses in an attempt to fit
them into the biomedical model has illuminated both the inadequacy of the
biomedical model and the bidirectional nature of the biobehavioral transac-
tion. This volume tackles the complex nature of the mind-brain-behavior
relationship.
The guiding purpose of this book is to present a balanced, biopsychosocial
approach to exploring the role of gender in several representative MUIs. An
inclusive classification of MUIs would include such illnesses as chronic fa-
tigue syndrome (CFS), fibromyalgia (FMS), premenstrual syndrome, chronic
pelvic pain, irritable bowel syndrome (IBS), multiple chemical sensitivities
(MCS), Gulf War syndrome, temporomandibular joint dysfunction (TMD),
noncardiac chest pain, hyperventilation syndrome, and tension headaches
(Manu, 2004; Wessely, Nimnuan, & Sharpe, 1999). Common factors among
all the MUIs are a lack of sufficient medical explanation, significant im-
pairment in functioning, and female predominance. Many labels have been
used in the literature to describe these conditions, such as medically unex-
plained symptoms, functional somatic syndromes, chronic dysfunctional illnesses,
functional stress syndromes, chronic multisymptom illnesses, affective spectrum
disorders, multisomatoform disorders, antidepressant responsive disorders, and
unexplained illnesses. Although the literature often notes that these syn-
dromes are poorly understood and underresearched, there is actually an
abundance of research in a wide variety of disciplines, ranging from physi-
ology, medicine, psychology, sociology, and epidemiology to public health,
but these disparate reports do not always acknowledge the contributions
from other areas. The research from these myriad fields can contribute to a
further biopsychosocial understanding of MUIs and their preponderance
in women.
Female predominance is well documented and established in MUIs,
but the reasons for this gender disparity are still unclear (Jason, Taylor, Song,
Kennedy, & Johnson, 1999; Toner, 1995; Wessely et al, 1999; Whitehead,
Palsson, & Jones, 2002; Wool & Barsky, 1994). Relatively few investigators
have broached this topic other than to note the prevalence of disparities
between genders. The ratio of women to men is generally reported to 2:1 for
irritable bowel syndrome (IBS; Mayer, Naliboff, Lee, Munakata, & Chang,
1999) and CFS (Evengard, Jacks, Pedersen, & Sullivan, 2005; Lindal,
Stefansson, & Bergmann, 2002), 9:1 for FMS (Gran, 2003; Yunus, 2001),
and 4:1 for MCS (Fiedler & Kipen, 1997). Since vital health statistics have
been recorded in the United States, mortality rates have been higher among
men, whereas morbidity from acute and chronic conditions, short-term dis-
ability, health care use, and medical drug use have been higher among women.
Men suffer more than women do from life-threatening diseases that cause
earlier death. Women live longer than men, but they also live "sicker," re-
stricting their activity and spending more days in bed. The differences are
largest during the reproductive years for women, yet even when reproductive
conditions are excluded, differences in morbidity remain (Verbrugge, 1985).
The reproductive age is also the prime age for the development of MUIs,
although these illnesses (with the exception of premenstrual syndrome) are
not closely related to women's reproductive physiology. Because they are so
prevalent and disabling, MUIs account for a great deal of women's morbidity
(Wessely et al., 1999).
This book is based on the premise that there is an interaction of physi-
ological, psychological, and sociocultural variables that contribute to female
predominance in MUIs. The relative influence of these three factors varies
among individuals. The trauma of childhood sexual abuse may be strongly
salient for one individual with FMS or IBS, whereas another may be psycho-

4 MEDICALLY UNEXPLAINED ILLNESS

logically unscathed yet have neuroendocrine dysfunction expressed as
hypocortisolism and resulting in fatigue, sleep difficulties, pain symptoms,
and reduced coping abilities.
Accordingly, the approach to understanding the relationship between
gender and MUIs must be interdisciplinary. This book presents a
biopsychosocial model for several representative MUI syndromes: IBS, FMS,
CFS, and MCS. These four syndromes are explored in depth because they
represent a broad spectrum of body systems. They range in terms of medical
legitimacy from IBS (less controversial and more accepted) to MCS (more
controversial and less clearly defined). These syndromes challenge traditional
perspectives on illness and demand innovative paradigms to advance our
understanding. By examining the empirical evidence through the lens of gen-
der, this book shows that MUIs result from an interaction of physiological,
psychological, interpersonal, and sociocultural factors that affect symptom
expression differently in men and women.
A brief history of MUIs is presented in chapter 1. Chapter 2 addresses
the issue of comorbidity of somatization, depression, and anxiety in MUIs as
well as the high co-occurrence of somatization with other psychiatric disor-
ders and the high rates of health care use by people with somatizing tenden-
cies. Bidirectional processes in MUIs (the psychosocial factors discussed in
chap. 3) influence physiological processes presented in chapter 4, and physi-
ological processes impact the psychosocial experience of the patient. Chap-
ter 3 highlights the explanations for gender differences in symptom report-
ing, sensation thresholds, stressful life events, and health care seeking.
Additionally, chapter 3 explores the problem faced by people with MUIs of
having to prove the legitimacy of their illnesses when the medical system
does not validate their illness experiences. Because patients recognize the
stigma of psychiatric diagnosis, much patient activism is directed toward
achieving a medical diagnosis. The evidence for hypothalamic—pituitary—
adrenocortical axis, autonomic, and neuromuscular dysregulation in patients
with medically unexplained syndromes, such as cortisol and serotonin defi-
ciencies, smooth muscle contractions, and central nervous system and vis-
ceral hypersensitivity, are presented in chapter 4- These biological alterations
may be experienced as symptoms by the patient. The influences on this pro-
cess are cognitions (beliefs, interpretations, attributions, expectancies), mood
factors (depression, anxiety), and sociocultural expectancies, which differ
for men and women. These psychosocial differences influence MUIs through
biological systems that mediate sensation and function and through the de-
velopment of illness behavior.
Part II considers the arguments for approaching MUI as one syndrome
or as distinct syndromes. Chapters 5 through 8 present a detailed analysis of
the state of current research on IBS, FMS, CFS, and MCS. Approaches to
epidemiology, classification criteria, biopsychosocial etiology, gender influ-
ences, course of illness, and outcomes for these MUIs are discussed.

INTRODUCTION 5
 General treatment issues in MUIs are addressed in Part III. The effi-
cacy of approaches such as pharmacology, cognitive-behavioral treatments,
stress management, hypnotherapy, and graded exercise are presented. Treat-
ment for women with MUIs should take into consideration the unique thera-
peutic needs of women in relation to socialization around issues of self-
esteem, assertiveness, role strain, and dependency. Sex-specific triggers such
as history of sexual abuse, battering, stressful life events, and the relation of
symptoms to menstrual cycle or hormonal events should all be addressed as
part of an individualized treatment approach. The experience of some pa-
tients who engage in endless rounds of "doctor shopping," in fruitless at-
tempts to legitimate their illness experiences, results in frustration in pa-
tients and physicians alike. Doctor shopping can also result in excessive
medical testing and overprescribing of pharmaceuticals, which can result in
iatrogenic symptoms. Physicians often view unexplained symptoms as a threat
to medical competence and dismiss such symptoms as psychogenic. This does
not satisfy the patient whose physical body is suffering and who views psy-
chological explanations as inadequate and stigmatizing.
A helpful approach discussed in Part III is the framing of MUIs as stress
disorders, thereby providing an entry intro framing the biopsychosocial ap-
proach for the patient and emphasizing the importance of stress manage-
ment. In chapters 9 through 12, treatment approaches are highlighted for
each MUI, which emphasize identifying and managing stressors in the patient's
life. This is crucial, because chronic life stress is a powerful predictor of symp-
tom intensity in MUIs.
The paradigmatic model in health psychology is the biopsychosocial
model. Although universally accepted as the cornerstone for theory and re-
search, a reflexive Cartesian dualism still seeps into much of the discourse on
MUIs. The approach herein attempts to move beyond "either-or" mind-
body labeling and synthesize contemporary theory and research into a better
understanding of the mechanisms through which MUI symptoms occur. This
understanding can then be translated into more effective treatment approaches
for individuals disabled by MUIs.
This volume is intended for health psychologists, clinical psychologists,
gender researchers, physiological psychologists, public health officials, and
medical sociologists. Physicians, nurses, physical therapists, and other medi-
cal personnel, as well as lay people who are affected by these very prevalent
syndromes, can also gain insight into a broader theoretical understanding of
MUI.
MUIs exist in a gray zone between psychiatry and medicine. MUIs tend
to defy efforts to be simplified, just as individuals with MUIs cannot be lumped
into a single category. Early diagnosis and management can help reduce dis-
ability, and integrating psychological treatment into general medical care
will improve the care of patients with MUIs. The treatment evidence pre-
sented in this volume indicates that psychological approaches are generally

6 MEDICALLY UNEXPLAINED ILLNESS

more efficacious than biomedical treatments for MUI. The evidence in this
volume should help psychologists and health care practitioners advocate for
a biopsychosocial approach to patients with MUIs rather than for treatments
guided by dualistic explanations.
Researchers must avoid biological reductionism and examine the con-
tributions of interdependent mechanisms. The complexity of understanding
MUIs calls for more dynamic models to better apportion variance among
multiple factors (Hamilton & Gallant, 1993; Van Houdenhove, Egle, &
Luyten, 2005). This volume presents the evidence for multiple factors and
for the complex and dynamic interaction of biopsychosocial factors that un-
derlie MUIs.

INTRODUCTION
 OVERVIEW OF MEDICALLY
I
UNEXPLAINED ILLNESS

The chronic and disabling medically unexplained illnesses (MUIs) rep-

resent a confluence of multifactorial mechanisms. A complex interaction of
psychological, biological, and socio-environmental factors contribute to a
varied symptom complex. One of the perennial debates surrounding MUIs is
the extent to which they have always been with us. As Simon Wessely (1990)
has asked, are the MUIs "old wine in new bottles"—age-old symptom pat-
terns dressed up with new diagnostic criteria? Certainly there is evidence for
this thesis as explicated in the brief history of MUIs presented in chapter 1.
The labels for MUI vary with the Zeitgeist, but irritable bowel syndrome (IBS),
fibromylagia (FMS), and chronic fatigue syndrome (CFS) have a long his-
tory, whereas a diagnosis of multiple chemical sensitivities (MCS) is more
dependent on exposure to modern chemicals and toxins and thus has a shorter
history. It is important to emphasize the "new bottles" aspect of Wessely's
observation, however. New research presented in this volume suggests that
investigators are gaining more sophisticated understanding of MUIs using
broader conceptual models that include biopsychosocial and person-centered
approaches to MUIs (Masi, White, & Pilcher, 2002).
The question of whether MUIs are somatically disguised psychiatric
disorders is discussed in chapter 2. This chapter connects the high preva-
lence of psychiatric disorders with the etiology of MUIs. Higher symptom
 Biological
Genetics
Sensitization
Hyperalgesia
HPA axis
CNS excitability
Immune
dysfunction

Social
Stress of validation
Physician skepticism
Maladaptive coping
Employment stress
Role strain

Cognitive
Catasttophizing
Amplification
Symptom vigilance
Disease conviction
Somatic attribution

Figure 1. Integrated biopsychosocial model of mutually influential factors of

medically unexplained illness. HPA = hypothalamic-pituitary-adrenocortical;
CNS = central nervous system.

reporting among women is linked to higher rates of depression and anxiety,

and thus an increased likelihood of symptom somatization. Currently, the
MUIs do not fit comfortably into a Diagnostic and Statistical Manual of Mental
Disorders (DSM; American Psychiatric Association, 1952, 1968, 1980, 1994,
2000) framework, although the overlap in symptoms with depression, anxi-
ety, and somatoform disorders is substantial. DSM scholars have been debat-
ing the limitations of the categorical classification system that is the hall-
mark of the DSM (Widiger & Samuel, 2005). It is interesting to note that
criticism of the DSM's approach—that psychiatric syndromes do not repre-
sent distinct categorical etiologies, do not have laboratory markers, and have
high rates of co-occurrence—echo the controversies surrounding classifica-
tion of MUIs. A dimensional framework has been proposed for the not-yet-
published fifth edition of the DSM (Widiger & Samuel, 2005), and it is pos-
sible that MUIs would fit into new dimensional classification systems. MUIs
may represent the extreme end of a continuum of somatic complaints. It is

10 INTRODUCTION TO PART I
debatable whether this advances understanding or just creates a more acces-
sible box into which MUIs can be wedged. What is not debatable is the
interaction of social and cognitive factors with biological sensitivities that
influence symptom perception. The contributions of these factors are ad-
dressed in chapters 3 and 4, with an emphasis on the role of gender.
Chapter 3 makes an argument for sociocultural and cognitive factors as
mediators of MUIs. The key psychosocial explanations include gender ste-
reotypes, role strain, and history of abuse; cognitive explanations include
negative affect, catastrophizing, symptom reporting style, and symptom per-
ception. The biological factors that appear to play an important role in MUIs
include genetic explanations, physiological sensitization, and neuroendocrine
influences on immune system functioning. Past research has primarily de-
scribed gender as a demographic variable rather than a variable that may
directly influence other risk factors. Further research is needed to look more
explicitly at how gender informs the biopsychosocial model.
Figure 1 presents an integrated biopsychosocial model of factors mutu-
ally influencing MUIs that are discussed in great detail in chapters 2, 3, and
4. The relative influence and interaction of these factors varies across indi-
viduals and across different MUIs. Future research is required to address ques-
tions generated by this model: How does gender influence physician skepti-
cism to increase symptom vigilance and disease conviction in MUIs? Biological
sensitization has been shown to be a factor in FMS and IBS; is a similar
sensitization operating in CFS? Is there an underlying factor in autoimmune
disease that would help explain female predominance in MUIs? Does the
stress of working to validate MUIs contribute to interpersonal conflict and
stronger somatic attribution? How can multimodal treatment be effectively
delivered in primary care settings? How can health care providers deliver the
message of the biopsychosocial model effectively to patients to reduce doctor
shopping? Would feminist therapy be more effective than cognitive-be-
havioral therapy? Would disease conviction, somatic attribution, and its
role in doctor shopping be reduced if complementary and alternative medi-
cine approaches were tried ? The model outlined in Figure 1 should gener-
ate many more similar questions for researchers and clinicians. The research
that lays the foundation for these questions is presented in this volume.

INTRODUCTION TO PART I I1
 A BRIEF HISTORY OF GENDER IN
1
MEDICALLY UNEXPLAINED ILLNESS

Mysterious symptoms that confound physicians have been reported for

centuries in various cultures. Any discussion of the history of medically un-
explained illness (MUI) must begin with hysteria. Hysteria was recognized as
a medical condition by early Egyptian and Greek cultures, and references to it
were made in the writings of Hippocrates and Galen. Hysteria has traditionally
been viewed as a women's disease; its literal translation from the Greek is '"wan-
dering womb." Trimble (2004) noted that symptoms similar to those reported
in MUI today, and with a gender-specific etiology, were documented more
than 2,000 years ago in at least two different cultures. The term hysterical be-
came almost "interchangeable with 'feminine' in literature, where it stood for
all extremes of emotionality" (Showalter, 1985, p. 129). Showalter (1985) ar-
gued that the vast repertoire of emotional and physical symptoms ranging
from fits, fainting, vomiting, choking, sobbing, laughing, paralysis, and the
rapid passage from one symptom to another was consistent with the percep-
tion of the lability and capriciousness associated with feminine nature.
Neurotic hysteria has been viewed as either a heroic protest against
Victorian repression or as a pathetic collapse into maladaptive illness (Micale
1995; Smith-Rosenberg, 1985). The Freudian perspective was extremely in-

13
fluential in establishing hysteria as an expression of unconscious conflicts
displayed through bodily symptoms (Breuer & Freud, 1895/1987). Symptoms
served a symbolic function in the world of the Victorian woman. Freud's
female patients became the prototype for the hysterical neurotic, and psy-
choanalysis has even been called the child of the hysterical woman. Because
Freud viewed the repression of sexual impulses to be the source of all neuro-
sis, psychoanalytic treatment was aimed at unearthing this unconscious re-
pression in the hysterical patient. Her bodily symptoms were then expected
to dissipate as she gained insight into her unconscious conflicts.
By the late 19th century, hysteria was often confounded with neuras-
thenia; together they were referred to as the "nervous" disorders. Their symp-
toms could certainly overlap, and both resulted in profound disability. Hys-
teria tended to consist of more dramatic, colorful symptoms, whereas
neurasthenia was characterized by fatigue (Micale, 1995; Oppenheim, 1991).
Becker (2005) argued that the pairing of "nerves" and distress in hysteria, the
'"female" disease, preceded the appearance of neurasthenia, the "American"
nervous disease. Showalter (1985) contended that neurasthenia was a more
attractive form of female nervousness than hysteria, although the two were
not always distinguishable.
Fatigue as a debilitating symptom, first reported in the mid-1800s, was
believed to afflict primarily upper-class women (Shorter, 1993; Wessely, 1991).
These women complained mainly of fatigue and muscle weakness, but pain
was also often a prominent symptom. George Beard, an American physician,
was the first to describe neurasthenia as a distinct clinical category (Beard,
1880). The symptoms of neurasthenia included general malaise, disability,
weakness, poor appetite, neuralgic pains, hysteria, hypochondriasis, avoid-
ance of mental labor, and headaches (Macmillan, 1976). By 1900, neuras-
thenia had become an extremely common diagnosis, although it appeared to
be a "catch-all" category (Shorter, 1993). Neurasthenia was used alternately
as a synonym for general nervousness and evolving psychosis, as the '"male"
equivalent of hysteria, as a synonym for minor depression, and as a diagnosis
for unexplained fatigue states (Shorter, 1993; Torres-Harding & Jason, 2005).
Showalter (1985) described neurasthenia patients as women who lan-
guished with fatigue and who were often incapable of any purposeful activity
or of even rising from bed. Although she acknowledged the occurrence of
the illness in men, the main thrust of her argument was that it arose in women
as a form of protest against their empty and unfulfilled lives. Primary sources
reveal contradictory views on the gender distribution of neurasthenia. Some
writers saw it as a disease of professional and intellectual men, leaders, and
captains of industry (Pritchard, 1905). However, some believed that women
were more vulnerable owing to their "weaker nervous systems." Medical
texts of the late 1800s contained comments indicating that young women
were much more prone than young men to nervous complaints. They also
voiced the common concern that educating women could contribute to ner-

14 MEDICALLY UNEXPLAINED ILLNESS

vous symptoms and damage women's reproductive capacities (Oppenheim,
1991).
Although neurasthenia was diagnosed in both men and women, phy-
sicians perceived numerous differences related to symptoms, causes, and
treatments (Becker, 2005). Beard (1880) made the distinction between male
"cerebrasthenia" brought on by mental overwork and female "myelasthenia"
brought on by physical or emotional shocks. The rest cure was more often
applied to women, whereas men were more likely to be instructed to build
up their energy reserves through vigorous exercise. Gender was an impor-
tant factor in diagnosis; physicians were loathe to diagnose hysteria in men
because it was considered a "feminizing"' label, implying weakness and
vulnerability.
Over time, diagnoses of hysteria and neurasthenia declined as they came
to be redefined as psychiatric because of the stigma of psychiatric labels
(Wessely, 1991). Within the medical profession, the development of psy-
choanalysis and the increase in psychological treatments all but eliminated
the diagnosis of disorders that were a physical expression of distress (Swartz,
Blazer, George, & Landerman, 1986). Shorter (1992) argued that the de-
creased prevalence of neurasthenia was due to a paradigm shift in medicine
in which neurasthenic symptoms came to be regarded as psychological.
Somatizing patients therefore selected symptoms that were more likely to be
construed as organic from the "symptom pool." As people became more psy-
chologically literate, they understood the psychodynamics behind "nervous"
symptoms. Then, as now, psychological symptoms were seen as less legiti-
mate than organically based ones.
Micale (1995) argued that as society progressed away from Victorian
strictures on women, escape into illness became less necessary. It has been
acknowledged that hysteria and neurasthenia may have acted as symbols for
women's restricted opportunities (Showalter, 1985; Smith-Rosenberg, 1985).
The emancipation of women and the liberation of sexual attitudes were im-
portant in decreasing women's need to express themselves somatically
(Showalter, 1985; Smith-Rosenberg, 1985). It is interesting that today's dis-
cussions of MUI rarely link women's current role requirements to burgeon-
ing rates of MUIs.
Neurasthenia and hysteria were diagnosed less frequently as more work-
ing class people began to suffer from them. New research has indicated that
symptoms of hysteria and neurasthenia were not rare among the working
classes but that the conditions were unrecognized, untreated, and
underreported (Micale, 1995; R. Taylor, 2001). This is similar to the case
of chronic fatigue syndrome (CFS), which was originally labeled "yuppie
flu" until several community-based epidemiological studies showed that
higher levels of fatigue were found among non-White minority groups (Song,
Taylor, & Jason, 1999; Steele et al, 1998), and the yuppie label became
obsolete.

A BRIEF HISTORY OF GENDER IN MEDICALLY UNEXPLAINED ILLNESS 15

 The first Diagnostic and Statistical Manual of Mental Disorders (DSM;
American Psychiatric Association, 1952) had several categories for Hyste-
ria: by symptom, conversion disorder, and personality trait ("Emotionally
Unstable Personality"). The second edition of the DSM (DSM-II; American
Psychiatric Association, 1968) further categorized hysteria as "Hysterical
Neurosis" (conversion reaction and dissociative reaction) and "Hysterical
Personality." In the third edition of the DSM (DSM-III; American Psychiat-
ric Association, 1980), the term Hysterical Personality was replaced with His-
trionic Personality Disorder to emphasize the histrionic behavior pattern and
to reduce the confusion caused by the historical links of hysteria to conver-
sion symptoms. Hysterical Neurosis, Conversion Type became Conversion Dis-
order. The third revised edition of the DSM (DSM-III-R; American Psychi-
atric Association, 1987) retained the term Histrionic Personality Disorder, but
the criteria for it were revised. The fourth edition of the DSM (DSM-IV;
American Psychiatric Association, 1994) includes the classification
Somatoform Disorders, which includes Conversion Disorder, and it still re-
tains Histrionic Personality Disorder.
The history of neurasthenia in the DSM is equally convoluted. Neuras-
thenia did not appear in the original DSM; it appeared in DSM-II, but it was
summarily dropped in DSM-III. It reappeared in DSM-IV in the appendices
as a culture-bound syndrome. The core symptoms of neurasthenia were de-
scribed in DSM-IV as persistent mental or physical fatigue accompanied by
at least two of seven symptoms: dizziness, dyspepsia, muscular aches or pains,
tension headaches, inability to relax, irritability, and sleep disturbance. Ex-
clusion criteria were described as mood or anxiety disorders.
Some have argued that neurasthenia has not disappeared but that the
symptom complex was first subdivided into various neuroses, including
obsessive-compulsive disorders, anxiety neuroses, and hysterical personality
(Shorter, 1992), and more recently as CFS, fibromyalgia (FMS), multiple
chemical sensitivities (MCS), and various other MUIs (Ford, 1997; Micale,
1995; Wessely, 1996). Neurasthenia is still included in the latest revision of
the International Classification of Diseases, 10th Revision (World Health Orga-
nization, 1992), and it is still diagnosed in parts of Europe, Russia, and Asia,
where it is seen as a physical disorder (P. Y. Schwartz, 2002; Wessely, 1991).
In the 1970s, a variant of hysteria apparently began to be diagnosed as
a psychiatric disorder called Briquet's syndrome. First described by a French
psychiatrist in 1859, Briquet's syndrome was formally defined by Guze, Woo-
druff, and Clayton (1971) as a subtype of hysteria occurring predominantly
in women with a complicated and dramatic medical history beginning before
age 30. Briquet's syndrome consists of the presence of a minimum of 25 medi-
cally unexplained symptoms in at least 9 of 10 symptom groups (Guze, 1975);
it is found to be a reliable and valid diagnosis (Guze, Cloninger, Martin, &
Clayton, 1986). Briquet's syndrome is associated with familial aggregation in
women but not in men (Cloninger, Martin, Guze, & Clayton, 1986).

16 MEDICALLY UNEXPLAINED ILLNESS

 Liskow, Othmer, Penick, DeSouza, and Gabrielli (1986) found that fe-
male psychiatric outpatients with Briquet's syndrome had an average of 4.3
other psychiatric syndromes. These disorders include depression, panic, pho-
bia, obsessive-compulsive disorder, antisocial personality disorder, and sub-
stance abuse. Liskow et al. suggested that Briquet's syndrome patients have a
response bias and answer yes to many questions regarding psychopathology
just as they do to questions relating to medical symptoms. Support for the
sheer multiplicity of complaints in Briquet's was also found by Wetzel, Guze,
Cloninger, Martin, and Clayton (1994). They compared women with pri-
mary affective disorder with women with Briquet's syndrome on the Minne-
sota Multiphasic Personality Inventory. The women with Briquet's syndrome
reported more complaints of all types in all areas than depressed women,
even after controlling for response bias. Wetzel et al. concluded that women
with Briquet's syndrome present with multiple somatic and psychological
symptoms. Orenstein (1989) proposed that Briquet's syndrome represents
the most extreme expression of a tendency for the aggregation of physical
symptom reporting, depression, panic disorder, and agoraphobia.
In DSM-III, Briquet's syndrome surfaced as somatization disorder; the
criteria for identifying it were simplified and fewer symptoms were required
for diagnosis. Thus, one could argue that hysteria has evolved into the
somatoform disorders. Rief and Sharpe (2004) observed that the medical
community rarely uses the term somatoform disorder. Rather, every medical
specialty has its own MUI syndrome: gastroenterology has irritable bowel
syndrome, rheumatology has FMS, gynecology has pelvic pain syndrome, and
so on. Rief and Sharpe argued that a general label such as medically unex-
plained symptoms or functional somatic syndromes, although not ideal, is re-
quired, because separate MUI categories are not sufficiently distinct, and
their similarities outweigh their differences.
The symptom of fatigue is a good example of a commonly occurring
symptom in MUIs that has garnered different taxonomy throughout history.
Shorter (2005) charted the rise and fall of fatigue as a psychiatric symptom.
In the first edition of the DSM, which appeared in 1952, general fatigue
was listed as the chief symptom in the condition "psychophysiologic ner-
vous system reaction." In DSM-II, published in 1968, the term neurasthenic
neurosis (neurasthenia) was introduced as an official diagnosis. Also added
was a seldom-used diagnosis, asthenic personality, characterized by easy fati-
gability. In DSM-III, American psychiatry thus relegated fatigue to the level
of one of many symptoms required to meet criteria for various affective disor-
ders. The former asthenic personality was collapsed into "dependent person-
ality disorder."
As fatigue faded from psychiatric taxonomy, it started to become epi-
demic in physicians' offices (Shorter, 2005), perhaps because it was perceived
as a physical symptom without the stigma associated with asthenia. In the
1980s, patients began attributing feelings of chronic weariness and chronic

A BRIEF HISTORY OF GENDER IN MEDICALLY UNEXPLAINED ILLNESS 17

pain to infection by Epstein-Barr virus. Shorter (2005) contended that this
epidemic differed from other similar epidemics across the ages by the tenac-
ity of patients' belief in a particular pathogen. Although Epstein-Barr virus
was soon discredited scientifically as the cause of fatigue symptoms, the diag-
nosis of CFS or myalgic encephalitis took hold, purported to be the conse-
quence of a breakdown in the immune system or a viral infestation (Shorter,
1992, 2005; Wesselv, 1990).
Torres-Harding and Jason (2005) summarized the view of many mid
20th century physicians who espoused a holistic approach to fatigue and
emphasized the need to take into account physical factors, such as infection
or overwork, in addition to psychogenic or personality factors. Several out-
breaks of illnesses with fatigue as a chief or principal symptom and with un-
known etiology were also reported (Levine, 1994; Wessely, 1991). These
unexplained fatigue illnesses were given multiple labels, including epidemic
neuromyasthenia, myalgic encephalomyelitis, Iceland disease, and atypical polio-
myelitis.
In addition to neurasthenia, other unexplained illnesses were reported
in the late 19th and early 20th century. Some of these illnesses were called
effort syndrome, disordered action of the heart, and neurocirculatory asthenia.
T. Lewis (1940) first described effort syndrome, the symptoms of which in-
cluded breathlessness, pain, palpitation, fainting, giddiness, headaches (es-
pecially after exertion), and complaints of fatigue (summarized by Torres-
Harding & Jason, 2005). Initially, these disorders were regarded as arising
from anomalies of cardiac function. Over time, however, as efforts to find
underlying physiological abnormalities were not successful, these illnesses
began to be regarded as primarily psychosomatic in nature.
Feinstein (2001) described a number of syndromes that have affected
soldiers since the Crimean War. Among the names given to these syndromes
were DaCosta syndrome (DaCosta, 1871); soldier's heart; shell shock; combat
stress; neuocirculatory neurasthenia; and most recently, Gulf War syndrome. A
syndrome akin to fibromyalgia was described by Cowers (1904) as fibrositis,
marked by tenderness in a number of body regions that was not accompanied
by tissue inflammation. Later, disturbed sleep, particularly a deficit in deep
sleep, and exhaustion were part of the syndrome (Smythe, 1989). The term
fibrositis was widely used until the American College of Rheumatology devel-
oped the criteria for FMS in 1990.
Multiple chemical sensitivity emerged as a descendant of food allergy
problems, which were described in the 1920s and 1930s, when theorizing about
sensitization to low levels of chemicals was set in the framework of allergy.
Concerns about food allergies were transferred to the environment more broadly
by the 1960s, when the term chemical sensitivity began to be used, and the clini-
cal definition was developed in the 1980s (Shorter, 1992, 1997).
Many individuals report a complex mix of somatic and psychological
symptoms that belie discrete categorization (Hickie, Hadzi-Pavlovic, & Ricci,

18 MEDICALLY UNEXPLAINED ILLNESS

1997). MUIs have always challenged traditional perspectives on illness. Al-
though the lack of definitive pathophysiology is frustrating, there do appear
to be subtle physiological abnormalities in most MUIs (S. K. Johnson, DeLuca,
&Natelson, 1999). Some have argued that many of Freud's classic "hysteria"
cases were likely suffering from undiagnosed neurological disorders (Webster,
1995). Slater and Glithero (1965) asserted that in a group of patients diag-
nosed with hysteria in the 1950s, 33% actually suffered from serious organic
disease. Increases in medical sophistication have significantly reduced the
number of inaccurate hysteria diagnoses, but prognosis for chronic symptoms
remains poor (Mace & Trimble, 1996). Stone et al. (2005) systematically
reviewed 27 studies done since 1965 that had median follow-up durations of
5 years and included a total of 1,466 patients. Misdiagnosis was considered to
have occurred when investigators concluded that most of a patient's original
symptoms or signs were subsequently explained by disease. The average rate
of misdiagnosis in these later studies was only 4%, which led the researchers
to conclude that most medically unexplained symptoms were rarely misdiag-
nosed in contemporary investigations.
R. Taylor (2001) noted that a core cluster of nonspecific unexplained
symptoms can be identified in historical case records and have continued to
be reported by a significant proportion of individuals seeking medical treat-
ment over the past 2 centuries. The diagnostic categories for these unex-
plained symptoms have fluctuated over time, with a shift in the 20th century
to psychological diagnoses. Patients with unexplained physical symptoms have
suffered considerably and have been passed to and fro between medical doc-
tors and psychiatrists (Shorter, 2005).
This brief history conveys some of the similarities among hysteria, neur-
asthenia, and contemporary MUI. A number of theorists (Barsky & Borus,
1999; Feinstein, 2001; Shorter, 1992; Showalter, 1997; Wessely, 1991) have
argued that MUIs are modern, media-driven forms of hysteria resulting from
a stressed-out, exhausted populace unwilling to accept their symptoms as
emotionally caused. They contend that the Zeitgeist of the times and a quest
for organicity determines the pattern of symptoms displayed. Ford (1997)
went so far as to call MUIs "nondiseases" and stated that "hysteria is alive
and well, and one contemporary hiding place is fashionable illness" (p. 7).
Ford claimed that certain diagnoses were fashionable, namely MCS, FMS,
reactive hypoglycemia, repetitive strain injury, and CFS. This skeptical view
was echoed by Shorter (1997), who contended that MCS was the latest in a
line of "pseudodiseases" that started with hypoglycemia in the 1960s and
1970s and was replaced by CFS and fibrositis in the 1980s and repetitive
strain injury and sick building syndrome in the 1990s.
The view of MUI as shaped by the media Zeitgeist, the Internet, and
peer groups is somewhat overstated. Furthermore, such arguments can
heighten the divisions between MUI advocates and the medical community.
There is no doubt that the culture plays a role in shaping symptoms and

A BRIEF HISTORY OF GENDER IN MEDICALLY UNEXPLAINED ILLNESS 19

labeling syndromes (Gureje, 2004). Additionally, economic factors may
motivate patients to be more inclined to present with physical symptoms,
because insurance reimbursement for psychiatric treatment is substantially
lower than for physical illness treatment. Some would argue that MCS is
an entirely socially constructed illness because it exists only in certain coun-
tries (Zavestoski et al., 2004). Yet, there are several important distinctions
between 19th-century interpretations and contemporary ones. Today's level
of medical sophistication makes medical diagnosis more accurate and effi-
cient, which means that fewer symptoms are unexplained. Moreover, tech-
nological advancement and knowledge of molecular biology, biochemistry,
infectious microbiology, and neurophysiology has helped advance the un-
derstanding of interactions between mind and body such as the stress/
hypothalamic-pituitary-adrenal axis connection.
A biopsychosocial model posits that culture may influence symptom
reporting and that there is also a bidirectional influence between brain physi-
ology and symptoms. Katon, Sullivan, and Walker (2001) gave the example
of irritable bowel syndrome, in which changes in brain physiology secondary
to stressful events can cause abnormalities in smooth muscle tone in the gut
and that these gut abnormalities are also associated with changes in brain
physiology. Thus, cultural, psychosocial, and cognitive processes can become
dominant in a vulnerable biological system.

20 MEDICALLY UNEXPLAINED ILLNESS

 2
PSYCHIATRIC DISORDER IN
MEDICALLY UNEXPLAINED ILLNESS

Many symptoms people experience cannot be explained by an estab-

lished medical condition. Seventy percent of people with symptoms who
visit primary care doctors leave without a diagnosis or treatment plan (Kroenke
& Harris, 2001). This implies that a huge number of symptoms that bring
people to physicians' offices are unexplained. Although many somatic symp-
toms are self-limited and have a favorable prognosis, about 25% of patients
report persistent, chronic symptoms such as pain, fatigue, and headache
(Kroenke, 2001a, 2001b; Kroenke et al, 1997; Kroenke & Harris, 2001;
Verhaak, Meijer, Visser, & Wolters, 2006). In up to 50% of primary care
visits, no organic cause is found for the presenting symptom, and most pa-
tients do not receive a definite diagnosis (Barsky & Borus, 1995; Kroenke &
Mangelsdorff, 1989). Fink, Rosendal, and Toft (2002) summarized this situ-
ation by stating that it is "the exception rather than the rule in primary care
for physical symptoms to be caused by organ pathology or pathophysiological
disturbances" (p. 99). Many medically unexplained symptoms (MUS) fall
into clusters and have evolved into syndromes. Irritable bowel syndrome (IBS),
chronic fatigue syndrome (CFS), fibromyalgia (FMS), and multiple chemi-

21
cal sensitivity (MCS), the medically unexplained illnesses (MUIs) exam-
ined in this volume, are among the most common.
A perennial topic in the MUI literature is the high prevalence of life-
time and comorbid psychiatric disorders. The most commonly reported of
such disorders are depression, anxiety, and somatization disorder (SD). (So
matization has a number of definitions, but its core characteristic is presenta-
tion of physical symptoms that are not sufficiently explained by medical,
organic findings.) This high prevalence may mean that psychiatric disorders
are a crucial part of the etiology of MUI and that there are many overlapping
symptoms, which suggests a common pathophysiology. Alternately, common
symptoms may be amplified because of psychiatric distress, because a person
with MUI may experience reactive depression to the disability imposed by
MUI, or because physicians may have a tendency toward "psychologizing"
women's symptoms. What is not in dispute is that numerous research studies
have shown high rates of lifetime and current diagnoses of somatoform, mood,
and anxiety disorders among MUIs. The relationship between these psychi-
atric disorders and MUIs and the role of gender is discussed in this chapter.
Strong epidemiological evidence suggests female preponderance in all
of the MUIs (Barsky & Borus, 1999; Kroenke & Spitzer, 1998). All of the
MUIs are diagnosed on the basis of subjective symptom report. Women have
consistently been shown to report higher numbers of symptoms than men.
Most physical symptoms are reported at least 50% more often by women
than by men, and this is not completely explained by higher levels of mental
disorders in women (Kroenke & Spitzer, 1998). Although many studies have
shown higher levels of somatization in women than in men, levels of hypo-
chondriacal concerns are not different between men and women. Women
also do not worry about serious illness more than men do (Barsky & Wyshak,
1990; Creed & Barsky, 2004).
There is no sharp delineation between symptoms of psychiatric disor-
der in MUIs that are clearly psychological and those that are clearly organi-
cally based. Numerous symptoms, such as fatigue, cognitive difficulties, sen-
sitivity to pain, and sleep problems, occur commonly in both psychiatric and
organic conditions. Thus, it is often the health care professional who must
make the distinction between psychological symptoms and organic symp-
toms. S. K. Johnson, DeLuca, and Natelson (1996a) found that designation
of CFS symptoms as organic strongly affects the diagnosis of SD within the
CFS population; if the examiner attributes the patient's CFS symptoms to
physical illness, diagnosis of SD is unlikely. Kirmayer, Robbins, and Paris
(1994) also make the point that the designation of symptoms as unexplained
vacillates, depending on current medical explanations of symptoms.
Although discussing MUIs in the context of SDs is controversial,
somatizing tendencies must be considered when organic findings are insuffi-
cient to explain high levels of disability. MUIs often share a number of char-
acteristics with somatoform disorders in addition to multiple unexplained

22 MEDICALLY UNEXPLAINED ILLNESS

symptoms in a variety of body systems: Doctor shopping, disease conviction,
aversion to psychogenic explanations, and comorbidity with other psychiat-
ric disorders are some of the most common (Bornschein, Hausteiner, Konrad,
Forstl, & Zilker, 2006).
Fink (1996) suggested that MUIs such as CFS and FMS may be arti-
facts of suggestibility in somatizing patients; for example, individuals with
somatizing tendencies grasp onto publicized syndrome criteria to shape their
symptom presentation. Similarly, Barsky and Borus (1995) viewed the in-
crease in MUIs as influenced by sociocultural trends that reduce people's
tolerance for mild symptoms and lower the threshold for seeking medical
care. People amplify and misattribute discomforts to disease, a process that
may be abetted by medical professionals and the media. They call for recog-
nition of the normative presence of symptoms and distress that do not re-
quire medical intervention. In this context, it is interesting to note that men
are more likely than women to make normalizing attributions for somatic
symptoms (see chap. 3, Somatic Attribution section, this volume).

SOMATOFORM DISORDERS AND SOMATIZATION

The behavioral tendency to note and report physical symptoms is
thought to be related to three cognitive traits: selective attention and ampli-
fication of somatic symptoms, a belief that these symptoms are caused by
physical disease, and attempts to seek medical care for symptom relief (Barsky
& Wyshak, 1990; Lipowski, 1988; Whitehead & Palsson, 1998). Kirmayer et
al. (1994) summarized a number of processes that contribute to somatic dis-
tress: neuroticism, individual differences in physiological reactivity, symp-
tom perception, symptom thresholds, somatic attention, coping resources,
and tendencies toward help seeking. Trait anxiety and trait negative affect,
both higher in women, appear to be associated with a cognitive style of height-
ened vigilance toward body sensations (Pennebaker, 1994). Numerous in-
vestigators (Barsky & Borus, 1999; Kirmayer et al., 1994; Kroenke et al.,
1997; Manu, 2004) have made persuasive arguments that somatizing pro-
cesses pervade the MUI, especially in those who seek medical care and medi-
cal validation and are very disabled by MUIs. Gleason and Yates (2002)
have noted that "female gender stands out as the most important risk factor
for somatization" (p. 309). They explained this in terms of the five mecha-
nisms proposed by Wool and Barsky (1994): (a) Somatic symptom reporting
is more culturally approved in women compared with men; (b) women more
readily seek medical care for symptoms than men do; (c) psychiatric disor-
ders that include somatizing tendencies are more common in women than
in men; (d) women have higher rates of childhood trauma than men; and
(e) women have greater sensitivity to bodily sensations than men.
Because so many terms are used to label SD, and because somatization
is often described as a behavior or a process, it is important to remember that

PSYCHIATRIC DISORDER 23
somatization does exist as a Diagnostic and Statistical Manual of Mental Disor-
ders (DSM) classification, albeit a problematic one. According to the fourth
edition of the DSM (DSM-IV; American Psychiatric Association, 1994),
SD is characterized by a lifetime history of multiple medically unexplained
physical symptoms, including at least four unexplained pain symptoms, two
unexplained nonpain gastrointestinal symptoms, one unexplained sexual
symptom, and one pseudoneurological symptom. SD is rarely diagnosed in
men. Most men with somatic complaints have disorders with prominent anxi-
ety symptoms (Cloninger, Martin, Guze, & Clayton, 1986).
Many patients with SD meet criteria for other psychiatric disorders
(Robins et al., 1984; Swartz, Blazer, George, & Landerman, 1986) and incur
very high rates of recurring health care utilization (Barsky &. Borus, 1995;
Hiller & Fichter, 2004; Kolk, Schagen, & Hanewald, 2004; G. R. Smith,
Monson, & Ray, 1986). SD seems to represent the extreme end of a somati-
zation continuum (Allen & Escobar, 2005; Escobar, Bumam, Karno, Forsythe,
& Golding, 1987; Katon et al., 1991; Melville, 1987). To describe individu-
als who do not meet SD criteria, Escobar et al. (1987) introduced the label
abridged somatization for men complaining of at least four unexplained physi-
cal symptoms and women complaining of at least six unexplained physical
symptoms. Abridged somatization is also associated with increased use of
medical services and elevated levels of disability and psychopathology (Escobar
et al., 1987; Katon et al., 1991). Moderate levels of somatization appear to be
widespread in primary care, with the prevalence of abridged somatization in
the population estimated to be 22% (Escobar, Waitzkin, Silver, Gara, &
Holman, 1998).
Fink, Hansen, and Oxhoj (2004) examined prevalence of full-blown
SD in a sample of 294 consecutively admitted general medical inpatients in
Denmark. They found that 18.1% of individuals met International Classifica-
tion of Diseases (World Health Organization, 1992) criteria for a diagnosis of
SD, whereas 20.2% met DSM-IV criteria for SD. SDs were much more preva-
lent among women, and there was a significant trend for female prevalence
to decrease with increasing age.
Other DSM-IV SDs include undifferentiated SD (which would include
most unexplained illnesses), conversion disorder, pain disorder, hypochon-
driasis, and SD not otherwise specified. Creed and Barsky (2004) reviewed
the epidemiology of SD and hypochondriasis in primary care and popula-
tion-based samples. They searched MEDLINE and PsycLIT from 1966 to
2002 and found that only 47 studies fulfilled the inclusion criteria of calcu-
lating a prevalence figure using a standardized definition. They concluded
that population studies do not support the assumption that SD and hypo-
chondriasis are discrete psychiatric disorders. Rather, there is considerable
evidence that these disorders are very closely allied with anxiety and depres-
sive disorders. They also noted that there was a predominance of women
with SD in population and primary care samples. When abridged somatiza-

24 MEDICALLY UNEXPLAINED ILLNESS

tion definitions are used, female predominance drops, underlining the con-
nection between multiple symptom reporting and female gender. Hypochon-
driasis, however, did not seem to show a gender bias. A preponderance of
evidence indicates that women somatize more than men, and women are
diagnosed significantly more frequently with SD (Gijsbers van Wijk & Kolk,
1997; Gleason & Yates, 2002).
Research has consistently shown that the number of unexplained symp-
toms is linearly associated with psychological dysfunction. Hotopf,
Wadsworth, and Wessely (2001) addressed this issue directly in a case con-
trol study using a national birth cohort sample. They found that 955 out of a
sample of 3,262 people were identified as having probable psychiatric disor-
der. On a separate question, 43% of these people acknowledged the presence
of psychiatric disorder; compared with the nonacknowledging group,
acknowledgers were found to be more likely to be female, more educated,
have more severe psychiatric disorder, and report more physical symptoms.
Thus, reporting multiple physical symptoms does not appear to act as a de-
fense against psychiatric disorder diagnosis or acknowledging psychiatric dis-
order. Yet it is clearly related to psychiatric disorder.

Dualism and Somatization

Does labeling behavior as somatizing set up a false dualism wherein

somatization is not a useful concept? The myriad problems and contradic-
tions inherent in the SD classification of the DSM have been cogently ad-
dressed by Mayou, Kirmayer, Simon, Kroenke, and Sharpe (2005), who call
for an abolition of the SD category from the DSM-IV. MUIs are the epitome
of what is wrong with the SD diagnosis. In its current form in DSM-IV,
classification of SD stigmatizes patients, is overtly dualistic, overlaps with
depression and anxiety in many shared symptoms, is unreliable, lacks a de-
fined threshold, and has unclear medico-legal status. Mayou et al. (2005)
gave the example of IBS as a disorder that could be diagnosed as an undiffer-
entiated Axis I SD as well as an Axis III general medical condition. Clearly,
this is an untenable position. More broadly, McWhinney, Epstein, and Free-
man (1997) criticized the label somatization as a product of Western medicine's
dualistic perspective. In many other cultures, the idea that emotions can be
embodied physically is overtly accepted, and a biopsychosocial model is im-
plicitly accepted.

Associations Among Depression, Anxiety, and Somatization

The World Health Organization has documented that depression, anxi-

ety, and somatic complaints are more common among women than men.
These conditions are related to risk factors such as gender-based roles, stres-

PSYCHIATRIC DISORDER 25
sors, and negative life experiences. The World Health Organization report
(2007) described gender-specific risk factors such as gender-based violence,
socioeconomic disadvantage, low or subordinate social status, and constant
care of others. These risk factors constitute a psychological burden that
have the potential to be expressed in depression, anxiety, or somatization
symptoms.
R. C. Smith et al. (2005) set out to determine the prevalence of DSM-
IV somatoform and nonsomatoform disorders in patients with MUS in a com-
munity-based health maintenance organization. Patients with MUS were
those picked from a chart review of 1,646 high utilizers; trained raters as-
sessed documented (severe MUS) and undocumented (mild MUS)
nonorganic disease. Patients who met the criterion for a high proportion of
undocumented and documented nonorganic symptoms were recruited into
the study. Two hundred six patients with MUS averaged 13.6 hospital visits
in the year preceding the study, 79.1% of them were women, and the average
age was 47.7 years. Patients with full or abridged DSM-IV somatoform diag-
noses were labeled "DSM somatoform-positive," whereas those without such
diagnoses were labeled "DSM somatoform-negative." R. C. Smith et al. found
that 60.2% had a nonsomatoform DSM-IV diagnosis, primarily anxiety or
depression. Only 4.4% had any full DSM-IV somatoform diagnosis, and only
18.9% had abridged SD. Thus, depression and anxiety characterized MUS
patients better than the somatoform disorders. Correlates of DSM somatoform-
negative status were female gender and less severe psychiatric and physical
dysfunction. These data suggest that multiple unexplained symptoms are not
the same as SD, are more closely related to depression and anxiety, and are
more common in women.

MOOD AND ANXIETY DISORDERS IN

MEDICALLY UNEXPLAINED ILLNESSES

The majority of patients with depression and anxiety who go to primary

care physicians do not present with psychological symptoms but rather with
somatic symptoms such as fatigue, pain, headache, gastrointestinal complaints,
and disturbed sleep (Kroenke, 2001). Patients with MUIs in both primary
care and medical specialty samples have significantly higher rates of depres-
sion and anxiety than do comparable patients with clearly defined medical
diseases (Katon, Sullivan, & Walker, 2001; Wessely, Nimnuan, & Sharpe,
1999). In a comprehensive meta-analysis, Henningsen, Zimmerman, and
Sattel (2003) examined the relationship between MUIs (FMS, CFS, IBS,
and nonulcer dyspepsia) and anxiety and depression. They reviewed 244 stud-
ies and concluded that depression and anxiety are a common feature of these
MUIs. The association with depression and anxiety is higher than in healthy
controls or in patients with similar symptoms explained by a medical diagno-

26 MEDICALLY UNEXPLAINED ILLNESS

sis. Compared with patients with IBS, patients with FMS were significantly
less anxious and patients with CFS were significantly more depressed.

Depression, Anxiety, and Gender

It is well established that anxiety and depression have a higher preva-

lence among women than among men and that these conditions are also
strongly related to symptom reporting (Wool 6k Barsky, 1994). One might
reasonably ask whether the higher rate of MUIs in women can be explained
by their higher rates of depression and anxiety. The data do not support this
parsimonious explanation, however. Haug, Mykletun, and Dahl (2004) ex-
amined the association between anxiety, depression, and somatic symptoms
in a large population-based study of all inhabitants in a Norwegian county
who were 20 years old or older. The association between anxiety and depres-
sion and number of functional somatic symptoms was found to be strong, and
it was as strong among men as among women, although women consistently
reported more symptoms.
Likewise, Kroenke and Spitzer (1998) assessed whether gender dispari-
ties in symptom reporting were attributable to psychiatric comorbidity in the
PRIME-MD 1000 study. Although physically unexplained symptoms were
more frequent among women, and depressive and anxiety disorders were the
strongest correlate of symptom reporting, gender had an independent effect
that persisted even after adjusting for psychiatric comorbidity. Thus, women's
tendency to report more unexplained symptoms is not solely explained by
women's higher rates of depression and anxiety.
Women with unipolar depression outnumber men 2:1. The gender dif-
ference in depression is robust, with a female preponderance in prevalence,
incidence, and morbidity risk for major depression, dysthymia, atypical de-
pression, and seasonal affective disorder (Piccinelli & Wilkinson, 2000). A
consistent factor that differentiates female and male depression is the pre-
ponderance of somatic symptoms in female depression. Women are much
more likely than men to report depression with appetite loss, sleep distur-
bances, and fatigue, but they are not more likely than men to report depres-
sion without these symptoms (i.e., "pure depression"; Silverstein, 2002). In a
study of 201 opposite-sex twin pairs in which both twins fulfilled DSM-III-
R criteria for major depression, the female twins reported significantly more
fatigue, hypersomnia, and psychomotor retardation than their male twins
(Khan, Gardner, Prescott, 6k Kendler, 2002). In an international study of 14
countries, females in all of the centers were twice as likely to report more
somatic symptoms than men (Maier et al., 1999). Thus, it is well established
that higher levels of somatic symptoms do characterize depression among
women.
In a review of gender differences in depression, several social factors
were found to contribute to the higher incidence of women among depressed

PSYCHIATRIC DISORDER 27
individuals. These factors included adverse events in childhood, depression
and anxiety disorders in childhood and adolescence, crises involving chil-
dren and housing, reproductive problems, and poor coping skills (Piccinelli
& Wilkinson, 2000). Girls are more likely than boys to be victims of sexual
abuse in childhood, which may contribute to their greater risk for depression
and anxiety disorders (Weiss, Longhurst, & Mazure, 1999).
Women are more likely to use a ruminative response style, dwelling on
negative events and focusing on their symptoms and the possible causes and
consequences of their symptoms. People who ruminate show longer lasting
depressions than people who take action to distract themselves from their
symptoms (Nolen-Hoeksema, Larson, & Grayson, 1999). Ruminative re-
sponses prolong depression because they allow the depressed mood to nega-
tively bias thinking and interfere with coping behavior. This rumination may
extend to health problems. In a series of studies, Silverstein and colleagues
(Silverstein & Blumenthal, 1997; Silverstein, Caceres, Perdue & Cimarolli,
1995; Silverstein & Lynch, 1998) found that anxious, somatic depression
(but not pure depression) in adolescent girls was associated with distress over
the achievement and occupational limits experienced by their mothers.
Klonoff, Landrine, and Campbell (2000) found that in a sample of 255
university students, women scored higher on anxiety, depression, and soma-
tization symptoms than men. Critically, women with low exposure to sexist
stress did not differ from men on these symptoms, whereas women with fre-
quent exposure to sexist stress accounted for the gender difference in symp-
toms. These findings were not explained by ethnicity, marital status, educa-
tion or income differences, or reporting bias. Klonoff et al. hypothesized that
an accumulation of stress contributes to women's symptoms of depression,
anxiety, and somatization. Because women experience gender-specific stres-
sors that men do not (e.g., discrimination, battering, and sexual harassment),
women exhibit more symptoms because they experience more stress.
Gender-related stress, as well as rumination about that stress, appears to be
related to depression, anxiety, and somatization.

Gender, Depression, and Pain

Gender may moderate the relationship between distress and pain. Find-
ings in this area have been inconsistent; some studies have found that de-
pression among women is associated with greater pain-related disability and
that anxiety is related to greater pain severity in men, whereas other studies
find no gender differences (Keogh, McCracken, & Eccleston, 2006). Keogh
et al. (2006) examined whether gender moderated the relationship between
anxiety and depression and pain and pain-related disability in 260 patients
enrolled in a British pain management center. When depression was high,
women reported greater disability than men, whereas men took more medi-
cations than women. Social gender roles may be operating here, with women

28 MEDICALLY UNEXPLAINED ILLNESS

having a stronger belief in the link between depression and pain than men,
thus rendering women more vulnerable to disability. We know that health
care practitioners are more likely to prescribe antidepressants and antianxi-
ety drugs for women than men, even for similar symptoms (Hohmann, 1989).
Women are also more likely to make psychologizing attributions for symp-
toms, whereas men are more likely to make normalizing attributions (Nykvist,
Kjellberg, & Bildt, 2002).

Depression and Anxiety in Medical Illness

Medical patients generally report higher rates of depression and anxi-

ety than matched healthy controls. Some of this may be attributable to con-
founding of symptoms. There is ample evidence that somatic symptoms can
artificially elevate depression levels in a variety of medical populations (Frank
et al, 1992; Nyenhuis et al., 1995; Plumb & Holland, 1977; A. Williams &
Richardson, 1993). Yet the core elements of depression, such as negative
self-evaluations, depressed affect, and suicidal ideation, are lower in many
medical populations than those seen in clinical depression. The high rates of
depression and anxiety in MUIs may also be partially explained by confound-
ing of symptoms on self-report and interview surveys. Symptoms such as fa-
tigue, pain, difficulty concentrating, difficulty sleeping, loss of appetite, and
excessive health worry can be part of a psychiatric assessment of depression
or anxiety but are also common in medical illness. In a study that specifically
examined depressive symptoms in CFS, S. K. Johnson, DeLuca, and Natelson
(1996b) found that although individuals with CFS may meet criteria for de-
pressive disorder or score in the depressed range on a self-report inventory,
they had significantly higher somatic and significantly lower self-reproach
scores than a clinical depressed comparison group. It may be more than a
confounding of symptoms and closer to a common pathophysiology, how-
ever. In a review of mood disorders in medical illness, Evans et al. (2005)
posited that a growing body of evidence indicates that biological mecha-
nisms underlie a bidirectional relationship between depression and many
medical conditions.
Simple explanations seem to elude us yet again. Clearly the high rates
of depression and anxiety in individuals with MUIs are not just a reporting
artifact of confounding symptoms and may be more than a reaction to dis-
ability wrought by illness. Lifetime history of depression and anxiety is higher
among individuals with MUIs than among those with comparable medical
diseases. Individuals with similar symptoms caused by medical disease have
higher psychiatric morbidity than healthy people, but they have consistently
lower levels of psychiatric distress than their counterparts with MUIs.
Rief, Martin, Klaiberg, and Brahler (2005) surveyed a representative
German sample of 2,507 people and identified those with panic disorder,
somatic syndrome, and depression on the Scale for the Assessment of Illness

PSYCHIATRIC DISORDER 29
Behavior (Rief, Ihle, & Pilger, 2003). Those with panic disorder showed the
highest scores for illness behavior and health care use. Depression was associ-
ated with illness consequences (e.g., '"Illnesses influence the way I act to-
ward family and friends") and illness expression (e.g., "Everyone can see when
I am suffering"). People with somatic syndromes had the highest scores on
medication and treatment (i.e., relied on and had confidence in pharmaco-
logical treatment) and scanning the body for symptoms. This study illus-
trates the connection between mood and anxiety disorders and greater ill-
ness expression and health care utilization—the intimate connection that
often exists between psychiatric morbidity and multiple somatic symptoms.
The presentation of multiple somatic symptoms also can mean an individual
meets criteria for several MUIs concurrently, which leads to the issue of overlap
among the MUIs.
The tendency for substantial overlap among the various MUIs rein-
forces the view that these disorders involve somatization. Numerous investi-
gators have noted this overlap—that is, individuals with one of these condi-
tions are more likely to have another of these conditions (Aaron & Buchwald,
2001, 2003; Barsky & Borus, 1999; Buchwald & Garrity, 1994; Clauw, 1994,
2001; Clauw & Chrousos, 1997; Deary, 1999; Hudson & Pope, 1989; Manu,
2004; Peres, 2003; Wessely et al., 1999; Whitehead, Palsson, & Jones, 2002;
Yunus, 2001, 2002). Specifically, the tendency to report a history of any one
unexplained symptom is associated with a tendency to report many others
(Deary, 1999). Additionally, those who seek care for MUIs are more likely to
have overlapping conditions than those identified within population-based
studies.

CONCLUSION

There are numerous reasons why women have more MUIs. It is well
established that women generally report more symptoms than men. Women
appear to somatize more than men. Women have higher rates of depression
and anxiety, which increase symptom reporting. This chapter has shown that
somatization, depression, and anxiety commonly co-occur in MUIs. It ap-
pears, however, that psychiatric disorder is neither necessary nor sufficient to
explain MUIs. Although the higher prevalence of somatization, depression,
and anxiety in women undoubtedly contributes to their greater prevalence
of MUIs, it is just one piece of the biopsychosocial puzzle. Further pieces of
the puzzle are discussed in chapters 3 and 4.

30 MEDICALLY UNEXPLAINED ILLNESS

 PSYCHOSOCIAL AND COGNITIVE
3
FACTORS IN MEDICALLY
UNEXPLAINED ILLNESS

The biopsychosocial model of illness is premised on the well-established

fact that psychosocial, contextual, and cognitive factors play a major role in
the experience of symptoms. A number of psychological factors may contrib-
ute to gender differences in medically unexplained illnesses (MUIs). Some
of the factors examined in this chapter are lowered thresholds for symptom
perception and reporting, health care utilization, and the effects of gender
roles and expectations on illness behavior. Compared with men, women may
accumulate more stressful experiences such as abuse, have differing beliefs
and attributions for symptoms, and use different coping styles.
There are many potential psychosocial explanations for the higher preva-
lence of MUI in women. The sick role is generally more accepted in women
because gender role stereotypes promote the notion that women are more
delicate and weaker than men. Evidence suggests that women who have strong
feminine gender role identification have more MUIs (Ali, Richardson, &
Toner, 1998; Toner, 1995; Toner & Akman, 2000). Illness behavior, emo-
tional expression, and attributional style can be affected by gender roles.
Women experience more childhood abuse and other stressors, which are as-

31
sociated with higher numbers of unexplained symptoms. Higher rates of child-
hood abuse can lead to hypervigilance regarding physical symptoms and the
perception of symptoms as threatening. Additionally, unexplained symptoms
may be a way to seek care through the medical system.

ILLNESS BEHAVIOR

Mechanic (1972) introduced the term illness behavior to describe the

observation that people with the same illness display a spectrum of illness
behaviors. Illness behavior encompasses characteristics such as health care
use, taking medications, work disability, avoiding activity, expression of symp-
toms to significant others, and doctor shopping. Pilowski (1969) coined the
term abnormal illness behavior to describe behaviors such as having a hypo-
chondriacal attitude and multiple somatic complaints, engaging in inappro-
priate treatment seeking, and displaying disability disproportional to physi-
cal findings. Illness behavior is only moderately associated with illness severity.
Compared with men, women engage in more illness behavior, spend more
days in bed, restrict more of their activities because of illness, and use more
prescription drugs (Kandrick, Grant, & Segall, 1991).
The concept of illness behavior is clearly relevant for the MUIs, wherein
disability levels appear in excess of organic pathology. A similar concept, the
sick role, refers to adopting behaviors such as staying in bed, restricting activi-
ties, and taking medications on their own initiative rather than having them
prescribed by medical professionals. Playing the sick role is generally permit-
ted in those diagnosed with medical conditions, but Western society does
not easily give people permission to be ill in the absence of recognized dis-
ease (Nettleton, 2006).

Learned Illness Behavior

Excessive illness behavior may have its origins in childhood learning

experiences. Children may imitate illness behavior modeled by parents. Al-
ternately, adults with excessive illness behaviors may have had stressful ex-
periences as children, such as early separation or loss of a parent or illness-
specific stressors like hospitalization. Secondary gains may also be operating
in some contexts. Whitehead, Winget, Fedoravicius, Wooley, and Blackwell
(1982) found that patients with irritable bowel syndrome (IBS) reported that
their parents were more likely to give them special attention, foods, or treats
when they were sick compared with healthy controls or patients with peptic
ulcers.
Levy et al. (2004) interviewed 208 mothers with IBS and their 296
children and 241 healthy mothers (controls) and their 335 children. Factors
assessed were stress, mothers' and children's psychological symptoms,

32 MEDICALLY UNEXPLAINED ILLNESS

children's perceived competence, and pain coping style. Children of women
with IBS reported more frequent stomachaches and nongastrointestinal symp-
toms, made more physician visits for gastrointestinal symptoms, had more
nongastrointestinal clinic visits, and missed more school than control chil-
dren. Children whose mothers made solicitous responses to illness complaints
independently reported more severe stomachaches, and they also had more
school absences for stomachaches, but solicitous behavior did not signifi-
cantly impact nongastrointestinal symptom reporting, clinic visits, or school
absences.
To rule out the possibility that children were imitating their parents'
illness behavior, Crane and Martin (2004) looked at mothers of infants
younger than 18 months. They compared mothers taking medication for func-
tional gastrointestinal symptoms (mostly IBS) with mothers with stomach
ulcers, who completed questionnaires when their children were 6 and 18
months old. The infants of mothers with IBS were taken to the doctor for a
significantly greater number of symptoms than were children whose mothers
had ulcers. The mothers did not differ on psychiatric distress variables. This
finding provides evidence for potential reinforcement of illness behavior in
childhood experiences, which may increase vulnerability to MUIs in adult-
hood. Studies of these childhood experiences indicate that children of par-
ents with IBS were more likely than children with non-IBS parents to report
secondary gain and to have more symptom reports, health care use, and dis-
ability, suggesting an intergenerational transmission of illness behavior.

Symptom Reporting

It is well established that women report more symptoms than men across
various age spans (Borglin, Jakobsson, Edberg, & Hallberg, 2005; Haug,
Mykletun, & Dahl, 2004; Kroenke & Spitzer, 1998; Tibblin, Bengstsson,
Furunes, & Lapidus, 1990; Verbrugge, 1985, 1989). In a review paper on
gender and symptom reporting, Gijsbers van Wijk and Kolk (1997) con-
cluded that researchers using health surveys and symptom and physician re-
ports found that adult women reported more frequent or more intense symp-
toms, particularly when symptoms were measured in retrospect. It is interesting
to note that most of this review was concerned with reports from healthy,
community-residing individuals. Conversely, when actual disease was present,
men tended to report more symptoms than women.
Researchers conducting large population-based studies found that
women reported more symptoms. In a Norwegian study of both men and
women that included 50,377 women, Haug et al. (2004) reported an average
of 3.8 symptoms in women compared with 2.9 in men. The most common
symptoms reported were tiredness, gastrointestinal symptoms, headache, back
pain, and pain in arms and shoulders. Tibblin et al. (1990) studied 30 symp-
toms and their prevalence in different age cohorts in men and women from a

PSYCHOSOCIAL AND COGNITIVE FACTORS 33

Swedish population based study. They found that most symptoms, particu-
larly depression and tension, were more common among women, and this
difference was more pronounced in younger age groups. Higher levels of
symptom reporting do not completely diminish with age, however; in a
study of community-dwelling elderly individuals aged 75 to 99 years, women
had a significantly lower health-related quality of life than men and a sig-
nificantly higher degree of self-reported health complaints (Borglin et al.,
2005).
These studies also make clear that the core symptoms of many MUIs,
such as fatigue, pain, gastrointestinal complaints, and headaches, are present
in very high base rates in the general population (Kroenke, 2001). The gen-
der difference in symptoms is not due to women's more complex reproduc-
tive system, gynecological disorders, or menstrual events. In the U.S. Epide-
miological Catchment Area study, 20 out of 22 nonmenstrually related
symptoms were more common in women; only chest pain and difficulty walk-
ing were more common in men (Kroenke & Price, 1993).
Kroenke and Spitzer (1998) also found that increased symptom report-
ing in women was a generic phenomenon and not restricted to particular
types of symptoms. They assessed gender differences in symptoms and inves-
tigated whether these differences were attributable to psychiatric comorbidity.
They analyzed data from the PRIME-MD 1000 study (1,000 patients from
four primary case sites evaluated with the Primary Care Evaluation of Men-
tal Disorders interview; Spitzer et al., 1994) examining the reporting of 13
common physical symptoms. This study controlled for a lower threshold for
seeking care than is often found in women, because all the individuals in the
PRIME-MD study were seeking health care. After adjusting for depressive
and anxiety disorders as well as age, race, education, and medical comorbidity,
all symptoms except one (sexual problems) were reported more commonly
by women, with statistically significant differences for 10 of 13 symptoms.
Medically unexplained symptoms were also more frequent in women. Gen-
der was the most important demographic factor associated with symptom
reporting, followed by lower education and younger age. Total symptom count
was similar to that found by Haug et al. (2004), with women on average
reporting 1.47 more symptoms than men.

Symptom Perception

Under most circumstances, women report more symptoms than men.

What are some possible explanations for this phenomenon? Hibbard and
Pope (1983) showed that women were more likely to perceive symptoms
than men, that women place a higher value on health, and that women have
a higher preventive orientation than men do. Their study population in-
cluded 1,648 adults between the ages of 18 and 59. Medical record data cov-
ering 7 years of outpatient services were linked with survey data on the re-

34 MEDICALLY UNEXPLAINED ILLNESS

spondents. The findings showed that although women were more likely to
perceive symptoms than men, there was no apparent sex difference in a ten-
dency to adopt the sick role when ill. Gender role factors such as level and
type of role responsibility and concern with health were related to female but
not male symptom reports. Illness orientation variables were related to rates
of medical utilization for both genders. However, it was primarily the greater
perception of symptoms and an interest and concern with health in women
that contributed to sex differences in medical utilization rates.
Several gender factors may influence symptom perception and symp-
tom reporting. Women may have lower thresholds for many sensations. There
is evidence that women have lower perceptual thresholds and sensitivity
(Dalton, Doolittle, & Breslin, 2002; Else-Quest, Shibley Hyde, Hill Gold-
smith, & Van Hulle, 2006). Wool and Barsky (1994) have argued that women
are more sensitive to sensations.
Pennebaker (1994) summarized a series of laboratory and field studies
noting consistent gender differences in how individuals perceive and react to
symptoms. His studies have found that women are particularly sensitive to
situational and environmental cues, whereas men are more sensitive to in-
ternal physiological cues. In controlled laboratory studies, men are more ac-
curate at detecting heart rate, stomach activity, blood pressure, and blood
glucose levels. In field studies or in the home, there are no gender differences
in accuracy. Pennebaker speculated that women's symptom-reporting pat-
terns reflect a context that is stressful or potentially toxic, whereas men are
more oblivious to setting and focus on physiological cues.
Personality tendencies that increase symptom reporting may be more
common in women. Subjectively reported symptoms have been shown to be
systematically biased by neuroticism, which is strongly correlated with health
complaints but not actual health status (P. T. Costa & McCrae, 1987). The
personality trait of neuroticism is associated with a tendency to experience
emotional distress, including anxiety, anger, sadness, and other emotions with
negative valence (P. T. Costa & McCrae, 1992). In a healthy student popu-
lation, Neitzert, Davis, and Kennedy (1997) found that depression and neu-
roticism levels were significantly associated with higher symptom reporting
and that symptom reporting was higher in women.
P. T. Costa, Terracciano, and McCrae (2001) analyzed Revised NEO
Personality Inventory (P. T. Costa & McCrae, 1992) data from 26 cultures
(N = 23,031) and found that adult women reported themselves to be higher
in neuroticism. However, in a large meta-analysis, Else-Quest et al. (2006)
studied children up to age 13 years and found few gender differences in nega-
tive affectivity, aside from slightly higher levels of fearfulness in girls. It is
possible that small childhood differences in negative emotions are later mag-
nified by gender stereotypes. Neuroticism, anxiety, and negative affect ap-
pear to be associated with a cognitive style of heightened vigilance toward
body sensations (Pennebaker, 1994). It appears that stereotypes and gender

PSYCHOSOCIAL AND COGNITIVE FACTORS 35

expectations allow women to more readily express negative emotions, which
may contribute to higher symptom reporting.
A study using the Tridimensional Personality Questionnaire (Cloninger,
1987) found increased scores on harm avoidance and lower scores on reward
dependence (constructs similar to neuroticism) in individuals with chronic
fatigue syndrome (CFS) and multiple sclerosis relative to healthy controls
(Christodoulou et al., 1998). Generally, studies reveal trends toward higher
neuroticism among persons with CFS (Buckley et al. 1999; Cristodoulou et
al., 1998; S. K. Johnson, DeLuca, & Natelson, 1996c), although not as high
as is seen in clinically depressed persons.

Health Care Seeking

Physicians have reported that female patients disproportionately present

to medical practices with vague and medically unexplained symptoms
(Gijsbers van Wijk & Kolk, 1997). Celentano, Linet, and Stewart (1990)
found in a random sample of 10,167 Washington County, Maryland, resi-
dents that women were more attentive to headache symptoms and were more
likely to use medical care for relief of symptoms than men. Depression and
health beliefs may directly influence health care seeking, whereas factors
such as life stress, poor coping skills, and catastrophizing about symptoms are
more likely to contribute to exacerbation and chronicity of symptoms
(Naliboff, Heitkemper, Chang, & Mayer, 2000).
L. K. Smith, Pope, and Botha (2005) performed a qualitative synthesis
of international research on cancer patients' experiences of help seeking and
what accounted for delays in help seeking. They looked for shared concepts
and themes in research published between 1985 and 2004 and found that
gender influenced help seeking. Themes that emerged were that men viewed
help seeking as unmasculine, did not want to appear neurotic, and associated
consultation with weakness. Men believed that women found help seeking
easier because they have more contact with health services for themselves
and families. When women delayed help seeking, it was because of compet-
ing priorities of work and family over their own needs.
Verbrugge (1985) found that women generally are more apt to label
their symptoms as physical illness and to adopt the sick role. She cited a
number of reasons for this: Men may tolerate more physical discomfort, have
fewer concerns about their personal health, and feel it is not "masculine" to
adopt the sick role. Conversely, women may be more likely to adopt the sick
role for a variety of reasons ranging from poor coping responses to stress, a
history of physical or sexual abuse, more learned helplessness, and depen-
dency to more trust in authority compared with men (Verbrugge, 1985,1989).
Physicians usually cannot formulate coherent causal explanations for
the symptoms of MUIs that are meaningful to their patients. This contrib-
utes to illness uncertainty (Mischel, 1999). Illness uncertainty is especially

36 MEDICALLY UNEXPLAINED ILLNESS

salient in MUIs because they are characterized by problems with diagnosis,
unknown etiology, unpredictable symptoms and outcomes, and largely inef-
fective treatments. Illness uncertainty is a strong predictor of psychological
distress and difficulty in social relationships (L. M. Johnson, Zautra, & Davis,
2006; Reich, Olmsted, & van Puymbroeck, 2006).
Not surprisingly, the medical encounters of women with MUIs are of-
ten difficult and frustrating for physician and patient alike (R. M. Epstein et
al., 2006; Malterud, 2000; Stone et al., 2002). Women with fibromyalgia
(FMS) and CFS report being judged as suffering from an imagined illness or
are given a psychiatric label (Asbring & Narvanen, 2002; Zavestoski et al.,
2004). Werner, Isaksen, and Malterud (2004) describe the themes from a
qualitative interview study of women with chronic pain. These women were
cognizant of the gendered views of women with MUIs as "whiners and com-
plainers," and they were vigilant about avoiding this taboo. Their narratives,
paradoxically, recognized other women's chronic pain complaints as atten-
tion seeking, avoidant, or psychological, but they emphasized their own
strength and credibility in suffering with chronic pain symptoms.

DISEASE CONVICTION BELIEFS

Do those with MUIs become any more obsessed with illness and illness
careers than people diagnosed with organic diseases who become excessively
involved with their illness? Data show higher rates of disability in individu-
als with MUIs compared with patients with organic disorders. For example,
Assefi, Coy, Uslan, Smith, and Buchwald (2003) surveyed 630 patients evalu-
ated at the University of Washington Chronic Fatigue Clinic regarding the
functional consequences of their fatiguing illness. They measured self-reported
disability in patients with CFS, FMS, and chronic fatigue (fatigue that is of at
least 6 months' duration but that does not meet all the symptom criteria of
CFS), compared with a chronically fatiguing but unrelated medical condi-
tion. Among the groups, the FMS group was the least likely to be employed.
Likewise, the FMS and CFS groups more frequently reported loss of material
possessions, valued activities, jobs, and support by friends and family as a
result of their illness than those with medical conditions.
Zavestoski et al, (2004) noted that MUI prevalence is increasing as
media coverage spreads awareness of these conditions. Diagnostic disputes
can arise among physicians, scientists, and sufferers over the struggle for le-
gitimacy of MUIs and how this influences the clinical interaction. Hadler
(1996) raised concerns over this struggle for legitimacy in FMS with the
notion that if patients must expend effort to prove they are sick, they are
never going to get well. Patient activism is largely motivated by the chal-
lenge of legitimating symptoms and receiving a medical diagnosis (Nettleton,
2006; Zavestoski et al., 2004).

PSYCHOSOC1AL AND COGNITIVE FACTORS 37

 Dumit (2006) monitored the content of Internet chat rooms among people
with CFS, multiple chemical sensitivities (MCS), and FMS. He noted that
many posts reflected the dilemma of "proving" the legitimacy of these illnesses
to doctors. Such research provides evidence that MUls require tremendous
amounts of work to achieve diagnosis and acknowledgement. Patients recog-
nize that psychiatric diagnosis carries a stigma and delegitimizes their claim to
the sick role. A medical diagnosis achieves social recognition that validates
sick role behaviors. The biomedical model that asserts "biological primacy" is
widely accepted by people with MUIs (J. A. Hamilton, 1994). These beliefs
can lead to excessive doctor shopping in search of a legitimate diagnosis.
To use a specific MUI as an example, a tendency to minimize psycho-
logical risk and maximize somatic risk has been found in IBS. Crane and
Martin (2004) used a questionnaire to assess worry about deep vein throm-
bosis and perceived future risk of developing the condition in individuals
with IBS and controls following a media scare concerning this condition.
Individuals with IBS reported higher perceived lifetime risk of deep vein
thrombosis than did healthy controls or individuals with asthma. This study
showed that a perception of enhanced vulnerability to illness is not specific
to cognitions about IBS but may spread to unrelated health issues.
Doctor shopping may arise out of strong disease conviction. Alterna-
tively, it may be related to somatization and dissociative tendencies. Indi-
viduals with MUIs may be out of touch with the connection between emo-
tions and bodily symptoms. Dissociation may work as a coping response to
blunt the horror of abuse. People with MUIs may be searching for an author-
ity figure to validate the suffering they are experiencing.
Aceves-Avila, Ferrari, and Ramos-Remus (2004) have described FMS,
CFS, MCS, Gulf War syndrome, and other conditions as "culture driven
disorders" and have contended that the physiological abnormalities found
are insufficient to explain the level of illness behavior. Because symptoms
are disregarded in Western societies if they cannot be interpreted as disease,
it is the drive to establish the legitimacy of symptoms that shapes symptom
reports. Aceves-Avila et al. observed that MUIs share a number of factors: a
focus on the legitimacy of these disorders as diseases; similar symptomatol-
ogy; and a focus on causative external agents such as injury, environmental
exposure, or infection. A diagnosis that implies a psychological problem is
more offensive to MUI patients because it does not provide social sanction of
the sick role (J. Stone et al., 2002). Looper and Kirmayer (2004) directly
examined the stigma experienced by MUI patients matched to patients with
comparable medical conditions with clear etiology. Thus, CFS was compared
with multiple sclerosis, FMS was compared with rheumatoid arthritis, and
IBS was compared with inflammatory bowel disease (1BD). Only the CFS
group was found to have a significantly higher level of perceived stigma com-
pared with its matched control group, although the overall group of MUI
reported a higher level of perceived stigma.

38 MEDICALLY UNEXPLAINED ILLNESS

 An example of striving toward greater legitimization is the active move-
ment to change the name of CFS. The label "chronic fatigue syndrome" is
viewed by advocates as connoting a vague, subjective condition thought to
carry a negative stigma with medical professionals and the general public,
which hinders access to medical care and social services (Jason, Holbert,
Torres-Harding, Taylor, et al, 2004). The name itself may influence the
type of medical care a person is offered. Medical trainees were presented with
identical patient case studies labeled with the diagnoses CFS, myalgic en-
cephalomyelitis (the name used in the United Kingdom), or Florence Night-
ingale disease (so named because Nightingale is rumored to have had a CFS-
like illness). Trainees who received cases labeled CFS were less likely to
attribute the illness to medical causes and more likely to prescribe psycho-
therapy and psychotropic medications (Jason, Holbert, Torres-Harding, &
Taylor, 2004).

Somatic Attribution

Feminist critiques of medical practice have pointed out that illnesses

that disproportionately affect women are more likely to be seen as psychiat-
ric or sociocultural in origin because medical power is dominated by "male-
centered" thinking (Findley & Miller, 1994; J. A. Hamilton, 1994). Gijsbers
van Wijk and Kolk (1997) have suggested that medicalization of the female
body may explain women's greater tendency to attribute physical symptoms
to physical illness as opposed to normalizing symptoms.
The flip side of overmedicalization is the finding that physicians are
more likely to attribute health problems to psychological causes in women
than in men. Chrisler and O'Hea (2000) have suggested that women with
autoimmune disorders often go through a long diagnostic process because
the vague symptoms of immune disorders are thought to be emotionally caused.
Individuals generally emphasize one of three types of attributions for
the cause of common symptoms. Somatic attributions maintain that the symp-
toms are caused from a physical problem, psychological attributions stress psy-
chological processes causing symptoms, and normalizing attributions empha-
size a transient, nonthreatening physiological or environmental process
(Robbins & Kirmayer, 1991). Somatic attributions and the concomitant ten-
dency to minimize psychological contributions to their illness are common
in MUIs. Many people with MUls have strong disease convictions, are well-
defended psychologically (S. K. Johnson et al,, 1999; Nettleton, 2006), and
prefer biomedical explanations (Binder & Campbell, 2004).
Robbins and Kirmayer (1991) reported that patients with unexplained
symptoms tend to make disease-related attributions for everyday somatic sen-
sations. Kolk, Hanewald, Schagen, and Gijsbers van Wijk (2002) found that
individuals who paid selective attention to bodily sensations had a distinct
preference for disease-related attributions for somatic symptoms. Furthermore,

PSYCHOSOCIAL AND COGNITIVE FACTORS 39

individuals with MUIs and strong organic illness attributions tend to have
higher health care use (Kolk et al., 2004).
It is interesting to note that although some studies have found that
people with MUIs prefer somatic attributions, women in the general popula-
tion are much more likely than men to consider psychological and multifac-
torial explanations for their symptoms. Nykvist et al. (2002) obtained data
from 678 persons after surveying a randomly selected Swedish community
sample regarding causal explanations for symptoms they had experienced.
Results showed that women rated a higher number of causes as important
compared with men. Men were significantly more likely to rate no cause as
important or a physical work situation as important, whereas women were
significantly more likely to cite illness, psychological causes, high demands
and responsibility, and strained work situations as important. Women were
also more likely to have chronic symptoms than men. Kessler, Lloyd, Lewis,
and Gray (1999) also found that men were more likely to make normalizing
attributions for symptoms, explaining them as being due to environmental
irritants or overexertion and thus playing down the symptoms' significance.
These studies suggest that women possess more of an implicit biopsychosocial
explanatory model for somatic symptoms than men do.
Women's ratings of self-assessed health are based on a wider range of
health-related and non-health-related factors. In a 5-year follow-up study of
830 community-dwelling elderly people, Benyami, Leventhal, and Leventhal
(2000) found that high levels of negative affect were related to lower self-
assessed health in both men and women and to higher mortality in men but
to lower risk of mortality in women. Presumably, this was because in men
high negative affect was linked to serious disease, whereas in women a vari-
ety of negative life events could increase negative affect. Furthermore, men's
self-assessed health was related to serious disease, whereas women's self-
assessed health was associated with mild and serious disease.
M. Martin and Crane (2003) examined attributions in 28 university
students who fulfilled diagnostic criteria for IBS, comparing those who sought
treatment for symptoms with those who had not. The two groups did not
differ in terms of depression and anxiety. Treatment seekers were more likely
than non-treatment seekers to make somatic attributions across 21 common
symptoms. Treatment seekers made more somatic attributions for gastrointes-
tinal symptoms and for nonspecific symptoms characteristic of depression
and anxiety, even when symptoms were placed in a context that indicated
the presence of a psychological stressor. Treatment seekers also perceived
themselves to be significantly less resistant to illness and to have a more
negative health outlook than non-treatment seekers. These findings suggest
that premorbid illness attitudes and attributional style influence the decision
to seek treatment. In a second study, M. Martin and Crane (2003) examined
attributions in a community sample with persistent IBS. In this group, a va-
riety of nonspecific symptoms became incorporated into the cognitive repre-

40 MEDICALLY UNEXPLAINED ILLNESS

sentation of IBS. This tendency to view all symptoms as a part of IBS may
increase the perception of IBS as a pervasive, unmanageable illness and con-
tribute to chronicity of illness.
In individuals with MUIs, somatic attributions and disease conviction
appear to be paramount. These beliefs contribute to high rates of medical
utilization in attempts at establishing legitimacy and easing suffering. The
drive for legitimacy is fueled by patients' awareness that the medical estab-
lishment perceives MUIs to be women's illnesses and thus implicitly less
serious than organic conditions, a perception that MUI patients resist.

Childhood Maltreatment and Unexplained Symptoms

According to the National Clearinghouse for Child Abuse and Ne-

glect, girls are three times more likely to be victims of sexual abuse than boys
(Snyder, 2000). It is possible that females may be more willing than males to
disclose histories of sexual abuse and to participate in consequent studies,
but this is unlikely to account entirely for the difference. Exposure to child-
hood sexual abuse has many detrimental psychological, behavioral, cogni-
tive, and physiological consequences for both sexes. Some of the psychologi-
cal problems exhibited by victims of child sexual abuse include depression,
anxiety, reduced self-esteem, sleep disturbances, personality disorders, and
cognitive dysfunction. Victims of child sexual abuse may also have behav-
ioral problems such as substance abuse, conduct problems, externalizing dis-
orders, or sexualized conduct (Arias, 2004).
The psychological consequences of child sexual abuse are relatively
well-known, and now emerging research has shown that a multitude of
physiological problems are associated with this as well, such as somatic
complaints, gastrointestinal problems, fatigue, headaches, migraines, and
pain disorders (Nelson, 2002). Among the MUIs, FMS and IBS in particu-
lar have been associated with high rates of reported child sexual abuse. A
large epidemiologic study showed that as the number of abuse and neglect
experiences increased, so did the number of unexplained symptoms. Walker,
Gelfand, et al. (1999) surveyed 1,225 randomly selected women from the
membership of a large health maintenance organization in Seattle, Wash-
ington. Women with and without histories of childhood maltreatment ex-
periences were compared. A history of childhood maltreatment was associ-
ated with perceived poorer overall health, greater functional disability,
increased numbers of distressing physical symptoms, and a greater number
of health risk behaviors. Women with multiple types of maltreatment
showed the greatest health decrements for both self-reported symptoms and
physician-coded diagnoses.
A preponderance of studies indicates that exposure to adverse child-
hood experiences increases sensitivity to somatic complaints. This hypersen-
sitivity may predispose individuals with this exposure to use the health care

PSYCHOSOCIAL AND COGNITIVE FACTORS 41

system more often than individuals without it. Individuals who have experi-
enced childhood adversity are more likely to report a health problem (Sachs-
Ericsson, Blazer, Plant, & Arnow, 2005). Women who have experienced
sexual assault have more lifetime health care contacts (Ullman & Brecklin,
2003), significantly higher primary care and outpatient costs, and more fre-
quent emergency department visits than women without such a history
(Walker, Unutzer, et al, 1999).
Individuals who report childhood adversity are more likely to report
medically unexplainable symptoms such as abdominal pain, headaches, fa-
tigue, limb or back pain, or noncardiac chest pain (Fiddler, Jackson, Kapur,
Wells, & Creed, 2004). In a study of 219 women military veterans, Stein et
al. (2004) found that the 44% who reported a sexual assault history were
more likely to report headache, abdominal pain, muscle pain, chest pain,
face or jaw pain, overwhelming fatigue, shortness of breath, insomnia, and
numbness. Again, significantly higher health anxiety and health care utili-
zation were also reported. Emotional abuse and neglect were also corre-
lated with higher reports of doctor visits (Spertus, Yehuda, Wong, Halligan,
& Seremetis, 2003). Walker, Keegan, Gardner, Sullivan, Bernstein, and
Katon (1997) have pointed out that abuse may be linked to multiple unex-
plained symptoms because for many women this may be the most accept-
able strategy, although oblique, for trying to secure treatment for traumatic
experiences.
Although medically unexplained symptoms in victims of child sexual
abuse are widely interpreted as somatization, underlying physical problems
may actually be the cause of the symptoms (Nelson, 2002). Adults with a
history of child sexual abuse have more surgeries, are hospitalized more of-
ten, and have more visits to general practitioners than do those without a
history of abuse (Finestone et al., 2000).
Both an individual's perception of a traumatic event and a determina-
tion of available resources are important in determining that individual's
emotional reaction and connection to potential pain pathways. Negative
emotional states, such as depression and anxiety, have been linked to pain
sensitivity and general overestimation of painful experiences (Keefe, Lumley,
Anderson, Lynch, & Carson, 2001). Understanding the perception of an
event is particularly important to note when discussing high rates of child
sexual abuse in individuals with MUIs. Studies cited here relied almost ex-
clusively on retrospective reports of abuse. In an important study, Raphael,
Spatz Widom, and Lange (2001) conducted a prospective study on docu-
mented child sexual and physical abuse and neglect and unexplained pain
complaints. They followed up 908 children with court-substantiated cases of
child abuse or neglect who were matched to 667 nonabused children. They
were able to locate and interview 76% of the original sample 20 years later.
One surprising finding was that the odds of reporting one or more unex-
plained pain symptoms were not associated with any childhood victimiza-

42 MEDICALLY UNEXPLAINED ILLNESS

tion experience. Raphael et al. argued that their findings contradicted the
widespread belief that unexplained pain is psychogenic; they maintained that
the Freudian view of expressing past trauma through current symptoms is too
simplistic. Certainly, this study suggests adopting a cautious approach to as-
sociations between child sexual abuse and unexplained symptoms.
Linton (2002) conducted a more limited prospective survey study of
the Swedish general population and found that women with self-reported
sexual and physical abuse were at increased risk for pain 1 year later. How-
ever, there was no increased risk for worse pain or poorer function for women
who reported back pain at baseline. Linton studied only women because an
earlier study had indicated that abuse was not a strong risk factor for men to
report back pain, whereas it was a powerful risk factor for women. Linton
interpreted this finding as indicating that abuse may affect reporting or oc-
currence of new pain episodes but not worsening of an initial pain problem.
Although child sexual abuse is implicated in MUIs, there is no specific
diagnosis or symptom cluster unique to this history. The extent to which a
history of childhood abuse influences adult health may be molded by the
dynamics of families characterized by sexual abuse or by inherent physiologi-
cal vulnerabilities. It is postulated that family dysfunction and insecure at-
tachment precedes the onset of sexual abuse (Lackner, Gudleski, & Blanchard,
2004). It is also notable that a review of long-term effects of child sexual
abuse concluded that up to one third of children who are sexually abused
remain free of symptoms (Finkelhor, 1990). These children are more likely
to have been abused for shorter periods of time without force or penetration
by a nonfather figure and to have received support from their family. This
confirms that it is the context of attachment relationships before and after
the abuse and the severity of abuse that determines the effects of abuse.
In a series of studies, Pennebaker (1994) found that undisclosed trau-
mas in particular result in elevated symptom reports. He speculated that this
could be due to altered stress response resulting from trauma; using symptom
reporting as a distraction to avoid thinking about trauma; or trauma thought
suppression, wherein a person experiences emotion but because the trauma is
suppressed he or she labels the emotion as a physical symptom. Secondary
gain of avoiding work or eliciting attention may also be operative in high
levels of symptom reports in someone with a trauma history (Pennebaker,
1994). Failure to recover positive affect after traumatic life events seems to
characterize the MUI; this has been shown specifically in FMS (Zautra et al.,
2005; Zautra, Johnson, & Davis, 2005).

GENDER AND COPING STYLES: CATASTROPHIZING

The cognitive coping style people adopt can influence the perception
of symptoms. There is some evidence for gender differences in coping styles,

PSYCHOSOCIAL AND COGNITIVE FACTORS 43

with women generally using more emotion-focused strategies and men en-
gaging in more problem-solving strategies, although in specific types of stressful
situations these differences are less evident (Sigmon, Stanton, & Snyder,
1995). Rollnik et al. (2003) examined gender differences in coping with ten-
sion headaches. Female episodic tension headache sufferers scored signifi-
cantly higher than males on the subscales that measured distracting and en-
couraging oneself. Among chronic headache sufferers, women scored lower
on active coping, were more depressed, and reported their pain as more in-
tense than the men with chronic headache.
Catastrophizing is a particularly dysfunctional coping response.
Catastrophizing entails worrying about symptoms and their negative impact
on a patient's activities and future and ruminating over worst case scenarios.
Persons who catastrophize have difficulty shifting their attention away from
painful stimuli and tend to magnify the threat value of pain stimuli (Peters,
Vlaeyen, & van Drunen, 2000; M. Sullivan et al., 2001). Catastrophizing is
positively correlated with neuroticism, negative affectivity, and emotional
vulnerability.
M. J. L. Sullivan, Bishop, and Pivik (1995) developed a Pain Catastro-
phizing Scale consisting of subscales of rumination, helplessness, and magni-
fication. Women report significantly higher total scores on this scale, ac-
counted for by women's higher scores on rumination and helplessness. This
is consistent with findings that women are more likely to use ruminative and
expressive styles when under stress (Nolen-Hoeksema et al., 1999).
M. J. L. Sullivan, Tripp, and Santor (2000) hypothesized that Catastro-
phizing may be a critical mediator in explaining gender differences in pain
experience. Perhaps women report more intense and disabling pain because
they are more likely to catastrophize. They examined the role of Catastro-
phizing on an experimental pain procedure. During immersion of the fore-
arm in ice water for 1 minute, men reported significantly less pain and dis-
played pain behavior for a shorter duration than women. Men also reported
lower scores on the Pain Catastrophizing Scale; for women the Helplessness
subscale was the most predictive of pain duration, whereas the Rumination
subscale was more critical for men's pain duration. When Catastrophizing
was statistically controlled, gender no longer contributed to pain intensity
and duration. M. J. L. Sullivan et al. suggested that although Catastrophizing
has typically been viewed as a maladaptive response, it may play an impor-
tant communicative function. By expressing distress, women may be able
to recruit the caregivers and support that they need, which suggests that it
is an adaptive coping response. The problem with this interpretation is
that Catastrophizing is universally reported to be associated with poorer
outcomes, so communicating distress does not appear to lead to improved
functioning.
According to Crombez, Van Damme, and Eccleston (2005), attentional
hypervigilance to pain has been found to be automatic and unintentional in

44 MEDICALLY UNEXPLAINED ILLNESS

experimental tasks. This does not mean that it is uncontrollable; Crombez et
al. noted that participants can switch attention back to tasks and complete
them. Individuals who catastrophize, however, have difficulty performing
distracting tasks and experience less analgesia from distraction. Crombez et
al. proposed that amplification of pain is due to repeated failure to distract
oneself from pain. Thus, pain may evoke a more intense and defensive fear
response in those who are hypervigilant.
I. Jensen, Nygren, Gamberale, Goldie, and Westerholm (1994) com-
pared men and women with long-term intractable musculoskeletal pain in a
large rehabilitation sample. They found that women, particularly those in
unskilled occupations, were more likely to use dysfunctional coping strate-
gies such as catastrophizing. McGeary, Mayer, Gatchel, Anagnostis, and Proc-
tor (2003) examined gender differences in 1,827 consecutively treated pa-
tients with chronically disabling spinal disorder undergoing a tertiary
functional restoration program. Patients were assessed before the start of the
program, on completion of the program, and 1 year later. Male patients showed
lower disability and depression scores than women and had higher levels of
physical functioning before and after treatment. The authors suggested that
men came into the program with less fear avoidance-induced inhibition of
physical activity. Women showed higher levels of depression, pain, and dis-
ability self-report and a higher rate of searching out new health care provid-
ers. In rehabilitation samples, women showed differences in pain perception,
pain report, and coping skills.

Gender Role Expectations

Gender role expectations endorse a stoic, brave role for boys in mes-
sages such as "big boys don't cry," whereas greater expressiveness is sanc-
tioned for girls and women. Girls and women are more likely to be reinforced
for emotional expressiveness than boys and men (Helgeson, 2005; Plant,
Shibley Hyde, Keltner, & Devine, 2000). It is generally more socially accept-
able for women to report subjective symptoms and seek medical care than
men. To some extent, complaining of symptoms and admitting illness vio-
lates gender role norms for boys and men (Helgeson, 2005).
Higher levels of catastrophizing, helplessness, fear of pain, and avoid-
ance in women is consistent with gender role behavior. Men may demon-
strate more tolerance for pain because it fits into the masculine gender role
to be stoic and to "tough it out." Similarly, the finding that men get back to
work sooner after pain episodes is consistent with the primacy of the bread-
winner role for many men. Lower self-efficacy in women can contribute to
lower pain threshold and tolerance and to experiencing pain as more un-
pleasant and intense.
Some investigators have highlighted modern social strains on women,
particularly multiple roles, that cause women to unconsciously seek relief in

PSYCHOSOCIAL AND COGNITIVE FACTORS 45

the sick role (Ware & Kleinman, 1992). The theory is that women who
cannot successfully integrate a fulfilling career and a rich family life may
escape into MUIs (Richman, Jason, Taylor, & Jahn, 2000). Hadler (2003)
also argued that FMS is a way of medicalizing the burdens of life with a so-
cially acceptable reason for coping failures. Although popular in the media,
there seems to be little scientific evidence to support this view.

Stress, Gender, and Medically Unexplained Illnesses

Documenting gender differences is useful, but one must also attempt to

explain them. Yoder and Kahn (2003) have noted that consideration of the
social context when gender differences are found is often overlooked. Gen-
der should be regarded as a marker or a moderator, not a cause of differences
in the health of women and men (Barnett, 1997). Women's health is broadly
influenced by social realities, reproductive life events, and the demands of
multiple roles. In terms of the social context of MUI, chapter 1 in this vol-
ume illustrates the idea that symptoms could change according to the zeit-
geist of the times. One leitmotif of our times is that of the overstressed woman,
the woman who has to balance every thing—marriage, children, and career—
and make it all work. Perhaps these social role demands and expectations
increase vulnerability to MUI.
Verbrugge (1989) summarized the view that too little or too much so-
cial involvement causes distress for women. The female nurturant role can
place continual burdens on women's lives. Davis, Matthews, and Twamley
(1999) performed a meta-analysis to determine whether there were gender
differences in stressful life events. They found that women reported greater
exposure to stressful events and that there was an even stronger gender dif-
ference in terms of appraisal of stressful life events. This self-reported inten-
sity appeared to be partially due to female gender role expectations of emo-
tional expressiveness. Women were also more likely to report interpersonal
stressors than males, consistent with the gender role of communality. Women's
tendency to report more psychological symptoms, however, was not an im-
portant predictor of differences in stress exposure and appraisal.
In their Swedish population-based study, Tibblin et al. (1990) found
that the biggest gender differences were in the symptoms of depression and
tension, which were more prevalent in women. Tibblin et al. explained these
differences as being due to women's situation of "double work"—being re-
sponsible for their job, their home, and bringing up the children. Repetti
(1998) echoed the theme that overwork, family pressures, and hassles can be
understood as role-related stressors that impact women's health. Lundberg
(2005) noted that Scandinavian countries have seen a dramatic increase in
absenteeism among women caused by what are often described as stress-
related health problems. The pace of modernity and continuous adjustment
to changes and ever-increasing demands may disrupt allostatic processes. An

46 MEDICALLY UNEXPLAINED ILLNESS

investigation into this widely accepted idea, however, found that people liv-
ing in simpler, nonindustrial settings actually reported significantly more
musculoskeletal complaints, fatigue, mood changes, and gastrointestinal com-
plaints than a representative Norwegian sample (Eriksen, Hellesnes, Staff,
& Ursin, 2004). These findings suggest that MUIs are not specific to the
stress of modern industrialized societies; concerns about modernity may be
the key issue, because worries about modern hazards such as toxins, pesti-
cides, and pollution are associated with more reporting of subjective health
concerns (S. K. Johnson & Blanchard, 2006; Petrie et al., 2005). Thus, it is
the perception of threat that is critical in linking stress to ill health.
Unruh (1996) hypothesized that women may attend to pain sooner
than men because the painful condition may result in more interference
with gender-related social roles. Because women have such pervasive duties,
pain needs to be attended to quickly, whereas for men pain is important only
if it interferes with occupational responsibilities. Becker (2005) contended
that the view of the overstressed woman with its subsequent health conse-
quences places too much emphasis on the individual and that it is persistent
structural gender inequalities that are the important culprits in women's
health.

CONCLUSION

A number of psychosocial and cognitive factors may contribute to the

higher prevalence of MUIs in women compared with men. This chapter has
presented evidence for robust differences in symptom reporting that may be
influenced by higher rates of depression and anxiety, negative affect, more
frequent and more intense stressful life events, lower thresholds for seeking
health care, higher likelihood of catastrophizing, and lower thresholds for
pain.
All of the above may be associated with gender role expectations wherein
it is more permissible within the feminine gender role to have a low thresh-
old for pain, report illness symptoms, and be more expressive and dependent.
Women's tendency to encounter more social stressors and childhood trau-
mas also appears to contribute to a vulnerability to MUIs, which could be a
result of physiological alterations subsequent to traumas. Stress-related symp-
toms could also represent an avenue through which to get help.

PSYCHOSOCIAL AND COGNITIVE FACTORS 47

 BIOLOGY OF MEDICALLY
UNEXPLAINED ILLNESS

This chapter examines the evidence for gender differences in physiol-

ogy that may help illuminate the higher incidence of medically unexplained
illnesses (MUls) among women than among men. There is evidence that
physiological factors such as hormonal influences on pain, lower thresholds
for pain, immune and hypothalamic—pituitary—adrenal (HPA) axis reactiv-
ity, and central nervous system hypersensitivity differ between men and
women. Specific physiological factors that have been investigated for each
MUI are examined, but the general issues relevant to the biology of MUI and
gender are discussed as well.

GENETIC EXPLANATIONS

MUIs may have genetic components. There is a coaggregation within

families of many of these disorders, such as fibromyalgia (FMS), chronic fa-
tigue syndrome (CFS), and migraine. This genetic vulnerability may then be
triggered by emotional stress, physical trauma, or infections (Clauw &
Crofford, 2003). Several population-based twin studies have examined

49
whether MUI symptoms (somatic distress) are distinct from anxiety and de-
pression. Hickie, Kirk, and Martin (1999) found that 44% of the genetic
variance in chronic fatigue was not shared by anxiety and depression. Gillespie,
Zhu, Heath, Hickie, and Martin (2000) found that 33% of genetic variance
in somatic distress was due to specific gene action unrelated to depression or
phobic anxiety, and 74% of environmental influence on somatic distress was
unrelated to depression or anxiety. Collectively, these studies have concluded
that fatigue is etiologically distinct from anxiety and depression. Conversely,
Roy-Byrne et al. (2002) studied a sample of 100 female twin pairs and found
a strong association between fatigue and psychological distress without evi-
dence of genetic covariation. Relatives of patients with FMS, particularly
female relatives, have a higher prevalence of FMS and more tender points
than the general population (Buskila & Neumann, 2005). Evidence for a
genetic contribution to FMS and CFS has been explored and is discussed in
chapters 6 and 7, respectively. Genetics and familial transmission may play a
role in MUls, but the specific mechanism is still unclear.

PHYSIOLOGY OF SOMATIZAT1ON

Chapter 2 reviewed the evidence that MUIs involve somatizing ten-

dencies. Although one of the hallmarks of somatization is that objective find-
ings do not explain symptoms and levels of disability, several studies have
found physiological abnormalities in somatoform disorders (SDs).
Hakala et al. (2002) found that 10 women with chronic SD and no
other Axis I diagnosis had significantly lower cerebral metabolism compared
with 17 healthy female volunteers. In a study of regional brain glucose me-
tabolism, 10 women with SD or undifferentiated SD were compared with 12
healthy women. Low caudate and low putamen glucose metabolism, as well
as low novelty seeking and high harm-avoidance temperament, were signifi-
cantly associated with severe somatization (Hakala, Vahlberg, Niemi, &
Karlsson, 2006).
Winfried Rief and her colleagues have performed a number of studies
investigating the physiology of SDs. In a replication and extension of Rief,
Shaw, and Fichter (1998), Rief and Auer (2001) found that people with SD
showed less physiological habituation in a mental challenge task. In con-
trols, heart rate decelerated when the experimental procedure changed from
task to break and reaccelerated when the task began again. Participants with
SD, however, did not show heart rate deceleration, and they stayed aroused
during break periods. The authors stated that these results confirmed a
cognitive-psychobiological model of somatization.
Rief, Pilger, Ihle, Bosmans, Egyed, and Maes (2001) examined the in-
flammatory response system in patients with SD compared with patients with
major depression. They found T-cell activation (increased CDS), monocytic

50 MEDICALLY UNEXPLAINED ILLNESS

activation (IL-1RA), and a lowered anti-inflammatory capacity of the serum
(lower CC16) in depression, whereas in SD there was monocytic activation
and lowered T-lymphocytic activity (lowered CDS and 1L-6). These results
suggest different immune alterations in SD compared with depression. In a
study examining serotonergic and noradrenergic monoamino acids in 150
participants from four groups (SD, depression, depression and SD, and healthy
controls), tryptophan, serotonin, and monoamines were decreased in patients
with SD (Rief et al, 2004). This research is preliminary, and more study is
needed to establish whether there are any consistently replicated physiologi-
cal patterns in individuals with SD that may illuminate the pathophysiology
ofMUl.

Stress Physiology

Stress is implicated in the etiology of MUIs, whether through stressful

life events, poor coping responses, dysfunctional stress regulation, or an in-
terplay between these factors. In both sexes, the sympathetic nervous
system-adrenal-medullary (SAM) and the HP A axis are the primary
physiological systems involved in responding to stressful stimuli. The stress
response consists of the sympathetic nervous system producing epineph-
rine and norepinephrine and the HPA axis producing glucocortocoids.
Corticotropin-releasing hormone (CRH) is synthesized in hypothalamic neu-
rons. When CRH acts on the anterior pituitary, endocrine cells secrete adreno-
corticotropic hormone (ACTH; Silverthorn, 2001). ACTH stimulates the
adrenal cortex of the adrenal glands. A group of stress hormones called corn-
costeroids, including cortisol, is then released from the adrenal cortex into
the body's circulatory system. Components within the HPA axis have the
ability to positively or negatively regulate other components within the sys-
tem. For example, when cortisol is secreted from the adrenal cortex, it nega-
tively regulates its own secretion by sending hormonal signals to the hypo-
thalamus and anterior pituitary. This halts the synthesis of CRH and ACTH,
respectively, which in turn decreases the amount of cortisol (Comer, 2005;
see Figure 4-1) - Although the HPA axis is self-regulating, chronic hyperarousal
may cause permanent changes in the release of hormones.
It was not until Marianne Frankenhaeuser's work in the 1980s that the
stress hormone responses of women began to be systematically studied and
were found to be different from those of men. Laboratory stressors resulted in
greater epinephrine response in men than women (Frankenhaeuser, Lundberg,
& Forsman, 1980), and mothers taking their children for check-ups had higher
norepinephrine levels than fathers (Lundberg, de Chateau, Winberg, &
Frankenhaeuser, 1981). Krantz, Forsman, and Lundberg (2004) compared
different physiological stress responses (systolic and diastolic blood pressure,
heart rate, urinary epinephrine and norepinephrine, salivary cortisol) as well
as trapezius muscle activity during mental and physical stress in women and

BIOLOGY OF MEDICALLY UNEXPLAINED ILLNESS 51

 Hypothalamus

Pituitary
Gland

NE
Adrenal
Gland

Figure 4.1. Hypothalamic-pituitary-adrenal (HPA) axis. CRH = corticotropin-

releasing hormone; ACTH = adrenocorticotropic hormone; NE = norepinephrine.

men. They found significantly increased activity on all measures except cor-
tisol and a significant association between sympathetic arousal and muscle
activity, which helps explain the high prevalence of musculoskeletal disor-
ders in mentally stressful but physically light work tasks. Men had higher
blood pressure and a more pronounced increase in epinephrine output than
women, whereas women had higher heart rate. It was concluded that sympa-
thetic activity is more sensitive to moderately intense stress exposure than
cortisol activity and that men respond to performance stress with more epi-
nephrine output than women.
Other Swedish studies have found that although men and women re-
spond similarly to stress at work, gender differences appear at the end of the
working day, with men relaxing and women's physiological stress levels re-
maining high at home (Lundberg & Frankenhaeuser, 1999). The conclusion
drawn from these studies was that gender roles and psychological factors were
more important than biological factors in explaining gender differences in
epinephrine response (Lundberg, 2005).
S. E. Taylor et al. (2000) have proposed an alternate biobehavioral stress
response in women that they labeled tend and befriend. They posited that it

52 MEDICALLY UNEXPLAINED ILLNESS

would have been evolutionarily adaptive for women to develop social net-
works to protect themselves and offspring when the "fight or flight" response
would endanger their young. Thus, women may exhibit relatively increased
parasympathetic responses as opposed to sympathetic ones during stress. Taylor
et al. proposed that the tend and befriend response is mediated primarily by
the lactational hormone oxytocin and endogenous opioids whose effects are
moderated by estrogens. They marshal a prodigious amount of animal re-
search in support of this claim. This cumulative downregulation of the stress
response may contribute to women's consistently greater longevity relative
to men. Only a limited amount of data for humans addresses the validity of
this theory. Ennis, Kelly, and Lambert (2001) collected cortisol before and
after an examination in college students. The men in the challenge appraisal
group demonstrated a significant increase in cortisol production from baseline
to pretest with the increased anxiety level compared with the threat appraisal
group. Women had a significant decrease in cortisol excretion in the chal-
lenge appraisal group and no difference in the level of anxiety between the
challenge and threat groups. The authors interpreted these findings as con-
sistent with the tend-and-befriend framework. It remains to be seen whether
this gender difference in stress response has any bearing on the prevalence of
MUIs or is more relevant to an evolutionary understanding of healthy women's
stress responses.

Hypothalamic-Pituitary-Adrenal Axis and Medically

Unexplained Illnesses

Alterations or malfunctions with components of the HPA axis have

been implicated in a number of conditions. Fries, Hesse, Hellhammer, and
Hellhammer (2005) reported that 20% to 25% of patients with "stress-
related" disorders such as CFS, chronic pelvic pain, FMS, inflammatory bowel
syndrome (IBS), posttraumatic stress disorder (PTSD), low back pain, burn-
out, and atypical depression show evidence of hypocortisolism. Rief and Barsky
(2005) described the "overadjustment" of the HPA axis that can occur in
"somatoform-associated disorders" (p. 996). The HPA axis may change from
an initial hypercortisolism when a stressor becomes chronic. After prolonged
periods of stress, whether from infection, work pressures, or interpersonal
stress, an individual may begin to report fatigue, widespread pain, and stress
sensitivity that signal a hypocortisolemic state. Different patient subgroups
within one "stress-related" disorder can also be characterized by different
patterns of hypocortisolism, such as decreased free cortisol, cortisol resistance,
and reduced biosynthesis of CRF, ACTH, or cortisol (Fries et al., 2005).
Early life stressors may result in acute and chronic changes in the activ-
ity and regulation of the brain's biological stress response system that creates
a vulnerability or increased sensitivity to stressors in adulthood (Bremner,
2005; Diseth, 2005; Weber & Reynolds, 2004). There is substantial evidence

BIOLOGY OF MEDICALLY UNEXPLAINED ILLNESS 53

that early childhood trauma influences stress reactivity, behavioral sensitiza-
tion, brain function, and pain processing. Brain areas that are particularly
affected by emotion are the prefrontal cortex, amygdala, thalamus, hypo-
thalamus, hippocampus, and anterior cingulate cortex (ACC; Bremner et
al., 1997; Bremner, Vermetten, et al., 2003; Bremner, Vythilingam,
Vermetten, Southwick, McGlashan, Nazeer, et al., 2003; Bremner,
Vythilingam, Vermetten, Southwick, McGlashan, Staib, et al., 2003; Car-
rion et al., 2001; De Bellis et al., 1999; Vermetten & Bremner, 2002).
Girls are more likely than boys to be victims of sexual abuse in child-
hood and subsequently are at greater risk for depression and anxiety disorders
(Weiss et al., 1999). Adverse events in childhood, particularly sexual abuse,
may activate the HPA axis and result in a perpetuating negative feedback
loop; this hypercortisolism can contribute to symptoms such as fatigue and
depression (Kiecolt-Glaser, McGuire, Robles, & Glaser, 2002). PTSD is an
example wherein differences in cortisol levels may be associated with dura-
tion of the stressor and symptoms. Putnam and Trickett (1997) conducted
longitudinal studies of sexually abused girls and found that the girls had an
increased cortisol level around the time of the stressor, and those who devel-
oped PTSD symptoms later had a decreased level of cortisol. Women are
more likely to develop PTSD than men; approximately 8% of men and 20%
of women who have been traumatized develop PTSD (Schnurr, Friedman, &
Bernardy, 2002). Rape victims are more likely to develop PTSD than acci-
dent and natural disaster victims (Brewin, 2005). Leserman, Li, Drossman,
and Hu (1998) found that symptoms consistent with PTSD were common
among women with functional gastrointestinal disorders, particularly those
who had abuse histories.
Studies on the effects of chronic stress report converging evidence for
decreased cortisol secretion in a variety of MUIs (A. J. Cleare, 2003; Heim,
Ehlert, & Hellhammer, 2000; Jerjes et al., 2006). Early childhood sexual
abuse and trauma can result in hypercortisolism in some cases; in others it
appears to result in hypocortisolism (Heim et al., 2000). Thus, early abuse
can initiate a trajectory toward depression, anxiety, and a hyperactive HPA
axis (Bhagwagar, Hafizi, & Cowen, 2005; Burke, Davis, Otte, & Mohr, 2005)
or PTSD, FMS, CFS, or other fatigue and pain disorders characterized by a
hypoactive HPA axis. The HPA axis is clearly relevant in the MUIs, al-
though further research is needed to determine whether the HPA axis eluci-
dates etiological and treatment issues.
McEwen and Lasley (2003) proposed a concept they called allostatic
load, meaning that recurrent stress responses and prolonged activation of car-
diovascular and neuroendocrine systems lead to wear and tear on the body
and increase the risk for a variety of health problems. Mellner, Krantz, and
Lundberg (2005) investigated whether the construct of allostatic load could
be used to explain high levels of medically unexplained symptoms. They
studied 222 healthy Swedish women who were part of a longitudinal health

54 MEDICALLY UNEXPLAINED ILLNESS

initiative; all of the women were 43 years old. They were assessed with a
multisystem summary index of allostatic load and were examined on physi-
ological indicators including blood pressure, heart rate, blood lipids, and stress
hormones as well as self-reported symptoms. Women with a high symptom
load were found to have significantly higher levels of cortisol and higher
heart rate than those with low symptom load, whereas women with low symp-
tom load had significantly higher levels of epinephrine on a work-free day.
No differences were found in norepinephrine or in the summary measure of
allostatic load. Although the differences between high- and low-symptom
groups were not consistent over all physiological stress indicators, there were
signals of dysregulation in stress-related biomarkers.
Several studies have found that CFS was associated with a high level of
allostatic load. The allostatic load components that best discriminated CFS
patients from controls were waist:hip ratio and aldosterone and urinary cor-
tisol levels (Maloney et al., 2006). Among CFS patients, a high allostatic
load was significantly associated with worse bodily pain, poorer physical func-
tioning, and greater symptom frequency and intensity (Goertzel, Pennachin,
de Souza Coelho, Maloney, et al., 2006). At least in the case of CFS, allostatic
load appears to be a potentially fruitful avenue for research.

Stress, Immune System, and Endocrine Interactions

The immune system is closely integrated with the nervous and endo-
crine systems, and social factors influence the immune system through these
systems. Psychological stress can downregulate the immune system by affect-
ing the interplay between the HPA axis, autonomic nervous system, and
endocrine and immune systems (Glaser & Kiecolt-Glaser, 1998; Kiecolt-
Glaser, Bane, Glaser, & Malarkey, 2003). A large body of literature associ-
ates perceived stress with vulnerability to illness and slower recovery from
illness (Kiecolt-Glaser et al., 2002; Kiecolt-Glaser, Page, Marucha,
MacCallum, & Glaser, 1998). Segerstrom and Miller (2004) examined the
relationship between stress and the immune system in a meta-analysis that
included more than 300 empirical studies. They found that chronic stressors
were associated with suppression of immunity and that those who were more
vulnerable because of age and disease were more likely to experience im-
mune changes during stress. There is evidence that women differ from men
in terms of stress experiences, appraisals of stress, and stress physiology.
Serotonin regulates the circadian fluctuations of the HPA axis and the
release of CRH from the hypothalamus (Silverthom, 2001). There is evi-
dence for low brain serotonin levels or function in a number of MUIs, par-
ticularly FMS and CFS. Nishizawa et al. (1997) were able to measure seroto-
nin synthesis in living brains of 8 male and 7 female healthy participants
using positron emission tomography (PET). They found that the mean rate
of serotonin synthesis was 52% higher in the male individuals and noted that

BIOLOGY OF MEDICALLY UNEXPLAINED ILLNESS 55

this is one of the largest gender brain differences not related to hormone
binding sites. They went on to speculate that the lower rate of synthesis in
the women's brains may mean that women are not as efficient at maintain-
ing adequate stores of serotonin. They proposed that in stressful situations,
serotonin would decline more in female than in male individuals, making
them more vulnerable to depression. Gender linkages between serotonin syn-
thesis and its interactions with HPA axis function could prove an important
avenue for future MUI research.

Autoimmunity and Gender

It has been suggested that several MUIs, particularly CFS, involve al-
teration in immune function. It is well established that women are about 2.7
times more likely than men to acquire an autoimmune disease (Jacobson,
Gange, Rose, & Graham, 1997; Walsh & Rau, 2000). Women have enhanced
immune systems compared with men, which increases women's resistance
to many types of infection but also makes them more susceptible to au-
toimmune diseases (Cannon & St. Pierre, 1997). Sinaii, Cleary, Ballweg,
Nieman, and Stratton (2002) surveyed 3,680 women with physician-
diagnosed endometriosis. Compared with published rates in the general
population, women with endometriosis had higher rates of diagnosed CFS,
FMS, hypothyroidism, autoimmune diseases, allergies, and asthma. The clus-
tering of pain and fatigue syndromes with autoimmune and atopic disor-
ders suggests a common interactive pathophysiology involving autoimmune
inflammatory processes.
Markers of inflammatory response have shown gender differences. For
example, the plasma activity level of phospholipase A2, a key enzyme in-
volved in chronic inflammatory diseases, is significantly higher in Caucasian
and Asian Indian women than their male counterparts (Kuslys, Vishwanath,
Frey, & Frey, 1996). Conversely, interleukin-1-receptor-II, which is impor-
tant in reducing the inflammatory response, is present in higher concentra-
tion in white blood cells from men than from women (Daun, Ball, & Can-
non, 2000). These biological factors indicating greater susceptibility to
autoimmune processes and increased inflammatory responses in women may
play a role in CFS, FMS, and IBS pathophysiology. Researchers should in-
vestigate these connections.

SENSITIZATION AND MEDICALLY UNEXPLAINED ILLNESSES

There is evidence that women have lower odor thresholds and sensitiv-
ity (Dalton, Doolittle, & Breslin, 2002), which may have implications for
multiple chemical sensitivity (MCS). Women also have lower thresholds for
pressure touch (Komiyama & De Laat, 2005) and pain (Chesterton, Barlas,

56 MEDICALLY l/NEXPLA/NED ILLNESS

Foster, Baxter, & Wright, 2002), which has implications for IBS, FMS, and
CFS. In a large meta-analysis of gender differences in children's tempera-
ment, Else-Quest et al. (2006) found small to moderate gender differences in
perceptual sensitivity. Girls were better at perceiving low-intensity environ-
mental stimuli than boys, which may translate into greater female awareness
of subtle environmental changes. Women may have an innately greater sen-
sitivity to bodily sensations (Wool & Barsky, 1994).
Lee, Mayer, Schmulson, Chang, and Naliboff (2001) surveyed 714 con-
secutively screened IBS patients to explore gender differences in reported
symptoms. Women reported more symptoms that involved increased sensi-
tivity to food, medications, taste, and smell. Lee et al. concluded that these
differences in sensitivity may represent altered sensory processes, autonomic
responses, or cognitive hypervigilance. These differences in autonomic and
sensory processes may parallel male and female differences in the general
stress response.
Sensitization describes the phenomenon that the same signals can lead
to more and more amplified perceptions. Sensitization includes biological
sensitization, such as visceral hyperalgesia, and psychological Sensitization,
when hypervigilance to a subjective symptom leads to amplification of the
symptom (Wilhelmsen, 2005). Psychobiological sensitization mechanisms
may be operating in MUIs, wherein chronic stress contributes to increased
sensitization of the central nervous system, autonomic nervous system, and
the HPA axis.
Eriksen and Ursin (2004) have maintained that subjective health com-
plaints become intolerable conditions through a process of sensitization. Sen-
sitization occurs at the central and peripheral levels of the nervous system
and then at a higher level through cognitive bias. Similarly, Rief and Barsky
(2005) described a "filter model" for explaining subjective health complaints.
They described MUIs as disorders that involve altered perceptions, which
may amplify sensory input resulting from increased arousal, distress, chronic
HPA stimulation, deconditioning, and sensitization. This amplification re-
duces filtering capacity, as does vigilance, anxiety, depression, and lack of
distraction, and this leads to a lower threshold for perception of symptoms.
Individuals with MUIs may have more labile or reactive physiological
systems that make them more prone to experience a number of physical symp-
toms in response to stressful events or negative emotional experiences
(Kirmayer, Robbins, & Paris, 1994). It is even possible that a trait like neu-
roticism is associated with increased symptom reporting through a physi-
ological tendency to experience higher levels of symptoms.

Sex Differences in Pain

Female gender and increasing age are the primary determinants of de-
creased pain tolerance and pain threshold. Most of the MUIs involve pain

BIOLOGY OF MEDICALLY UNEXPLAINED ILLNESS 57

experiences; IBS and FMS are defined by pain. Gender differences in behav-
ioral responses to pain are clear and well-investigated. Women report more
health care utilization and disability in response to pain (Unruh, 1996).
Additionally, studies have shown that somatosensory perception and pain
sensitivity are influenced by sex hormones (Aloisi, 2003).

Pain Perception

Most experimental paradigms show that women have lower pain thresh-
olds and tolerance and rate pain as more intense and more unpleasant than
do their male counterparts (Jensen, Rasmussen, Pederson, Lous, &. Oleson,
1992; Weisenberg, Tepper, & Schwarzwald, 1995). Tactile detection, pres-
sure pain detection thresholds, and pressure pain tolerance threshold have
been found to be significantly lower in healthy women, using a variety of
paradigms and testing at various body sites (Chesterton et al., 2002; Komiyama
& De Laat, 2005). Women show greater perceptual sensitization and "wind-
up," which is a temporal summation of pain, indicating that women's central
nociceptive processing is upregulated compared with that of men (Sarlani &
Greenspan, 2002). Sarlani and Greenspan (2005) also found that women's
central processing of nociceptive input may be more easily upregulated into
pathological hyperexcitability, possibly accounting for the predominance of
pain syndromes among women.
Although sex differences in experimental pain perception are well docu-
mented, a minority of studies have found no differences. The consistency
and magnitude of sex differences vary across pain induction techniques; for
example, the smallest differences appear to be in thermal pain stimuli (Riley,
Robinson, Wise, Myers, & Fillingam, 1998).
Menstrual cycle changes in pain perception are an important area for
examining the role of gonadal hormones on pain sensitivity. The menstrual
cycle has been reported to alter pain perception, although patterns differ
somewhat among studies. It has been reported that estrogens may influence
somatic sensory processes. Women generally have less pain sensitivity dur-
ing the phases that are associated with higher estrogen levels (Johns &
Littlejohn, 1999) and are more sensitive to pain during periods of low estro-
gen. De Leeuw, Albuquerque, Anderson, and Carlson (2006) found that ACC
activation was greater during the low estrogen phase of the menstrual cycle
in healthy women.
Riley, Robinson, Wise, and Price (1999) reviewed 16 studies of experi-
mentally induced pain across menstrual cycle phases in healthy women. Meta-
analyses found that for pressure stimulation, cold pressor pain, thermal heat
stimulation, and ischemic muscle pain, higher thresholds and tolerance for
pain were found in the follicular (high estrogen) phase. The authors pro-
posed that menstrual cycle effects on human pain perception are large enough
that it should be controlled for in pain studies.

58 MEDICALLY UNEXPLAINED ILLNESS

 Although biological factors play a role in gender differences in pain
experiences, a number of studies have found that psychosocial factors also
influence pain perception and report. Wise, Price, Myers, Heft, and Robinson
(2002) investigated the accuracy of the Gender Role Expectations of Pain
(GREP; Robinson et al., 2001) in measuring pain. The GREP consists of 12
visual analog scales that assess a participant's personal attribution of his or
her pain sensitivity, pain endurance, and willingness to report pain relative
to a typical man and woman (Robinson et al., 2001). Wise et al. found that
GREP scores were significant predictors of threshold, tolerance, and pain
unpleasantness, although they did not account for all of the variance. Bio-
logical sex remained a significant predictor of pain tolerance after control-
ling for GREP scores. Wise et al. concluded that both psychosocial factors
and biological sex differences are viable explanations for gender differences
in pain reports. Similarly, Jackson, lezzi, Gunderson, Nagasaka, and Fritch
(2002) found that men's greater physical self-efficacy and task-specific self-
efficacy mediated their higher tolerance and lower reports of pain intensity
on a cold pressor test. Anxiety and pain appear to be strongly associated in
men. Jones and Zachariae (2004) found no effect of gender on a cold pressor
pain procedure, but they did find that low-anxious men tolerated the cold
pressor significantly longer than high-anxious men. There was no effect of
anxiety on pain response in women. Keogh and Herdenfeldt (2002) manipu-
lated sensory-focused and emotion-focused coping instructions and found
that men exhibited lower pain responses when using sensory-focused coping
compared with women, whereas emotional focusing increased the affective
pain experiences in women.
Pain reports in women may be augmented by a catastrophizing coping
style. Altered peripheral or central processing mechanisms are correlated with
pain catastrophizing in women with FMS (Geisser et al., 2003). Evidence
presented in chapter 3 of this volume indicates that women are more prone
to catastrophizing.

Brain and Pain

The ACC plays an important role in pain processing and affective-

motivational experiences and affects the impact of pain-related distress on
cognitive function through its role in attention. We have seen in the discus-
sion of sensitization that some individuals may be more prone to
hypervigilance than others, allocating attention to symptoms and pain and
finding it harder to distract themselves. Cognitive efficiency and memory
can be affected by chronic stress, which repeatedly activates both the HP A
axis and ACC areas. The vigilant anticipation of pain and symptoms, espe-
cially in individuals with high trait neuroticism, disrupts attention and cog-
nitive efficiency (Hart, Wade, & Martelli, 2003). This could explain some of
the cognitive complaints reported by individuals with MUIs.

BIOLOGY OF MEDICALLY UNEXPLAINED ILLNESS 59

 CONCLUSION

MUI symptoms can be due to biobehavioral changes that occur with

life experiences that modify central brain areas, neuroendocrine, and HPA
axis functioning. These include changes in beliefs (catastrophizing), behav-
ioral changes (vigilance to symptoms, amplification, reduced activity, de-
conditioning), conditioned responses, and sensitization processes. Physiologi-
cal vulnerabilities can exist in various body systems as a result of genetics,
physical insult (viral, accident, toxic exposure, infection), or chronic stres-
sors. Additionally, behavioral and cognitive factors may keep physiological
systems from recovering adequately after a physical insult or psychosocial
stressor.

60 MEDICALLY UNEXPLAINED ILLNESS

 5
IRRITABLE BOWEL
SYNDROME

Irritable bowel syndrome (IBS) is a complex, multidetermined syndrome

involving altered gut reactivity, altered pain perception, and brain-gut
dysregulation that is modulated by psychosocial and biological factors (Bose
& Farthing, 2001; Mayer, 1999, 2000; Naliboff, Chang, Munakata, & Mayer,
2000; Palsson & Drossman, 2005). The symptomatology of IBS is a combi-
nation of abdominal pain or discomfort, rectal distension, and altered bowel
habit (either altered stool frequency, such as diarrhea or constipation, or
altered stool form). Symptoms commonly associated with IBS include ab-
dominal bloating, passage of mucus with a bowel movement, sensation of
incomplete evacuation after having a bowel movement, and abdominal pain
or discomfort. Four subgroups of IBS are described according to their most
predominant symptom: constipation predominant, diarrhea predominant,
having an alternating pattern of constipation and diarrhea, or abdominal
pain (Horwitz & Fisher, 2001; Talley, Zinsmeister, & Melton, 1995). No
pathologic pattern of gut motility can be identified specifically with IBS, in
contrast with other functional or organic disorders of the gut (McKee &
Quigley, 1993).

67
 DIAGNOSIS

Three diagnostic sets of criteria have been commonly used for research
and diagnosing IBS: the Manning criteria, Rome I criteria, and Rome II cri-
teria. The Manning criteria were developed in 1978 and required pain re-
lieved by defecation, pain followed by change in frequency or form of stool,
abdominal distension, mucus in stool, and a feeling of incomplete evacua-
tion (Talley et al., 1990). A diagnosis using the Rome criteria requires the
presence of two or more of these symptoms in addition to abdominal pain.
IBS can currently be diagnosed using the Rome II criteria (Thompson et al.,
2000). See Exhibit 5.1. The Rome I and Rome II criteria were developed
using a consensus approach adopted by a panel of international experts and
are generally found to be both sensitive and specific for the diagnosis of IBS
(Vanner et al., 1999). This consensus has allowed a standardization of entry
criteria into clinical studies and more expeditious diagnosis (Talley 6k Spiller,
2002). Recently, Rome III criteria have been developed emphasizing subtyping
according to bowel habit (Longstreth et al., 2006). Four subtypes have been
proposed: IBS with constipation, IBS with diarrhea, mixed IBS, and
unsubtyped IBS.
In studies of people who are clinically diagnosed with IBS according to
Manning or Rome criteria, a higher percentage of women compared with
men fulfill Manning and Rome criteria. R. C. Smith et al. (1991) found that
the Manning criteria were of no diagnostic value in men. Thus, it appears
that the Manning and Rome I criteria are more sensitive and reliable in
women than men. Thompson (1997) found no gender d ifferences in the three
pain symptoms; however, mucus, incomplete evacuation, and abdominal dis-
tension and bloating were less common in men. Thompson suggested that
women may remember these more subtle symptoms better than men, and in
fact other studies have indicated that women are more likely than men to
remember symptoms. Gender differences have not been examined using the
newer Rome II criteria, so it remains to be seen if this problem of differential
sensitivity and reliability persists. The studies discussed below used Manning
or Rome criteria unless otherwise indicated.
Medical professionals have moved away from the concept of "diagnosis
of exclusion" toward a so-called "positive approach" to diagnosis. The posi-
tive approach sets a partnering tone for the physician-patient relationship.
Thus, patients who fit the epidemiologic profile for IBS and have IBS-like
symptoms that meet the Rome II diagnostic criteria for IBS are considered to
have IBS, unless so-called "alarm factors" are present. The symptoms of IBS
can also occur in many other structural disorders of the gastrointestinal tract.
Physicians using the framework provided by the Rome II diagnostic criteria
must rapidly exclude the possibility of other disorders and determine whether
alarm factors exist and require evaluation (Olden, 2002). Hammer, Eslick,
Howell, Altiparmak, and Talley (2004) found that older age, rectal bleeding,

68 MEDICALLY UNEXPLAINED ILLNESS

 EXHIBIT 5.1
Diagnostic Criteria for Irritable Bowel Syndrome
(IBS; Revised Rome Criteria)
At least 12 weeks or more, which need not be consecutive, in the preceding 12 months
of abdominal discomfort or pain that has two of three features:
• relieved with defecation, and/or
• onset associated with a change in frequency of stool, and/or
• onset associated with a change in form (appearance) of stool.

Symptoms that cumulatively support the diagnosis of IBS are as follows:

• abnormal stool frequency (for research purposes, abnormal may be defined as
more than three bowel movements per day or fewer than three bowel movements
per week),
• abnormal stool form (lumpy and hard or loose and watery stool),
• abnormal stool passage (straining, urgency, or feeling of incomplete evacuation),
• passage of mucus, and
• bloating or feeling of abdominal distension.
Note. From Rome II: The Functional Gastrointestinal Disorders (p. 360), by D. A. Drossman, E. Corazziari,
N. J. Talley, W. G. Thompson, and W. E Whitehead (Eds.), 2000, McLean, VA: Degnon Associates.
Copyright 2000 by Degnon Associates. Adapted with permission.

and unexplained weight loss are alarm features that separate IBS from or-
ganic gastrointestinal disease.

ETIOLOGY

Etiologic mechanisms for IBS include visceral hypersensitivity, auto-

nomic dysfunction, postinfectious IBS, and psychosocial factors. The patho-
physiology of IBS remains incompletely understood. Much research atten-
tion has focused on altered gut motility as a cause of IBS symptoms (McKee
& Quigley, 1993). However, this approach is limited because although al-
tered motility of the colon and small bowel can be demonstrated in IBS,
there is a poor correlation between IBS symptoms and the presence of alter-
ations in motility (Whitehead et al., 1992). Likewise, drugs that alter gas-
trointestinal motility alone do not provide any significant relief of IBS symp-
toms (Noor et al., 1998; Page & Dirnberger, 1981). It appears that altered
motility in IBS is currently seen as one of many factors associated with the
disorder rather than a cause of the disorder itself.
Several triggering events have been associated with the onset of IBS.
Such triggers include pelvic surgery, use of antibiotics, psychological trauma,
and acute gastroenteritis (Gwee et al., 1999). Yet, in many individuals who
develop IBS there do not appear to be any discernable triggers. Gwee et al.
(1999) prospectively studied 94 consecutive patients hospitalized for gastro-
enteritis who had completed standardized psychometric and life events scales
for the previous 12 months. Twenty-two patients were subsequently diag-
nosed with IBS. Anxiety, neuroticism, and somatization were higher in those

IRRJTABLE BOWEL SYNDROME 69

who developed IBS, and stepwise regression showed that disruptive life events
and higher hypochrondriasis scores predicted IBS independent of the other
psychological measures. Three months after the gastroenteritis hospitaliza-
tion, both IBS-positive and IBS-negative patients showed rectal hypersensi-
tivity, hyperreactivity, and rapid colonic transport compared with healthy
controls. Only the IBS-positive patients showed higher chronic inflamma-
tory response 3 months after infection. Gwee et al. speculated that a gastro-
enteritis attack might sensitize the bowel and that psychological factors bring
out the perception of these changes as symptoms.
Zar, Kumar, and Benson (2001) reviewed the evidence for food hyper-
sensitivity in the etiology of IBS. Seven studies of dietary exclusion followed
by food challenge found response rates from 15 to 67%, and the best response
was in those with diarrhea predominant IBS. This suggests that diet may be
implicated in a significant subgroup of IBS. Like the other medically unex-
plained illnesses (MUIs) discussed in this volume, the etiology of IBS is
multidetermined through interactions of physiological, psychosocial, and
behavioral factors (Drossman, 1998). Drossman (1998) proposed that early
life factors (genetics and environmental exposures) influence the later inter-
action of psychosocial and physiological functioning with the central ner-
vous system-enteric nervous system axis, which affects clinical expression
and outcomes such as physician visits, functional status, and quality of life.

PREVALENCE

A number of studies using standardized diagnostic criteria have been

performed to help determine the true prevalence of IBS. IBS is estimated to
affect between 10% and 20% of the population (Horwitz & Fisher, 2001;
Talley, Zinsmeister, & Melton, 1995). Its incidence varies by age; it is higher
in individuals in the 2nd to 5th decades of life and declines considerably
thereafter. In individuals younger than 50 years of age, IBS affects between
15% and 20% of the population, and in individuals older than 50 years of
age, prevalence is approximately 10% to 12% (Longstreth & Wolde-Tsadik,
1993).
IBS accounts for about 12% of patients seen in primary care practice,
although most IBS sufferers do not seek medical treatment. Studies have
indicated that IBS is the largest diagnostic group seen in gastrointestinal
practices; an estimated 50% of patient visits to gastroenterologists were re-
lated to IBS symptoms (Mitchell & Drossman, 1987; M. W. Russo, Gaynes,
& Drossman, 1999).
An estimated 70% of persons with IBS symptoms do not seek medical
attention (Drossman, Sandier, McKee, &Lovitz, 1982; Thompson & Heaton,
1980). Patients with IBS, when compared with individuals with IBS symp-
toms who do not seek medical treatment, have more nongastrointestinal

70 MEDICALLY UNEXPLAINED ILLNESS

complaints and consult physicians more for these symptoms (Levy et al.,
2001; Sandier, Drossman, Nathan, & McKee, 1984; Sperber et al., 2000).
Consulters have been found to be much higher on measures of psychological
dysfunction (depression and anxiety) than nonconsulters. Whitehead,
Bosmajian, Zonderman, Costa, and Schuster (1988) found that women who
met restrictive criteria for IBS but had not consulted a physician had no
more symptoms of psychological distress than asymptomatic controls. Con-
versely, medical clinic patients with both IBS and lactose malabsorption had
significantly more psychological symptoms than asymptomatic controls or
nonconsulters with the same diagnoses. Similarly, Drossman et al. (1988)
studied 72 IBS patients, 82 persons with IBS who had not sought medical
treatment, and 84 controls. When controlling for symptoms of pain and di-
arrhea, they found that IBS consulters had a higher proportion of abnormal
personality patterns, greater illness behaviors, and fewer positive life events
than IBS nonconsulters and controls. The IBS nonconsulters had higher cop-
ing capabilities, viewed IBS as less disruptive, and exhibited less denial than
consulting patients. Collectively, these studies indicate that psychological
factors influence who consults a doctor for IBS symptoms and who does not.
Much research in IBS is based on samples from specialty referral cen-
ters, so Thompson, Heaton, Smyth, and Smyth (2000) examined the preva-
lence in general practice prospectively in all patients of British clinics in six
locations. Of 255 patients with gastrointestinal complaints, 30% had IBS
and 14% had other functional disorders. Compared with the 100 patients
found to have "organic" disease, those with IBS were more often women, had
a greater number of unexplained symptoms, and were more likely to fear that
they had cancer.
An increasing number of transcultural and transracial population stud-
ies have documented a fairly constant prevalence for IBS across national
boundaries and ethnic and racial lines. No particular country or geographic
area stands out as having a higher or lower prevalence of IBS, although indi-
viduals who live in countries with universal health care are more likely to
consult a physician for IBS symptoms (Talley, Boyce, &. Jones, 1997).

OVERLAP WITH OTHER MEDICALLY UNEXPLAINED ILLNESSES

Abdominal pain or discomfort is the distinctive symptom for the diag-

nosis of IBS. This combination of altered bowel habits with abdominal pain
or discomfort is thought to separate IBS from other functional bowel disor-
ders, such as functional dyspepsia, functional constipation, or functional di-
arrhea. However, IBS and functional dyspepsia overlap to a large extent.
Because the symptoms of both conditions involve a lower threshold for re-
porting pain from intraluminal distension, Whitehead (1999) suggested that
they may have a common pathophysiologic basis. Lembo et al. (1999) re-

IRRITABLE BOWEL SYNDROME 71

ported that out of 443 new referrals to a tertiary functional gastrointestintal
disorders center who met criteria for IBS, 35% also had functional dyspepsia.
Interstitial cystitis is a chronic syndrome characterized by bladder and
pelvic pain, with urinary problems but with no distinctive tissue pathology.
It is 9 times more likely to occur in women than in men (Alagiri, Chottiner,
Ratner, Slade, & Hanno, 1997). In a survey of 2,405 individuals with inter-
stitial cystitis, the most commonly co-occurring disorders were allergies (45%)
and IBS (38%), followed by fibromyalgia (FMS), sensitive skin, vulvodynia,
migraine headaches, and endometriosis (Alagiri et al., 1997). Ninety seven
percent of those responding to the survey were women.
Naliboff, Heitkemper, et al. (2000) reported that dyspareria (painful
intercourse) is a specific problem for women with IBS and that 43% report
some sexual dysfunction, most often decreased libido. The authors specu-
lated that this may be due to an altered central stress response (increased
secretion of corticotropin-releasing hormone), similar to what is found in
chronic fatigue syndrome (CFS) and FMS. Walker, Gelfand, Gelfand, Green,
and Katon (1996) evaluated a sequential sample of 60 women with IBS and
26 women with inflammatory bowel disease in an urban gastroenterology
clinic. Chronic pelvic pain was reported in significantly more of the IBS
(35%) than the inflammatory bowel disease group (14%). Compared with
women with IBS alone, those with both IBS and chronic pelvic pain were
significantly more likely to have a lifetime history of dysthymic disorder,
current and lifetime panic disorder, somatization disorder (SD), childhood
sexual abuse, and hysterectomy. The mean number of somatization symp-
toms was the best predictor of comorbid IBS and chronic pelvic pain com-
pared with either inflammatory bowel disease or IBS alone. These findings
indicate that high rates of psychopathology associated with IBS and chronic
pelvic pain independently are even higher in women with both syndromes.
It is possible that women with IBS report more dysmenorrhea, interstitial
cystitis, and pelvic pain because of heightened visceral hypersensitivity.
In addition to functional disorders that affect the gastrointestinal sys-
tem and pelvic area, a number of conditions, such as fibromyalgia, CFS, and
certain psychiatric disorders, have been found more often in IBS patients
than in non-IBS controls (Barsky & Borus, 1999; Manu, 2004). Whitehead,
Palsson, and Jones (2002) found that individuals with IBS were twice as likely
as comparison groups to be diagnosed with nongastrointestinal somatic dis-
orders, most commonly FMS, CFS, chronic pelvic pain, and temporoman-
dibular joint disorder. These four conditions share certain features: They dis-
proportionately affect women; are stress related; and are associated with
fatigue, sleep difficulties, anxiety, and depression. These disorders overlap
not only with IBS but also with each other (as is discussed extensively in the
introduction to Part II, this volume).
Vandvik, Wilhemsen, Ihlebaek, and Farup (2004) did not investigate
the comorbidity of IBS with specific MUIs; rather, they investigated the cor-

72 MEDICALLY UNEXPLAINED ILLNESS

relation of IBS with level of subjective health complaints. They conducted a
prospective study of 208 consecutive patients with IBS (Rome II) in nine
general medical practices. They assessed comorbid symptoms, psychosocial
factors, and quality of life. Subjective health complaint data were collected
from 1,240 adults (controls). Health care seeking was assessed after 6 to 9
months. Patients with IBS reported comorbid symptoms significantly more
frequently than controls. Patients with high somatic comorbidity reported
higher levels of mood disorder, health anxiety, neuroticism, adverse life events,
reduced quality of life, and increased health care seeking when compared
with those with low and intermediate somatic comorbidity. These findings
indicate that people with IBS and numerous additional symptoms tend to
have more psychopathology and poorer functioning.
Perkins, Keville, Schmidt, and Chalder (2005) investigated the con-
nection between eating disorders and IBS. Similarities between the two con-
ditions include strong female predominance; high prevalence of childhood
sexual abuse; and characteristics of perfectionism, negative self-evaluations,
and self-blame (AH et al, 2000; Toner, 1994). Perkins et al. found that two
thirds of individuals with a current or past eating disorder fulfilled criteria for
IBS. They also found an association between the severity of attitudinal eat-
ing disorder symptoms, such as weight and shape concerns, and IBS. The
authors suggested this may be due to a common underlying factor of
hypervigilance to internal sensations and excessive self-focused attention.

ECONOMIC IMPACT

The economic impact of IBS on U.S. society is impressive and disturb-

ing. More easily quantified direct costs of medical care (i.e., medications,
hospitalizations, and emergency room and office visits) have estimated in
excess of $8 billion (Talley et al., 1995). Indirect costs, which encompass the
cost of absence from work, school, and other productive activities, have been
estimated to be about $20 billion a year (R. Martin, Barron, & Zacker, 2001).
Not captured in these estimates are the costs associated with unnecessary
cholecystectomy (gall bladder removal; Kennedy & Jones, 2000) and hysterec-
tomy (Walker et al., 1996), two types of operations that patients with IBS
frequently undergo. A study of HMO attendees with physician-diagnosed
IBS reported that patients with IBS are 3 times as likely to undergo cholecys-
tectomies and twice as likely to undergo appendectomies, hysterectomies,
and back surgery, compared with HMO patients without IBS (Longstreth &
Yao, 2004). The staggering cost of care for IBS patients, estimated to be in
the 10s of billions of dollars, does not even include the significant negative
impact on quality of life that is induced by IBS. It is difficult to measure the
intangible costs in human suffering, isolation, and social restrictions because
of IBS-related symptoms.

IRRITABLE BOWEL SYNDROME 73

 Levy, Whitehead, Von Korff, and Feld (2000) studied 631 children of
parents with IBS (cases) and 646 matched children (controls) in the data-
base of a large HMO to explore the intergenerational transmission of gas-
trointestinal illness behavior. Adult patterns of health care use for IBS pre-
dicted child visits; case children had significantly more ambulatory care visits
for all causes as well as more visits for gastrointestinal symptoms. These pat-
terns were associated with increased health care costs.

DISABILITY AND QUALITY OF LIFE

As with other MUIs, IBS is not associated with excess mortality. A

number of large retrospective studies have shown that patients diagnosed
with IBS do not go on to develop inflammatory bowel disease, colorectal or
other gastrointestinal cancers, or other life-threatening disorders in excess of
non-IBS controls. Overall life expectancy for individuals with IBS is as good
as (or somewhat better than) that of the population at large. However, IBS is
associated with significant levels of disability and impaired quality of life
(Hahn, Yan, & Strassels, 1999). Patients with IBS have been shown to have
rates of absenteeism from work that are almost 3 times that of non-IBS con-
trols. Likewise, studies have shown that absence from school and work; diffi-
culty in activities of daily living; and the need to modify one's work setting,
work fewer hours, or give up one's occupation because of IBS are common
consequences. In this respect, patients with IBS differ significantly from pa-
tients with many other chronic medical illnesses, and they differ dramati-
cally from controls.
In addition to income and productivity losses associated with IBS, a
number of studies have shown, as might be expected, that the health-
related quality of life of patients with IBS is significantly lower than that of
population-based controls. However, these studies also showed that com-
pared with individuals with rheumatoid arthritis, asthma, diabetes, and gas-
troesophageal reflux disease, IBS patients showed significantly lower levels
of quality of life as measured by the SF-36 Health Survey (El-Serag, Olden,
6k Bjorkman, 2002; Gralnek, Hays, Kilbourne, Naliboff, & Mayer, 2000).
Using the SF-36, Gralnek et al. (2000) compared the health-related qual-
ity of life of IBS patients (N = 877) with previously reported SF-36 data for
the general U.S. population and for patients with gastroesophageal reflux
disease, diabetes mellitus, depression, and dialysis-dependent end-stage re-
nal disease. On all SF-36 scales, IBS patients had significantly worse health-
related quality of life than the general population. Compared with patients
with gastroesophageal reflux disease, IBS patients scored significantly lower
on all scales except physical functioning. Similarly, IBS patients had sig-
nificantly worse health-related quality of life on selected SF-36 scales than
patients with diabetes mellitus and end-stage renal disease. IBS patients did

74 MEDICALLY UNEXPLAINED ILLNESS

have significantly better mental health SF-36 scale scores than patients with
depression. Lackner et al. (2006) studied 104 consecutive patients referred
by local physicians. All participants met Rome II diagnostic criteria as deter-
mined by a board-certified gastroenterologist; the number of overall unhealthy
days they experienced approximated that of patients with cancer and ex-
ceeded that of people with arthritis, diabetes, heart disease, stroke, or morbid
obesity. These studies highlight the dramatic impact that IBS has on quality
of life.

GENDER AND IRRITABLE BOWEL SYNDROME

IBS is more prevalent in women. Among individuals with IBS who do

not seek care, the number of women is double the number of men (Drossman,
Camilleri, Mayer, & Whitehead, 2002). Among individuals who seek care
for IBS, the female:male ratio jumps to 4:1 (Mitchell & Drossman, 1987;
Toner & Akman, 2000). Gender disparity in IBS may, in part, reflect the
general tendency of women to seek medical care for symptoms. However, it
is reasonable to assume that most patients with IBS who are seen in clinical
practice are women. One community sample of women in England found a
prevalence of IBS of almost 23% (Kennedy & Jones, 2000). One often cited
study found that in an Indian clinic sample, men outnumbered women (Jain,
Gupta, Jajoo, & Sidhwa, 1991), but more international studies are needed to
determine whether there is a consistent cross-cultural difference in gender
ratios.
Women generally have slower gut transit times than men. E. J. Bennett
et al. (2000) used imaging techniques to track the transit time of food through
the gastrointestinal track. Their main finding was that for the 110 outpa-
tients with functional gastrointestinal disorders, those with the most wide-
spread delay of gut transit were more likely to be female and older and to
have a low level of hypochondriasis, more severe gastric stasis, and high lev-
els of depression and anger control. Those with normal transit were more
likely to be male and have high levels of hypochondriasis. E. J. Bennett et al.
made the point that gut motor function changes in terms of the function of
the whole individual; consequently, depression and controlled anger affect
objectively measured gut stasis.
Men and women differ in terms of symptom expression in IBS; men
report more diarrhea and women report more bloating, pain, and constipa-
tion. Mayer, Berman, Chang, and Naliboff (2004) reviewed sex-based differ-
ences in gastrointestinal pain and concluded that there is a common core of
IBS symptoms across sexes but that women seem to report a larger number of
symptoms. Simren, Abrahamsson, Svedlund, and Bjornsson (2001) exam-
ined the impact of gender and bowel patterns on quality of life in IBS pa-
tients seen in referral centers versus primary care settings. They found lower

IRRITABLE BOWEL SYNDROME 75

quality of life in women and in referral center patients, but they did not find
differences in bowel patterns.
Several studies have investigated menstruation and IBS symptomatol-
ogy. Whitehead, Cheskin, et al. (1990) compared women with and without
IBS and found that although 34% of controls reported exacerbations of gas,
diarrhea, or constipation during menstruation, the women with IBS were
significantly more likely to experience these problems. Self-reports of bowel
symptoms during menstruation were not associated with psychological traits
or with menses-related changes in affect. Houghton, Lea, Jackson, and
Whorwell (2002) compared rectal responses to balloon distension during
Days 1 to 4 (menses), 8 to 10 (follicular phase), 18 to 20 (luteal phase), and
24 to 28 (premenstrual phase) of the menstrual cycle in 29 women with IBS.
Their data confirmed that IBS symptomatology and rectal sensitivity are
exacerbated during menses in women with IBS compared with healthy women.
However, anxiety and depression remained unaltered throughout the men-
strual cycle.
Although there is extensive literature on gender differences in somatic
pain perception (discussed in some detail in chaps. 3 and 4, this volume),
there are few studies of gender differences in visceral pain perception. It is a
much more common experience for women to experience pain or discomfort
in the pelvic region related to menstrual or reproductive system events.
Women may be more vigilant regarding sensory input from the pelvic vis-
cera. Lee, Mayer, Schmulson, Chang, and Naliboff (2001) surveyed 714 con-
secutively screened IBS patients to explore gender differences in reported
symptoms. They found that men and women were similar in terms of illness
severity, abdominal pain, psychological symptoms, and illness impact. How-
ever, women reported more bloating, constipation, nausea, alterations of taste
and smell, morning stiffness, and greater food and medication sensitivity.
They concluded that these differences in sensitivity may represent altered
sensory processes, autonomic responses, and cognitive hypervigilance.
Chang and Heitkemper (2003) concluded in a review of IBS that no
differences have been found in healthy controls in perception of visceral
stimuli. In contrast, research has found that women with IBS show enhanced
colorectal perception compared with men with IBS, particularly after a vis-
ceral stressor.
S. Berman et al. (2000) performed positron emission tomography scans
on men and women with IBS who were undergoing moderately aversive rec-
tal pressure. They found that despite similar ratings of stimulus intensity and
discomfort, men displayed stronger regional activation of anterior cingulate,
prefrontal cortex, thalamus, and cerebellum. Rectal pressure activated the
insula bilaterally in men but not in women. The insula receives extensive
visceral input and also plays a role in autonomic responding and emotional
processing. The authors speculated that the gender differences may be due to
greater variability of insula activation in women because of hormonal fluc-

76 MEDICALLY UNEXPLAINED ILLNESS

tuation or differences in the processing of emotional content; further inves-
tigation is required to address these issues.
Naliboff et al. (2001) performed a positron emission tomography study
with 26 female and 24 male nonconstipated patients undergoing a visceral
stimulus (moderate rectal inflation) and a psychological stimulus (anticipa-
tion of noxious visceral distension). Although there was overlap, this imag-
ing study showed differences between men and women in both conditions.
Men with IBS showed greater activation of cognitive areas (dorsolateral pre-
frontal cortex) and central autonomic areas (insula, periaqueductal gray) and
inhibition of limbic regions (amygdala, infragenual cingulated) during the
stressors, whereas women showed greater activation of autonomic regions
(ventromedial prefrontal cortex, infragenual cingulate, amygdala).
Noting that the female predominance in IBS may be partially due to
hormonal influences, Houghton, Jackson, Whorwell, and Morris (2000) in-
vestigated whether testosterone mediated some protection from IBS by com-
paring 50 male patients with IBS with 25 control men. There was a signifi-
cantly lower level of luteinizing hormone in men with IBS relative to controls,
which corroborates the dysfunction of the hypothalamic-pituitary axis found
in other studies. Although findings for testosterone were equivocal, luteiniz-
ing hormone may play a role in IBS by stimulating hormones detrimental in
women (estrogen, progesterone) and protective in men (testosterone).
Although there is more research on gender differences in IBS than on
any other MUI, it is clear that there are many unanswered questions. The
female preponderance, male and female physiological and behavioral responses
to stress, the role of hormones in pathophysiology of IBS, and male and fe-
male mechanisms of bowel symptoms are still not understood (Chang &.
Heitkemper, 2003).

GENDER ROLE AND IRRITABLE BOWEL SYNDROME

Several investigators have examined the association of typical femi-

nine gender role characteristics and illness behavior in IBS. Clinical obser-
vation had revealed that IBS patients appear to exhibit certain stereotypically
feminine traits such as nurturing, putting others' needs first, suppressing an-
ger, being servile, and seeking approval from others (AH et al., 1998; Toner,
1995; Toner & Akman, 2000). These gender role behaviors were found to be
associated with strong disease conviction in a study by AH et al. (1998), who
examined 34 women and 16 men with IBS on the Communal Femininity
subscale of the Personal Attributes Questionnaire (Spence, Helmreich, &
Stapp, 1974) and found significant positive correlations between disease con-
viction and general hypochondriasis. The relationship between stereotypically
feminine subordination and the conviction that physical disease accounts
for IBS symptoms was significant for male as well as female participants. Thus,

IRRITABLE BOWEL SYNDROME 77

it may be, as Toner and Akman (2000) have suggested, that women and men
with IBS are more similar than different. The feminine gender role (rather
than female sex) is influential in affecting illness attributions. Toner and
Akman proposed that the connection between feminine gender role and dis-
ease conviction could come from focusing on others' needs, which leads to
neglect of self, and that this lack of self-nurturance exacerbates stress. The
distressing symptoms of IBS cannot be ignored, but IBS patients who go to
specialists tend to selectively attend to physiological symptoms and are less
likely to acknowledge stress than are individuals with IBS who do not see
gastrointestinal specialists (Toner, 1994). Strong disease convictions also
contribute to high levels of doctor shopping to confirm somatic attributions.
Dancey, Hutton-Young, Moye, and Devins (2002) studied psychoso-
cial burdens in 63 women and 54 men with IBS. They found that with in-
creased illness intrusiveness, quality of life declined more rapidly among men
compared with women. This could be because men have different coping
skills and are more distressed by lifestyle disruptions and restrictions on per-
sonal freedom than women. Dancey et al. (2002) also suggested that the
belief that IBS is mostly a woman's disorder may make the lifestyle disrup-
tions more acceptable to women than men.
AH et al. (2000) investigated whether emotional abuse was associated
with IBS over and above the association of physical and sexual abuse with
IBS. Their study investigated the presence of emotional abuse, self-blame,
and self-silencing in a sample of 25 women with IBS compared with 25 women
with inflammatory bowel disease. They found that the IBS group reported
significantly higher levels of emotional abuse, self-blame, and self-silencing
than the inflammatory bowel disease group. It is interesting that depressive
symptoms did not correlate significantly with emotional abuse, self-blame,
or self-silencing in either sample. Ali et al. speculated that women who ex-
perience emotional abuse may be more likely to develop response patterns of
self-blame and self-silencing. These response patterns may increase stress,
which has been shown to be an important exacerbating factor in IBS.
Blanchard, Keefer, Galovski, Taylor, and Turner (2001) sought to de-
termine where there was a gender difference in psychological distress in IBS.
They used dimensional measures, the Beck Depression Inventory, the State-
Trait Anxiety Inventory, and the Minnesota Multiphasic Personality Inven-
tory (MMPI) as well as categorical Diagnostic and Statistical Manual of Mental
Disorders (3rd ed., rev. [DSM-I1I-R]; American Psychiatric Association, 1987)
diagnoses. The women (n = 238) were significantly more depressed and trait
anxious than the men (n = 83), but they did not differ on state anxiety.
Women scored significantly higher on the Depression and Hysteria scales of
the MMPI, whereas men scored significantly higher on the Mania scale. There
were no significant gender differences on any DSM-III-R Axis I disorder; a
total of 66% had at least one Axis I disorder. The most frequently occurring
disorders were Generalized Anxiety Disorder, Social Phobia, Dysthymia, and

78 MEDICALLY UNEXPLAINED ILLNESS

Panic Disorder with Agoraphobia. Because there were no differences in diag-
nosable psychiatric disorders, and the differences on dimensional measures
were small, Blanchard et al. argued that their data do not support the idea
that the higher prevalence of IBS among women is explained by more neuro-
sis than men that drives health care seeking.

PATHOPHYSIOLOGY

IBS involves both diffuse smooth muscle dysmotility and lower visceral
pain thresholds. Because there is no correlation between motility and pain
perception, these symptoms are thought to be mediated through two sepa-
rate mechanisms (Clauw, 1994). The finding that IBS patients experience
pain and bloating at lower levels of balloon inflation in the rectum and lower
bowel than do controls has been replicated in numerous studies, and the
concept of "visceral" hypersensitivity has been postulated (Mertz, Naliboff,
Munakata, Niazi, & Mayer, 1995).
In an important study, Whitehead, Holtkotter, et al. (1990) discovered
that after balloon distention in the rectum, individuals suffering from IBS
were more sensitive to distention than were individuals from a variety of
comparison groups. Tolerance for stepwise distention of a balloon in the sig-
moid colon was compared with tolerance for holding one hand in ice water
in 16 IBS patients, 10 patients with functional bowel disorder who did not
meet criteria for IBS, 25 lactose malabsorbers, and 18 asymptomatic con-
trols. IBS patients had significantly lower tolerance for balloon distention
but not ice water, and balloon tolerance was not correlated with neuroticism
or other measured psychological traits. Whitehead, Holtkotter, et al. pro-
posed a peripheral-visceral mechanism such as altered receptor sensitivity as
the cause of distention pain in IBS patients.
However, not all IBS study participants showed hypersensitivity; it was
found most reliably when using ascending stimuli wherein individuals an-
ticipate greater discomfort as the magnitude of stimuli increase predictably.
Because hypersensitivity is less likely to be found when rectal pressures are
unpredictable, Naliboff, Chang, et al. (2000) have surmised that there is
strong evidence for hypervigilance for visceral sensations influenced by fear
and anticipation, whereas hypersensitivity caused by true sensory alterations
is less consistently found. Generally, noxious sigmoid colon stimulation causes
hypersensitivity in patients with IBS but not in controls.
These findings indicate that under certain conditions individuals with
IBS have a unique local rectal response to visceral stimulation. Neuroimaging
studies have also shown that a visceral stimulus (e.g., rectal distention) is
processed in the brain differently than in non-IBS controls. Neuroimaging
studies have shown that compared with controls, IBS patients have differen-
tial responses in the anterior cingulate cortex (ACC) and other areas of the

IRRITABLE BOWEL SYNDROME 79

brain when stimulated with rectal or sigmoid colon distention (Mertz et al.,
1995, 2000; Silverman et al., 1997). The ACC is a cerebral cortical area that
is rich in opiate receptors and is thought to be a major component of cogni-
tive circuits relating to perception as well as descending spinal pathways in-
volving pain. Silverman et al. (1997) found that in healthy individuals, per-
ception of pain during actual or simulated delivery of painful stimuli was
significantly associated with activity of the ACC, whereas no ACC response
to perception of nonpainful stimuli was observed. However, in patients with
IBS, the ACC did not respond to the same stimuli, whereas significant acti-
vation of the left prefrontal cortex was seen. Thus, the perception of acute
rectal pain is associated with activation of the ACC in healthy individuals,
and patients with IBS show an aberrant brain activation pattern both during
noxious rectal distention and during the anticipation of rectal pain.
Mayer et al. (2005) found that certain areas of the ACC were activated
in IBS. They compared men with ulcerative colitis, IBS patients, and con-
trols using regional cerebral blood flow (analyzed in positron emission to-
mography scans) during actual and anticipated (but undelivered) rectal dis-
tensions. No differences in anterior insula or dorsal ACC were found.
However, IBS patients showed greater activation of the limbic and paralimbic
brain areas (amygdale, hypothalamus, ventral/rostral ACC, dorsolateral pre-
frontal cortex), indicating increased activation of pain pathways in IBS.
The enteric nervous system acts directly on effector systems such as
smooth muscles, endocrine cells, and blood vessels, facilitating serotonin-
mediated secretion and motility. However, the parasympathetic and sympa-
thetic nervous systems have a pivotal role in gastrointestinal function through
autonomic integrative processes that facilitate the brain-gut interaction
(Gershon, 1999). The discovery of altered processing of neural sensation in
IBS patients has led to the search for the specific neurotransmitters involved
in this abnormal signal transmission. Serotonin has provoked the greatest
research attention because it influences motility, visceral perception, and
secretion in the gut. The pervasive role of serotonin in normal and patho-
logical gastrointestinal conditions is apparent in its pattern of distribution:
95% of serotonin in the body is in the gastrointestinal tract, and approxi-
mately 5% is localized in the brain (Gershon, 1999; Talley, 1992).
Modulation of serotonin action in the gut could influence IBS and other
functional bowel symptoms. The subtypes of serotonin contained in the gut
consist mainly of 5-HT3 and 5-HT4, thus, drugs have been developed that are
designed specifically to act on these serotonin subtypes. Cholecystokinin
antagonists to block cholecystokinin and neurokinin are also being investi-
gated for their potential to influence IBS symptoms (D'Amato, Labum, &
Whorwell, 1999).
Collectively, these data suggest the possibility of a "brain-gut axis,"
where peripheral symptoms are processed in the end organ (i.e. the colon),
and then neural signals are carried via visceral afferents to the spinal cord

80 MEDICALLY UNEXPLAINED ILLNESS

and then to the brain, where they are subject to additional processing that
can influence descending pathways (Mertz, 2002; Talley, 1992). This bidi-
rectional pathway is modulated by a number of neurotransmitters; cholecys-
tokinin, enkephalins, serotonin, and corticotropin-releasing factor. Visceral
signals from the gut ascend to the midbrain, thalamus, limbic system, and
somatosensory cortex. The somatosensory cortex registers the location and
intensity of pain, whereas the limbic system (ACC, insula, medial thalamus)
mediates the affective and motivational aspects of pain. The limbic system
can activate the descending endorphin analgesic system to the dorsal horn of
the spinal cord and up or down regulate incoming visceral signals (Halpert &
Drossman, 2005). Uncovering differential activation of the brain-gut axis in
IBS relative to various comparison groups appears to indicate that pain is
experienced more intensely in IBS.
Mayer et al. (2004) summarized the perceptual findings in IBS as follows:
1. IBS is associated with hypersensitivity in the upper gastrointes-
tinal tract and the colon.
2. IBS is associated with heightened perception of normal intes-
tinal contractions.
3. IBS (unlike FMS) is not associated with a generalized hyper-
sensitivity to noxious somatic stimulation (I. J. Cook, van
Eeden, & Collins, 1987; Whitehead, Holtkotter, et al., 1990).
4. Perception of colonic distensions can be modified by atten-
tion, anxiety, and relaxation.
Because IBS is associated with an exaggerated response to stress, Sagami
et al. (2004) investigated whether a corticotropin-releasing hormone (CRH)
receptor antagonist would reduce IBS symptoms. They administered the CRH
antagonist intravenously to 10 diarrhea-predominant IBS patients and 10
healthy controls. The CRH antagonist successfully suppressed motility in-
duced by rectal electrical stimulation, abdominal pain, and anxiety in IBS
patients but not in controls. The authors concluded that the CRH pathway
must be involved in the mechanism of increased colonic motility to stimuli
in IBS.

PSYCHOLOGICAL DISORDERS
A number of studies have documented high rates of Axis I disorders in
people with IBS. Studies using the Diagnostic Interview Schedule (Robins,
Cottier, & Keating, 1991) and standardized criteria for IBS (Manning, Rome
I, or Rome II criteria) have found lifetime rates of psychiatric disorders at
90% or higher in patients with IBS (Lydiard, Fossey, Marsh, & Ballenger,
1993; Walker et al., 1990; Woodman et al., 1998). In these samples, about
80% of the patients in the IBS group were women. The most common psy-
chiatric diagnosis in these studies was major depression, followed by anxiety

IRRITABLE BOWEL SYNDROME 81

disorders. Woodman et al. (1998) found a high percentage of substance use
disorders (35%). It is important to note that it is past history of Axis I disor-
ders that is so high rather than current psychiatric disorder. Active psychiat-
ric disorder has been found in only about 25% of participants. After summa-
rizing findings regarding depression, anxiety, and somatization in IBS, Manu
(2004) concluded that the severity of somatization phenomena predicts the
burden of psychopathology and psychological distress in IBS.
The high rates of psychiatric disorders in IBS have been based largely
on patients who present to referral centers for care. In a general community
cohort, Talley, Howell, and Poulton (2001) investigated the rate of psychi-
atric disorders in 26-year-old adults (N = 890) in Ne\v Zealand. Prevalence
of IBS was assessed, with 12.7% meeting the Manning and 4.3% meeting the
Rome II criteria. Although prevalence rates were somewhat higher in women,
this difference was not significant. It is important to note that diagnosis of
IBS was not associated with a Diagnostic Interview Schedule DSM-III-R
(American Psychiatric Association, 1987) psychiatric diagnosis. They did
not separate out consulters from nonconsulters for IBS symptoms in this study.
Although some studies have found people with gastrointestinal symptoms in
general to be more neurotic and anxious, it is likely that psychological dis-
tress increases consulting behavior (Drossman et al., 1988; Whitehead et al.,
1988).
In a study of 709 college students, Hazlett-Stevens, Craske, Mayer,
Chang, and Naliboff (2003) found that 11% met Rome II criteria for IBS. As
in the Talley et al. (2001) study, women predominated, but gender differ-
ences were not significant. It is possible that increasing female predominance
in IBS develops later in the life course. In this group, Hazlett-Stevens et al.
found a significant association between IBS and anxiety-related measures of
worry, neuroticism, anxiety sensitivity, and generalized anxiety disorder. There
was a particularly strong association between IBS and anxiety about visceral
sensations. Hazlett-Stevens et al. speculated that a vicious cycle may de-
velop, with fears about gastrointestinal sensations leading to increased vigi-
lance toward these sensations and the visceral sensations increasing as a re-
sult of anxiety and vigilance, leading to greater fear and avoidance of
gastrointestinal sensations and situations associated with them.
A. R. Miller et al. (2001) explored psychiatric symptoms and illness
behavior in IBS in relation to SD. A total of 50 outpatients with IBS or
ulcerative colitis were evaluated with the Diagnostic Interview Schedule and
Illness Behavior Questionnaire in a university-based office setting. Although
no ulcerative colitis patients were diagnosed with SD, 42% of IBS patients
met criteria for SD. IBS patients with SD, but not those without SD, re-
ported more psychiatric symptoms and abnormal illness behaviors than did
ulcerative colitis patients. Thus, comorbidity with SD accounted for the as-
sociation of psychiatric symptoms with IBS.

82 MEDICALLY UNEXPLAINED ILLNESS

 Emmanuel, Mason, and Kamm (2001) examined the relationship be-
tween psychological factors and gut innervation in women with functional
gut disorders. Women with constipation had greater levels of anxiety, de-
pression, and somatization and felt "less feminine" compared with healthy
controls. The more impaired the score on psychological testing, the lower
the mucosal blood flow reading, suggesting a link between psychological state
and gut function.
Whitehead et al. (2002) found that among IBS patients with other
comorbid MUIs, psychiatric disorders were higher than in those with just
IBS. This fits in with the patterns of somatizing and doctor shopping that
separate consulters from nonconsulters. Thus, those who meet criteria for
IBS and other MUIs are more likely to be vigilant about symptoms, be dis-
tressed by symptoms, and seek treatment for symptoms. It is the consulters
who present the impact on the health care system and are most likely to need
psychological treatment. Hersbach, Henrich, and von Rad (1999) summa-
rized the difference between nonconsulters and consulters by saying that
nonconsulters with IBS tend not to differ from controls (healthy individuals
or individuals with organic disorders); conversely, consulters with IBS have
more psychopathology, more fear of "serious illness," more health complaints,
and are more affected by stress than nonconsulters.
Whitehead et al. (2003) performed a large, comprehensive study de-
signed to overcome the methodological pitfalls of previous examinations of
psychiatric prevalence in IBS, such as small sample, inappropriate controls,
and tertiary care settings. They matched 3,153 patients with IBS to 571 pa-
tients with inflammatory bowel disease and to 3,153 individuals without gas-
trointestinal diagnosis and examined the psychiatric diagnoses in the elec-
tronic records of a large HMO. The presence of at least one psychiatric
diagnosis was found for 51.2% of IBS patients, 21.4% of inflammatory bowel
disease patients, and 29.1% of controls. The most prevalent diagnoses were
depression, stress reaction, and anxiety. In summary, in IBS clinic and treat-
ment trial samples that used standardized psychological assessment through
interview, about half of the patients met criteria for psychiatric disorder.

ILLNESS BEHAVIOR

Dancey et al. (2002) examined illness intrusiveness in IBS and found

that the burden in IBS was similar to that seen in more serious disorders such
as rheumatoid arthritis, bipolar disorder, and end stage renal disease. Crane
and Martin (2004) found that individuals with IBS have a perception of
increased susceptibility to unrelated health threats (deep vein thrombosis,
arthritis, bowel cancer) but not to nonhealth risks. This perception may in-
crease illness behaviors and partly explain the overlap with other MUIs.

IRRITABLE BOWEL SYNDROME 83

 Koloski, Boyce, and Talley (2005) examined the correlates of health
care seeking in IBS and functional dyspepsia in an Australian population-
based survey. They found that there were no differences between consulters
and nonconsulters in social learning of abnormal illness behaviors such as
encouragement, reinforcement of the sick role, and modeling of illness be-
havior. The only important factor predicting IBS or functional dyspepsia
status was disease conviction, which operated independently of age, gender,
psychiatric diagnoses, and symptom severity. Other studies of determinants
of health care consulting have found symptom severity and fears of serious
illness to be the most important predictors. Similarly, M. Martin and Crane
(2003) found that attributional style was key to consulting versus
nonconsulting for IBS symptoms among university students. Treatment seek-
ers were more likely to make somatic attributions for gastrointestinal symp-
toms as well as physiological symptoms usually characteristic of depression
and anxiety than nonconsulters.
To summarize the differences between those who consult for IBS symp-
toms and those who do not, IBS consulters display increased illness behavior,
greater psychological distress, more fears of serious illness, and more overlap
with other MUIs. They are also more likely to be women.

CHILDHOOD SEXUAL ABUSE

A number of studies have documented the high prevalence of reported
childhood sexual abuse in individuals with IBS (Blanchard et al., 2004;
Drossman et al., 1990; Walker et al., 1990; Walker, Katon, Roy-Byrne,
Jemelka, &. Russo, 1993). Drossman, Talley, Leserman, Olden, and Barreiro
(1995) found that generally about one third of women with IBS report a
history of sexual abuse. Drossman et al. (1990) conducted a survey of con-
secutive women patients seen in a gastroenterology practice over a 2-month
period. Compared with patients with organic disease, patients with func-
tional bowel disorders (including IBS, dyspepsia, chronic pelvic pain, and
constipation) reported significantly more experiences of sexual exposure,
threatened sex, incest, rape, and physical abuse.
In a controlled study using a structured psychiatric interview (abridged
DIS), Walker et al. (1993) examined sexual victimization in 28 IBS patients
compared with 19 inflammatory bowel disease patients. The IBS group had
significantly higher rates of lifetime history of severe sexual victimization
(with severe defined as any form of penetration). All of the individuals with
IBS who had experienced sexual victimization were women. Compared with
IBS patients with no sexual trauma, those with severe trauma had more medi-
cally unexplained symptoms, anxiety symptoms, and psychiatric diagnoses.
Drossman, Li, Leserman, Toomey, and Hu (1996) evaluated 239 fe-
male outpatients at gastroenterology clinics in North Carolina and found
that on interview, 60% reported a history of physical or sexual abuse. There

84 MEDICALLY UNEXPLAINED ILLNESS

was no difference in prevalence of abuse between those with functional as
opposed to structural disease. Regardless of diagnosis, those with self-reported
abuse reported more pain and more disability than those not reporting abuse.
Talley and Boyce (1996) argued that the Drossman et al. study was subject to
selection bias. They also asked whether self-reported abuse identifies people
who are "positive reporters" and who are more predisposed to distress. Addi-
tionally, there is a need to define abuse more clearly; the Drossman et al.
study encompassed a wide range of experiences; however, it appears that the
context of the abuse is critical—that is, whether it is a single episode or
repeated episodes, how severe the abuse is, and whether there is emotional
support for the victim.
Talley, Boyce, and Jones (1998) performed a population-based survey
of 730 individuals and found that 12% met Rome II criteria, with signifi-
cantly more women meeting the criteria than men. They explored the asso-
ciation between IBS, abuse, and psychological disturbance. Almost half of
the respondents reported some abuse history, and abuse was associated with
IBS. However, after they controlled for neuroticism and psychological mor-
bidity, there was no significant link between childhood abuse and IBS.
Selected symptoms associated with abuse were examined by Leserman,
Li, Drossman, and Hu (1998) in 239 women from a gastroenterology clinic
with a variety of organic and functional gastrointestinal disorders. Leserman
et al. found that women with sexual and physical abuse histories were much
more likely to report panic; depression; skin rashes; and musculoskeletal,
genito-urinary, and respiratory symptoms. As in other studies, a dose-re-
sponse effect was observed, with a more severe abuse history associated with
more symptoms, greater health care use, and worse functional disability.
Reilly, Baker, Rhodes, and Salmon (1999) examined the association of
sexual and physical abuse in patients presenting with IBS and nonepileptic
attack disorder and compared them with organic (Crohn's disease and epi-
lepsy, respectively) control groups. Although presenting with very different
symptom profiles, the IBS and nonepileptic attack disorder groups recalled
more sexual and physical abuse, both as children and adults, than their con-
trols. The IBS and nonepileptic attack disorder groups were also very similar
in terms of higher anxiety and depression, stronger disease conviction, soma-
tization symptoms, and poorer social function than their respective compari-
son groups.
A model for the relationship between early abuse and gastrointestinal
disorders was developed by Scarinci, McDonald-Hale, Bradley, and Richter
(1994) using sensory decision theory tasks. Early traumatic stress can lead an
individual to develop hypervigilance, which results in low response bias and
low pain thresholds. Hypervigilance may predispose patients to experience symp-
toms as more salient; the past trauma may make physical symptoms more threat-
ening. Scarinci et al. demonstrated, among patients with gastroesophageal re-
flux disease, noncardiac chest pain, and IBS, that abused patients had

IRRITABLE BOWEL SYNDROME 85

significantly lower pain thresholds to finger pressure stimulation; lower cog-
nitive standards for judging stimuli as noxious; higher levels of functional
disability; and a greater number of psychological disorders, daily hassles, and
other pain syndromes than their nonabused counterparts. In terms of treat-
ment implications, patients with an abuse history more frequently blamed them-
selves for their pain and were more likely to use maladaptive pain strategies.
Self-blame is common in abuse victims, and this tendency, combined with
multiple painful symptoms, appears to engender catastrophic coping responses,
hopelessness, disability, and doctor shopping to achieve ever-elusive relief.
Medicinal treatment, however, is unlikely to relieve their symptoms. Drossman
et al. (2000) found that among 239 women referred for gastrointestinal disor-
ders, catastrophizing, low perceived ability to decrease symptoms, and a history
of abuse significantly predicted poor outcome over a 1-year follow-up period.
These findings are consistent with the Scarinci et al. model.
Numerous studies have documented that individuals with IBS who have
an abuse history have worse outcomes than those without such a history.
Creed, Guthrie, et al. (2005) assessed 257 patients with severe IBS and found
that 12.1% reported a history of rape and 11% reported forced touching.
Those who reported abuse were more impaired on pain and physical function
scales of the SF-36. They found that the association between abuse history
and impaired functioning was mediated by somatization tendencies. The good
news was that those with an abuse history also got the most out of therapy. In
a 15-month trial of psychotherapy and paroxetine, Creed et al. (2003) found
the greatest beneficial response in those with abuse history, particularly those
with a reported history of rape.
Several studies have found that women with IBS and no history of abuse
have lower pain thresholds than women with a history of abuse (Ringel et
al., 2004; Whitehead, Crowell, Davidoff, Palsson, & Schuster, 1997). White-
head et al. (1997) suggested that lower pain thresholds are due to perceptual
response bias. Thus, modifying the psychological processes that affect pain
perception may be more effective than drug therapies. These studies indicate
that the greater pain reporting and poorer health status in IBS patients with
abuse history are not related to increased rectal pain sensitivity.
Guthrie et al. (2003) performed a cluster analysis to differentiate sub-
groups in 107 treatment-resistant individuals with IBS. They investigated
the relationship between symptoms, psychological variables, and rectal sen-
sitivity and produced three clinically meaningful subgroups. The three groups
were not different in terms of age, sex, type of IBS, or symptom severity as
measured by daily diary. Group I was called "distressed high utilizers" because
they had low rectal distension discomfort thresholds, highest prevalence of a
history of childhood sexual abuse, higher doctor consultations, more psychi-
atric diagnoses, more interpersonal problems, and higher unemployment.
Group II, "distressed low utilizers," also had low distension thresholds and

86 MEDICALLY UNEXPLAINED ILLNESS

high prevalence of psychiatric disorders but a lower prevalence of childhood
sexual abuse, less disability, and less consulting behavior. Group III, "toler-
ant low utilizers," consisted of patients with high distension thresholds; they
were constipation predominant, had lower levels of psychological and inter-
personal problems, and low consultation rates. This study illustrates the com-
plex interaction between past trauma, distress, pain thresholds, functioning,
and help seeking.
The prior studies demonstrate that a significant percentage of people
with IBS are likely to report a history of sexual and physical abuse and that
they tend to have worse health outcomes than those without reports of such
abuse. Salmon, Skaife, and Rhodes (2003) attempted to implicate dissocia-
tion as a mechanism that could link abuse history to IBS. Specifically, they
examined the role of dissociation in explaining the relationship between
abuse and somatization, and then they looked at whether somatization could,
in turn, explain the relationship of abuse and dissociation to IBS. They com-
pared 67 outpatients with IBS with 61 patients with Crohn's disease or ulcer-
ative colitis. They developed a regression model that found increased disso-
ciation was associated with abuse and could account statistically for the link
between childhood sexual abuse and somatization. This study also found that
individuals with IBS recalled more sexual abuse as adults, more physical abuse
as children, and more psychological abuse as adults than those in the organic
disease group. Only childhood sexual abuse and adult psychological abuse
were uniquely associated with IBS (Salmon et al., 2003).
When discussing high rates of childhood sexual abuse in IBS patients,
studies have almost exclusively relied on retrospective reports of such a his-
tory. Raphael, Spatz Widom, and Lange (2001) conducted a prospective study
on documented childhood sexual and physical abuse and neglect and unex-
plained pain complaints. Surprisingly, they found that reporting one or more
unexplained pain symptoms was not associated with any childhood victim-
ization experience. Their findings indicate that explaining MUIs as expres-
sions of past trauma through current symptoms is too simplistic. Lackner,
Gudleski, and Blanchard (2004) also contended that investigators need to
move "beyond abuse," because an emphasis on severe stressors may overlook
the importance of less extreme parenting variables in influencing somatic
complaints. Lackner et al. investigated whether negative parenting behav-
iors may be more strongly associated with IBS symptoms than abuse-specific
factors in 81 consecutively evaluated IBS patients (70 women, 11 men). They
found that although both abuse and a negative, rejecting parenting style were
correlated, only parenting style correlated with somatization. They argued
that their findings were consistent with stress physiology and abuse research,
which has found that family social climate is a stronger predictor of adult
health issues than abuse-specific variables. Although the abuse is certainly
related to IBS, the extent to which it influences adult health may be molded

IRRITABLE BOWEL SYNDROME 87

by day-to-day parental nurturance. As discussed in great detail in chapters 3
and 4, this volume, there is substantial evidence that early caregiving influ-
ences stress reactivity, brain function, and pain processing.

CONCLUSION

Although various physiologic and psychological mechanisms are im-

plicated in IBS, no one mechanism explains the majority of patients with
IBS (Whitehead et al., 2002). The biopsychosocial model applied to IBS has
been explicated by Drossman (1998, 1999), who maintained that (a) many
factors contribute to symptom development, (b) no one factor is necessary to
develop IBS, and (c) factors interact in different combinations. Thus, in some
patients, higher levels of stress predict who develops IBS after a bout of gas-
troenteritis, whereas patients with a low sensory threshold are more sus-
ceptible to gastrointestinal pain in IBS (Whitehead et al., 2002). Whitehead
et al. (2002) also suggested that people with IBS with comorbid MUIs have
somatization tendencies and predominantly psychological etiology, whereas
those without comorbid conditions and few excess symptoms are more likely
to have a physiologic etiology for IBS. The female predominance in IBS is
likely due to a number of biopsychosocial factors. Women's higher levels of
somatic reporting, higher rates of a history of childhood sexual abuse, differ-
ent brain-gut axis, and sensitivity could all be important contributors.

88 MEDICALLY UNEXPLAINED ILLNESS

 6
FIBROMYALGIA

Fibromyalgia syndrome (FMS) is a common rheumatic disorder char-

acterized by chronic, widespread pain that does not radiate from a particular
region of the body. The term fibrositis was used for the same condition before
fibromyalgia became the accepted label in the 1990s. Chronic widespread pain
is another rubric seen in the literature, and fibromyalgia is often viewed as
existing on a continuum of chronic widespread pain (Gran, 2003); others
view FMS as a distinct disorder (Russell, 1999).

DIAGNOSIS

The diagnosis of FMS is based on a history of at least 3 consecutive

months of widespread bilateral pain. The pain is in response to stimuli not
normally considered painful (allodynia), as well as a reduced threshold for
reporting pain (hyperalgesia; Price & Staud, 2005; Staud, 2005). The pain
must be accompanied by excessive tenderness on application of pressure to at
least 11 of 18 muscle-tendon sites (tender points) during clinical examina-
tion (Wolfe et al, 1990; see Exhibit 6.1 and Figure 6.1). These American
College of Rheumatology (ACR) 1990 classification criteria (Wolfe et al.,
1990) for the diagnosis of fibromyalgia provide a sensitivity (88%) and speci-

89
 EXHIBIT 6.1
American College of Rheumatology Criteria for Fibromyalgia
1. Widespread muscular and joint pain for over 3 months. Pain is bilateral and ap-
pears above and below the waist.
2. Extreme tenderness in 18 specific "tender points." Digital palpation should be
performed with an approximate force of 4 kilograms. For a tender point to be
considered positive, the subject must state that palpation was "painful."
Patients will be classified as having FMS if both criteria are satisfied.
Note. Data from Wolfe et al. (1990, p. 171).

ficity (81%) in differentiating FMS from other forms of chronic musculosk-

eletal pain. Sleep disturbance, fatigue, and morning stiffness are common in
FMS, but these symptoms do not distinguish the syndrome as reliably as wide-
spread pain and tender points. The ACR criteria have been useful in guiding
research, although FMS remains a controversial disorder, with debate sur-
rounding its etiology and treatment.
No definitive physical findings or laboratory or imaging abnormalities
exist in FMS. A number of nonpain symptoms commonly occur in FMS,
including morning stiffness, nonrestorative sleep, headache, numbness, chilli-
ness, low blood pressure, mood and cognitive problems, fatigue, and bowel
problems (Hazlett & Haynes, 1992; Neeck, 2002). These symptoms can be
modulated by activity, weather, and stress (Goodnick & Sandoval, 1993).
Clauw (1994) noted that the multiple nonrheumatic symptoms associated
with FMS can be clustered into cohorts of patients with (a) primary neuro-
logic symptoms (sleep disturbances, paresthesias, cognitive and mood prob-
lems); (b) primary smooth muscle dysmotility (bowel and bladder symptoms,
migraine); (c) increased skeletal tone (myalgias, temporomandibular disor-
der, tension headache); and (d) inflammatory symptoms (cystitis, rhinitis,
pharyngitis).
One of the distinguishing characteristics of FMS is the presence of ten-
der points. The presence of tender points is associated with psychological
distress and a tendency toward increased medical utilization (McBeth,
Macfarlane, Benjamin, Morris, & Silman, 1999). A high tender point count
is associated with intermediate levels of fatigue; low levels of self-care; and
reports of more somatic symptoms, more medical consultations, and psycho-
logical symptoms (McBeth et al., 1999). Researchers have also found that
individuals with a high tender point count are more likely to have been ex-
posed to childhood adversity, such as abuse or parental loss.
Common assessment measures for individuals with FMS in clinical prac-
tice and research paradigms are tender point and dolorimeter evaluation.
Tender points are generally assessed by manual palpation of the 18 tender
points specified by the ACR (see Figure 6.1). Individuals indicate when they
first feel pain (not just pressure), and the sum of positive tender points is
reported. Dolorimetry is generally conducted with a pressure algometer, which

90 MEDICALLY UNEXPLAINED ILLNESS

Figure 6.1. Eighteen tender point sites. Digital palpation should be performed with
an approximate force of 4 kilograms. A tender point has to be painful at palpation,
not just "tender." From Diagnosing Fibromyalgia Syndrome, by We Are FMily
(2002). Copyright 2002 by Tigi Higgins. Reprinted with permission.

applies pressure uniformly to tender points and control points. Pressure is

applied at a rate of 1 kilogram/second, and individuals also indicate when
they first feel pain.
The course of FMS varies from individual to individual. Fluctuating,
intermittent symptoms characterize the course for some individuals. For many
individuals with FMS, however, the syndrome follows a progressive course,
with symptoms worsening over time and with few or no periods of remission
(Boissevain & McCain, 1991a, 1991b).

PREVALENCE

Fibromyalgia is the most common cause of chronic, widespread muscu-

lar pain. Six to 10 million Americans meet the classification criteria for FMS;
as many as 10% of women aged 50 to 60 may be affected (Meisler, 2000). In

FIBROMYALGIA 91
 the overall population, it has been estimated that 3.4% of women and 0.5%
of men have FMS (Wolfe, Ross, Anderson, & Russell, 1995). Given these
numbers, most FMS patient visits are to the primary care physician, whereas
specialists provide care for about 20% of Americans with FMS (Goldenberg,
1995). Weir et al. (2006) recently conducted a population-based retrospec-
tive cohort study of 62,000 enrollees in a nationwide health insurance claims
database. Cases of FMS were identified from 1997 through 2002. Weir et al.
found that female preponderance was not as substantial as reported in previ-
ous studies, although incidence was 6.9 cases per 1,000 person years for men
and 11.3 cases per 1,000 person years for women. Patients with FMS were 2
to 7 times more likely to be diagnosed with one or more of the examined
comorbid conditions: chronic fatigue syndrome (CFS), irritable bowel syn-
drome (IBS), depression, anxiety, headache, systemic lupus erythematosus,
and rheumatoid arthritis.
FMS is primarily an illness of middle age. However, adolescents, par-
ticularly female teenagers, may present with symptoms of FMS, and initial
attempts have been made to classify a disorder called juvenile primary
fibromyalgia syndrome (Kashikar-Zuch, Graham, Huenefeld, & Powers, 2000).
Nevertheless, the median age of onset for fibromyalgia is between the ages 29
and 37, whereas the average age of diagnosis is between the ages of 34 and 54.
The gap between these medians indicates that it generally takes several years
before an appropriate diagnosis is made (Boissevain & McCain, 1991a). One
reason for the delay may be that some patients are mistakenly diagnosed with
connective tissue disorders. Additionally, some physicians may be hesitant
to assign a diagnosis of FMS because they perceive that the label may pre-
cipitate illness behavior or learned helplessness. K. P. White, Nielson, Harth,
Ostbye, and Speechley (2002) explored prospectively whether labeling with
FMS has adverse effects on outcome. They surveyed southwestern Ontario
residents using random digit dialing and identified 100 individuals who met
criteria for FMS by screening 3,395 adults. Only 28 had already been diag-
nosed, all of them women, and 14 of those newly diagnosed were men. White
et al. then compared those who had a prior label with the newly labeled at
study entry and at 18- and 36-month follow-up points. Although those car-
rying a preexistent diagnosis at baseline were clinically worse than the undi-
agnosed, those assigned and informed of their FMS label did not worsen over
time. It appears that the label of FMS did not adversely affect clinical course
or health care utilization, so fears of learned helplessness may be unfounded.

OVERLAP WITH OTHER MEDICALLY UNEXPLAINED ILLNESSES

Rheumatologists continue to argue over whether FMS is a distinct dis-

order (Hadler, 2003; Malleson, 2002). No sharp boundaries distinguish FMS
from other functional disorders such as CFS, IBS, or muscular headaches

92 MEDICALLY UNEXPLAINED ILLNESS

(Aaron & Buchwald, 2001). Although FMS is the only diagnosis that re-
quires tender points on examination, many patients with these other condi-
tions also feel pain in tender point areas. In many patients who meet the
criteria for diagnosis for CFS, the only difference between them and a typical
FMS patient is the degree of pain. Seventy percent of patients with FMS
meet the criteria of the Centers for Disease Control and Prevention for CFS
(Aaron & Buchwald, 2003; Buchwald, Goldenberg, Sullivan, & Komaroff,
1987), and 66% of patients with CFS meet the ACR criteria for FMS
(Goldenberg, 1989a). It seems unlikely that these patients have two separate
disease processes. Perhaps dividing these two groups of patients on the basis
of whether they have prominent pain is as artificial as division on the basis of
prominence of any other associated symptoms. In summarizing studies of FMS
overlap with other medically unexplained illnesses (MUIs), Aaron and
Buchwald (2003) found that the greatest overlap was with CFS (21%-80%),
IBS (3296-80%), temporomandibular disorder (75%), headache (10%-80%),
multiple chemical sensitivity (33%-55%), interstitial cystitis (13%-21%),
and chronic pelvic pain (18%).
Veale, Kavanagh, Fielding, and Fitzgerald, (1991) examined overlap in
groups of patients with FMS and IBS compared with healthy and disease
control populations. They studied four patient groups (those with FMS, IBS,
inflammatory arthritis, and inflammatory bowel disease) and controls. There
were 20 people in each group. Seventy percent of the FMS patients had IBS,
and 65% of the IBS patients had FMS. In the disease control groups, 12%
met FMS criteria and 10% met IBS criteria. Clearly, there is consistently
strong evidence that FMS overlaps substantially with CFS, IBS, temporo-
mandibular disorders, and headache. When people with FMS also meet cri-
teria for other MUIs, they obviously have a number of additional symptoms,
but they also have been found to have greater impairment, disability, dis-
tress, and economic problems than those with only the FMS diagnosis (Wolfe
et al., 1997a). Aaron and Buchwald (2003) hypothesized that the best expla-
nation for the overlap is that both a genetic predisposition and environmen-
tal triggers alter the balance between hypothalamic-pituitary-adrenal (HPA)
axis, autonomic nervous system, and pain processing.

PROGNOSIS

Although FMS is generally viewed as a chronic condition, outcomes

for FMS have varied across studies, with some finding significant improve-
ment or remission over time and others finding very little improvement.
Granges, Zilko, and Littlejohn (1994) assessed the outcome of patients with
FMS who were diagnosed and treated with minimal intervention in a com-
munity rheumatology practice. Forty-four ambulant patients with FMS, first
seen and treated with a simple 2-month pain management program, were

FIBROMYALGIA 93
reviewed 2 years after diagnosis. Forty-seven percent no longer fulfilled crite-
ria for FMS, and remission was objectively identified in 24.2% of assessed
patients. Regular physical exercise, rather than drug or specific physical thera-
pies, correlated highly with low FMS scores, whereas mood and coping strat-
egies at the 2-year review were not related to FMS. Granges et al. concluded
that community FMS has a better prognosis than the literature suggests and
that simple intervention may be associated with good outcome in a signifi-
cant number of patients with FMS.
Wolfe et al. (1997a) conducted a longitudinal outcome study by mailed
questionnaire administered every 6 months to 538 patients at six rheumatol-
ogy centers over 7 years. Measures of pain, global severity, fatigue, sleep dis-
turbance, anxiety, depression, and health status were markedly abnormal at
study initiation and were essentially unchanged over the study period. Al-
though there was a great deal of variability in scores at one center compared
with another, there was very little change from patient to patient from baseline
over the 7 years of the survey.
Hamilton, Gallager, Thomas, and White (2005) performed a longitu-
dinal survey of 18,122 patients diagnosed by their general practitioner with
FMS, CFS, myalgic encephalitis, or postviral fatigue syndrome from 1988 to
2001 using electronic records from the General Practice Research Database
in England. The length of illness was calculated as the interval between the
diagnosis and the last recorded fatigue symptom, expressed as days per year.
Patients with CFS and myalgic encephalitis combined had a worse prognosis
than patients with FMS or postviral fatigue syndrome. There were differ-
ences in outcome between the various fatigue labels, with myalgic encepha-
litis having the worst prognosis and postviral fatigue syndrome the most fa-
vorable. Hamilton et al. suggested that the myalgic encephalitis label itself
has an adverse effect. (In chap. 7, this volume, the effects of numerous treat-
ment approaches on the prognosis of FMS are examined.)

ETIOLOGY

The etiology of FMS appears to be multifactorial in nature. Genetics,

lower pain threshold, neural sensitization, neuroendocrine alterations, hor-
monal perturbations, sleep abnormalities, and psychosocial factors have all
been implicated in FMS. The evidence for these factors is detailed below.

Genetic Contributions

Familial studies have suggested that genetic and familial factors may
play a role in the etiology of FMS. Several studies have reported an elevated
prevalence among first degree relatives of those diagnosed with FMS, but
these studies had small sample sizes and did not use standardized criteria or

94 MEDICALLY UNEXPLAINED ILLNESS

direct interviews with relatives. Arnold et al. (2004) examined 533 relatives
of 78 probands with ACR criteria FMS and 272 relatives of 40 probands with
rheumatoid arthritis. They found that FMS aggregated strongly in families
(much more so than rheumatoid arthritis), suggesting a possible genetic con-
tribution to the etiology. They used a dolorimeter and found that tender
point and myalgic scores were strongly associated with FMS in families, indi-
cating a possible inherited factor in pain sensitivity. The results for familial
aggregation were almost entirely attributed to the effect of female relatives.
Hudson, Arnold, Keck, Auchenbah, and Pope (2004) further found that
fibromyalgia coaggregated with other forms of affective spectrum disorder in
families. Several recent genetic studies suggest the possibility of an increased
prevalence of specific genotypes of neurotransmitters and their receptors in
FMS (R. M. Bennett, 2005). There is evidence that polymorphisms of genes
in the serotoninergic and catecholaminergic systems are linked to the patho-
physiology of FMS and related conditions and are associated with personal-
ity traits. Although the mechanisms of genetic factors in FMS remain un-
known, it is likely that several genes are operating together to initiate FMS
(Buskila & Neuman, 2005). The burgeoning of genotype research will un-
doubtedly shed more light on this topic.

Pain Hypersensitivity and Central Sensitivity

Pain research in FMS has demonstrated abnormalities in neurotrans-

mitter and neuroendocrine function, and FMS appears to fit the model of
sensitization in central pain mechanisms with peripheral modulation (Eriksen
& Ursin, 2004; Goldenberg, 1999; Yunus, 1992). A number of studies have
assessed pain sensitivity in FMS through experimental paradigms. The meth-
ods generally used to measure altered pain sensitivity involve pain stimuli
delivered to various body sites administered in ascending or random series of
intensities. Thresholds for reporting pain as well as hypervigilance,
responsivity, and aversion for pain sensations have been measured.
Maquet, Croisier, Demoulin, and Creilaard (2004) measured pressure
pain sensitivity in FMS by blunt pressure applied to tender point areas. They
studied 50 healthy men, 50 healthy women, and 20 women with FMS. Force
was applied by a dolorimeter and was increased gradually until the partici-
pant asked the researcher to stop. They found that the pressure pain thresh-
old was lower in women than men and even lower in women with FMS in all
examined areas.
Because the ascending paradigm used by Maquet et al. (2004) presented
stimuli in a predictable pattern, it is possible that participants were biased
toward increased sensitivity because of expectation of pain; conversely, bias
could decrease reported sensitivity because the predictable ascending pat-
tern could reduce anxiety and instill a greater sense of control than a random
stimulus. Petzke, Clauw, Ambrose, Khine, and Gracely (2003) addressed this

FIBROMYALGIA 95
question by varying stimulus type, using both pressure, heat, and mode of
presentation, comparing ascending with random presentation in 43 FMS
patients (4 men and 39 women) and 28 healthy controls (2 men and 26
women). Manual tender point counts and dolorimetry can also induce bias,
because FMS patients might expect to be tender at the tender points. There-
fore, Petzke et al. used a remote hydraulic stimulation device to apply pres-
sure to the thumbnails to eliminate direct examiner-subject interaction. In-
creases in heat pain sensitivity paralleled those in pressure sensitivity,
indicating that central as well as peripheral pain mechanisms are involved.
Contrary to expectations, both groups of participants rated pain intensity as
higher in the random compared with the ascending paradigms. The results
suggest that expectancy, response bias, and hypervigilance may not play an
important role in pain sensitivity in FMS, because random paradigms are not
as influenced by distress or bias. Ascending methods, such as dolorimeter
and tender point count, correlate more with psychological state. The num-
ber of positive tender points is even more influenced by distress than dolo-
rimetry, where the subject exerts some control by stating when his or her
pain threshold has been reached (Wolfe et al., 1997a).
Peters, Vlaeyen, and van Drunen (2000) similarly found no evidence
for hypervigilance in FMS patients compared with healthy controls. Thirty
women with FMS did not show a faster reaction time for detecting a weak
electrocutaneous stimulus in four body locations when compared with 30
healthy women. Women with FMS did not evidence hypervigilance under
single task or dual task conditions where two tasks competed for attention.
The lack of response bias or hypervigilance is contrary to what has been
reported in IBS. Naliboff et al. (1997) delivered rectal distension stimuli to
IBS patients and controls using an ascending series and a random threshold
tracking task and found that discomfort levels were lower for patients in the
ascending series, but there was no difference between groups on the random
task. Chang et al. (2003) used the same method to examine female patients
with IBS alone (N = 10) and those with IBS and comorbid FMS (N = 10) to
somatic pressure stimuli applied to the skin. Although IBS patients had simi-
lar pain thresholds during the ascending series as healthy controls, they were
found to have higher pain thresholds and lower pain frequency and severity
during random stimulus series than IBS and FMS patients and controls. Chang
et al. concluded that people with IBS and FMS had somatic hyperalgesia
with lower pain thresholds and higher pain frequency and severity than those
with IBS alone.
Geisser et al. (2003) examined the perception of contact thermal heat
at both noxious and innocuous intensities in 20 women with FMS and 20
healthy women. Women with FMS displayed significantly lower pressure pain
thresholds at tender point locations as well as at five control sites. Compared
with the controls, women with FMS had significantly lower heat pain thresh-
olds and tolerances when stimulated on the volar surface of the left forearm.

96 MEDICALLY UNEXPLAINED ILLNESS

Women with FMS gave consistently higher pain intensity and unpleasant-
ness ratings at both noxious and innocuous temperatures. These findings sup-
port the idea that people with FMS display perceptual abnormality to varied
stimuli, although other investigators have not found differences in response
to electrical or laser stimuli (Peters et al., 2000). Geisser et al.'s results do not
support a generalized hypervigilance hypothesis, because self-reported pain
scores were not related to pain threshold and tolerance. Geisser et al. also
reported that greater pain catastrophizing was associated with decreased pain
thresholds and tolerances in the entire sample, although surprisingly, self-
report of depressive symptoms was associated with increased thresholds and
tolerances. These findings indicate that people with FMS display altered per-
ception of both pressure and thermal stimulation even at innocuous levels,
and catastrophic cognitions appear to increase pain perception.
Contrary to Geisser et al. (2003), Petzke, Harris, Williams, Clauw, and
Gracely (2005) found lower unpleasantness ratings induced by experimental
pressure pain in patients with FMS relative to healthy controls. Ratings were
obtained from both ascending and random methods of stimulus presenta-
tion. Although the patients with FMS reported greater pain intensity, they
reported relative lower unpleasantness compared with healthy controls when
stimuli were presented in random fashion. This indicates that FMS patients
are less bothered by pain in experimental settings. Perhaps because they are
more familiar with pain, their clinical pain becomes a reference point to
which they have adapted, and evoked pain is thus less aversive, or they are
more adept at modulating pain unpleasantness.
Staud, Robinson, Vierck, and Price (2003) investigated the role of the
diffuse noxious inhibitory control system (DNIC) in FMS. The DNIC is part
of the central pain modulatory system regulated by the spinal cord and its
inputs. Previous studies had reported deficiencies in experimental tests of
the DNIC. Lautenbacher and Rollman (1997) reported that FMS patients
were unable to induce DNIC in response to painful tonic heat stimulation,
whereas healthy individuals could inhibit the painful stimulus. Pain modula-
tion, produced by a concurrent tonic stimulus in healthy persons, was not
seen in the FMS group. The patients either had deficient pain modulation or
were unable to tolerate a tonic stimulus intense enough to engage a modula-
tory process. Staud et al. compared the differences between 11 healthy men,
22 healthy women, and 11 women with FMS (to determine whether DNIC
was a factor in pain sensitization). They found that it was female gender
rather than FMS that was crucial, as both groups of women had less effective
central inhibitory mechanisms compared with the men. Individuals with FMS
may have deficient pain modulation in the DNIC or may be unable to toler-
ate a tonic stimulus intense enough to engage a modulatory process.
The experimental paradigms described above seem to indicate that
people with FMS have lower thresholds for a variety of pain stimuli, which
may be operating through central mechanisms such as the DNIC.

F/BROMYALG/A 97
Pain and Emotion

Catastrophizing may augment pain perception through enhanced at-

tention to painful stimuli and heightened emotional responses to pain. Gracely
et al. (2004) hypothesized that catastrophizing would be positively associ-
ated with activation in pain-processing brain structures. They examined the
association between catastrophizing and brain responses to blunt pressure
through functional magnetic resonance imaging among 29 individuals with
FMS (19 women and 10 men). The results suggest that pain catastrophizing,
independent of the influence of depression, was significantly associated with
increased activity in brain areas active in anticipation of pain (medial fron-
tal cortex, cerebellum), attention to pain (dorsal anterior cingulate, dorso-
lateral prefrontal cortex), emotional aspects of pain (claustrum, closely con-
nected to amygdala), and motor control. Results show that catastrophizing
influences pain perception through altering attention and anticipation and
heightening emotional responses to pain.
It has been hypothesized that widespread pain may affect not only pain
threshold but self-monitoring mechanisms as well, particularly in disturbances
of central nervous system origin. Karst et al. (2005) investigated whether
there was a spectrum of dysfunction in self-monitoring ranging from that
seen in 10 patients with acute schizophrenia (4 men, 6 women) to 10 pa-
tients with somatoform pain disorder (2 men, 8 women), and 10 patients
with FMS (1 man, 9 women) compared with 10 healthy individuals (2 men,
8 women). Karst et al. assessed self-monitoring with a tactile stimulus device
that used a plastic pointer to deliver pressure to the paltn. Participants either
delivered pressure themselves with the opposite hand or pressure was deliv-
ered by the experimenter. Controls experienced self-produced stimuli as less
intense than identical stimuli produced by the experimenter, whereas the
patients with pain disorder, schizophrenia, and FMS gave the same percep-
tual ratings for both types of stimuli. Karst et al. argued that these results
indicate that central pain disorders involve a self-monitoring problem in dis-
tinguishing self-produced from externally produced sensations, and distur-
bances in central tactile processing are not limited to somatosensory process-
ing in the painful areas.

Neuroendocrine System

The findings of greater pain sensitivity in FMS reflect a lower central

pain processing threshold. This is likely mediated by imbalances in neurotrans-
mitter and neuropeptides. A wide range of neuroendocrine abnormalities
have been documented in FMS (Dessein, Shipton, Stanwix, & Joffe, 2000).
Biochemical findings support the hypothesis that there are central changes
in pain processing in FMS. Studies have found that FMS patients have higher
concentrations of Substance P, a pro-nociceptive peptide, and lower levels

98 MEDICALLY UNEXPLAINED ILLNESS

of norepinephrine, which mediates pain inhibitory pathways (Clauw &
Crofford, 2003). The concentration of Substance P, a peripheral pain neu-
rotransmitter, is several times higher in the cerebrospinal fluid of FMS pa-
tients than in pain-free controls, implying a peripheral origin for FMS pain
(Russell et al, 1994). Other areas of hypofunction in growth hormone, thy-
roid, glutamates, and reduced sympathetic nervous system responses have all
been reported in FMS (Dessein et al., 2000; Garrison & Breeding, 2003) and
point to a central mechanism. Dehydroepiandrosterone sulphate (DHEAS)
is a more sensitive marker of HPA axis functioning than glutamate secre-
tion. Low DHEAS levels have been reported in FMS and CFS (Dessein et
al., 2000). In women, DHEAS concentrations decrease with age, and the
prevalence of FMS increases.
Serotonin deficiencies have been found in FMS with low serum levels
of serotonin and its dietary precursor tryptophan (Russell, 1996). Serotonin
is important in deep sleep and in central and peripheral pain mechanisms
(Chase, Shoulson, & Carter, 1976). Estrogen and progesterone ratios regu-
late serotonin and norepinephrine levels, and menstrual cycle variations in
serotonin levels may modulate tender point sensitivity. Whether serotonin
abnormalities are etiologically important in FMS or secondary to the illness
process is not yet known.

Gender

Nine out of 10 FMS patients are women (Yunus, 2001). Gran (2003)
summarized the prevalence of chronic widespread pain and FMS in general
population studies and described FMS as a variant of chronic widespread
pain. Both Yunus (2001) and Gran concluded that the most obvious risk
factor for chronic widespread pain and FMS is female gender and noted
that the factors responsible for the skewed sex distribution remain to be
delineated.
Yunus, Inanici, Aldag, and Mangold (2000) studied 536 patients (469
women, 67 men) who had been newly diagnosed with FMS in an outpatient
rheumatology clinic. Yunus et al. found that the men experienced signifi-
cantly less fatigue, IBS, morning fatigue, generalized pain, and fewer tender
points than the women. The authors cited the number of tender points as the
most powerful discriminator between men and women with FMS. Wolfe et
al. (1995) conducted a population based survey of 3,006 randomly selected
persons in Wichita, Kansas, and identified 193 persons with chronic wide-
spread pain. These people were given a clinical examination, and 36 of them
were found to meet the ACR criteria for FMS. Tender point counts, dolo-
rimetry scores, and clinical and psychological variables were measured. Do-
lorimetry scores were lower in women than men, and women were almost 10
times more likely to have 11 tender points than men. Women were also
more likely to have generalized pain, sleep disturbance, fatigue, and IBS than

FIBROMYALGIA 99
men. Yunus (2001, 2002) summarized the concordant findings of these two
studies; women had greater or more frequent fatigue, morning fatigue, gener-
alized pain, anxiety, IBS, and number of tender points. Features that were
similar between men and women were pain intensity, functional disability,
and global severity.
Buskila, Neuman, Alhoashle, and Abu-Shakra (2000) examined 40 men
with FMS matched by age and educational level with 40 women. All partici-
pants were asked about the presence and severity of FMS symptoms; a count
of 18 tender points was conducted by thumb palpation, and tenderness thresh-
olds were measured by dolorimetry. Men with FMS reported more severe
symptoms than women, decreased physical function, and lower quality of
life. Women had lower tender point thresholds than men; however, their
mean tender point counts were similar. Buskila et al. concluded that although
FMS is uncommon in men, its manifestations in their study population were
worse than in women.
In an examination of 40 men compared with 160 women with FMS,
Yunus, Celiker, and Aldag (2004) evaluated anxiety, stress, and depression
using validated psychological instruments. Both men and women scored much
higher than normative values on the psychological variables measured, with
no significant differences between them. This was similar to findings of Buskila
et al. (2000), who also found no differences between men and women with
FMS on measures of anxiety and depression.
Clauw and Crofford (2003) believed that the tender point requirement
is what has caused FMS to become an almost exclusively female disorder.
Tender points are also tightly associated with high levels of distress, because
as pressure is applied, distressed individuals "bail out" so as not to experience
even slight pain. Clauw and Crofford argued that dropping the tender point
requirement in the criteria would result in a disorder with more equal gender
distribution and lower levels of distress. However, one also could argue that
dropping the tender point requirement would make FMS akin to CFS, which
is also much more common in women.
Hormones are always candidate factors for explaining sex differences in
the prevalence of MUI. Associations between hormonal levels and pain re-
ports are inconsistent in healthy women. Hapidou and Rollman (1998) tested
90 healthy students in the four different phases of the menstrual cycle. They
found that normally cycling women had more tender points during the folli-
cular phase compared with the luteal phase, whereas those who used oral
contraceptives showed no cyclical differences. For all participants, pain thresh-
olds measured by pressure dolorimetry remained stable throughout menstrual
cycles. Self-reports of pain and mood on a visual analog scale revealed no
phase differences. These findings suggest that tender point counts are more
sensitive to global pain than dolorimetry. Johns and Littlejohn (1999) also
found that dolorimetry thresholds were not affected by menstrual phases in
healthy women.

100 MEDICALLY UNEXPLAINED ILLNESS

 Macfarlane, Blinkhorn, Worthington, Davies, and Macfarlane (2002)
performed a population postal survey of 1,178 women living in the north-
west of England. The questionnaires contained the symptoms of the ACR
criteria for FMS, menstrual history, premenstrual symptoms, oral contracep-
tive use, and hormone replacement therapy. Macfarlane et al. found that
pain was not related to any of the hormonal or menopausal factors examined
in premenopausal, perimenopausal, or postmenopausal women. They specu-
lated that more fruitful explanations for gender differences in FMS preva-
lence may be that women have a lower threshold for reporting pain symp-
toms, which in turn may be due to differences in pain processing, coping, and
psychosocial factors.
Despite these findings, several other studies appear to indicate that some
individuals with FMS do report greater pain and other symptoms in the pre-
menopausal and perimenstrual phases of the cycle. Anderberg, Marteinsdottir,
Hallman, and Backstrom (1998) examined pain, stress, anxiety, and other
symptoms through prospective daily ratings in healthy women compared with
women with FMS and women with FMS and premenstrual dysphoric disor-
der. Anderberg et al. found that the healthy controls had increased fatigue,
headache, and anxiety during the luteal and premenstrual phases compared
with the ovulatory and follicular phases. In women with FMS and with both
FMS and premenstrual dysphoric disorder, there was a significantly more
pronounced difference in fatigue, depression, anxiety, stress, and pain symp-
toms during luteal and perimenstrual phases compared with the ovulatory
and follicular phases. In another study, Anderberg, Marteinsdottir, Hallman,
Ekselius, and Backstrom (1999) compared premenopausal and postmenopausal
women with FMS and postmenopausal healthy controls. There were no dif-
ferences between the patient groups on pain measures, threshold, or physical
symptoms, but the postmenopausal FMS patients reported greater psycho-
logical distress than healthy controls. Anderberg et al. (1998, 1999) have
also reported changes in the levels of neuropeptide Y and nociceptin in FMS
patients compared with healthy controls. These neuropeptides that regulate
pain and stress were found to vary across the menstrual phase in FMS pa-
tients (Anderberg, Lui, Berglund, &Nyberg, 1998,1999). Anderberg (2000)
concluded that women with FMS have greater sensitivity in brain areas that
regulate pain, affect, and stress and that these are to some extent influenced
by female sex hormones.
Alonso, Loevinger, Muller, and Coe (2004) examined the influence of
the menstrual cycle on pain and emotion in FMS (n = 57) compared with
rheumatoid arthritis patients (n = 20) and healthy women (n = 48). The
participants assessed menstrual status and pain symptoms through daily logs
for the week before their appointment and tender point and dolorimeter evalu-
ation once during the luteal and once during the follicular phase. The women
with FMS experienced more pain, more menstrual symptoms, and more nega-
tive affect than comparison women. All women reported less positive affect

FIBROMYALGIA 101
during the luteal phase, although this was more marked in the women with
FMS and rheumatoid arthritis. Collectively, these findings indicate that fe-
male hormones influence pain and psychological symptoms in FMS patients,
whereas a similar but more subtle effect can be found in healthy women.
Ostensen, Rugelsjoen, and Wigers (1997) performed a retrospective
analysis based on personal interviews on the influence of pregnancy, abor-
tion, menstruation, use of oral contraceptives, and breastfeeding on FMS
symptomatology. Twenty-six women with an established diagnosis of FMS
and a total of 40 pregnancies were included in the study. With the exception
of 1 patient, all women described worsening FMS symptoms during preg-
nancy, particularly the last trimester. A change of FMS symptoms within 6
months after delivery was reported for 37 of the 40 pregnancies; 4 improved
and 33 worsened, resulting in a prolonged sick leave for 14 patients. An
increase in depression and anxiety was a prominent problem in the postpar-
turn period. FMS had no adverse effect on the outcome of pregnancy or the
health of the infant. In the majority of patients, hormonal changes connected
with abortion, use of hormonal contraceptives, and breast-feeding did not
modulate symptom severity. A premenstrual worsening of symptoms was re-
corded by 72% of the patients. Pregnancy and the postpartum period ap-
peared to exert a negative effect on FMS symptoms by increased functional
impairment and disability.
Women with FMS often have pelvic symptoms, including pelvic pain,
dysmenorrhea, and painful sexual intercourse. A study of Turkish women
investigated sexual function in FMS and evaluated whether concurrent ma-
jor depression has an additional negative effect on sexual function. One hun-
dred women were enrolled in the study, including 40 with FMS only, 27 with
FMS plus depression, and 33 healthy volunteers as a control group. This
study demonstrated that women with FMS had sexual dysfunction compared
with healthy controls but that coexistent depression had no additional nega-
tive effect on sexual function (Tikiz et al., 2005). In a telephone survey of
442 women with FMS compared with 205 women without FMS, women
with FMS were significantly more likely to have had reproductive system or
sleep disorder diagnoses, including PMS, dysmenorrhea, breast cysts, bladder
cystitis, sleep apnea, restless leg syndrome, and abnormal leg movements
during sleep. Women with FMS were less than half as active as control women,
had sleep pattern difficulties, more negative changes in sexual function, and
lower alcohol use than controls (Shaver, Wilbur, Robinson, Wang, & Buntin,
2006). Although nearly two thirds of the women in their survey had been
diagnosed with depression, Shaver et al. (2006) found that the physical im-
pacts of FMS were more severe than mental health impacts according to the
SF-12 (derived from the SF-36). They recommended that sexual function
should be assessed in FMS. The interference with sexual function and moti-
vation in FMS is likely due to a complex combination of dysphoria and the
low threshold for touch pressure to become painful.

102 MEDICALLY UNEXPLAINED ILLNESS

 It is not obvious why women are more susceptible to FMS than men.
The gender and pain issues discussed in chapters 4 and 5 of this volume are
certainly contributors. Factors such as reduced pain thresholds, greater sensi-
tivity to pain (which may be mediated by sex hormones), gender role sanc-
tions allowing expression of pain, psychosocial vulnerabilities in stress, and
trauma experiences may all play a role. FMS seems to involve alterations in
pain processing mediated by central processes that can be influenced by a
range of psychosocial factors.

Stress

FMS is widely viewed as a stress-related disorder, and disturbances of

the HPA axis and sympathetic nervous system axes may explain some of the
symptoms. The neuroendocrine abnormalities found in FMS are strongly in-
fluenced by the body's biological stress system. A number of studies have
found that the HPA axis and sympathetic nervous system processes are dis-
rupted in FMS and that these stress axes interact with pain processing at
many levels. Basal hypocortisolism, overactivity of corticotropin-releasing
hormone (CRH), and an altered response to stressful challenge are the pri-
mary findings (Parker, Wessely, & Cleare, 2001).
Several studies have found increased levels of adrenocorticotropic hor-
mone (ACTH) in response to CRH injections in FMS, which resembles that
seen in depression (Neeck, 2002). CRH is the principal regulator of ACTH
release and coordinator of the stress response. CRH can suppress gonadal
function by inhibiting luteinizing hormone-releasing hormone from the
hypothalamus.
Torpy et al. (2000) examined whether CRH hypoactivity was patho-
genic in FMS. The researchers administered interleukin-6, a strong stimula-
tor of the HPA axis via activation of hypothalamic CRH, to female FMS
patients and their age-matched controls. They found that ACTH release was
delayed in FMS patients, which is consistent with a defect in hypothalamic
CRH neuronal function. Basal norepinephrine levels were higher as well in
FMS patients, which suggests abnormal regulation of the sympathetic nervous
system that may be caused by a chronically deficient level of hypothalamic
CRH. The results found by Torpy et al. demonstrate the mediating effects of
CRH on the stress system at the hypothalamic and brain stem levels and may
contribute to the primary symptoms of FMS. These alterations of the stress
system, along with central sensitization, may be factors in the amplification of
pain perception (Kashikar-Zuch, Graham, Huenefeld, & Powers, 2000). This
hypoactivity is associated with underactivity of the stress system. Clauw (1994)
surmised that FMS patients have an impaired ability to respond to stressors,
consistent with an exhaustion of the autonomic nervous system.
As has been shown in CFS (see chap. 11, this volume), findings of
hypocortisolism are not consistent. In a naturalistic study, Cately, Kaell,

FIBROMrALGIA 103
Kirschbaum, and Stone (2000) asked 21 FMS patients, 18 rheumatoid ar-
thritis patients, and 22 healthy controls to complete a diary (assessing psy-
chosocial- and lifestyle-related variables) or provide a saliva sample (for cor-
tisol assessment) during normal daily activities when they received a signal
with a preprogrammed wristwatch alarm. Participants were signaled to pro-
vide six diary reports and six saliva samples over 2 days. Reports of sleep
quality and sleep duration were also made on awakening. FMS and rheuma-
toid arthritis patients had higher average cortisol levels than controls; how-
ever, there were no differences between the groups in diurnal cycles of corti-
sol or reactivity to psychological stress. The patient groups actually reported
less stress than the controls. Furthermore, statistically accounting for psy-
chosocial- and lifestyle-related differences between the groups did not change
the cortisol findings. The elevations in cortisol in this study were also not
related to ongoing daily stress. Because some studies have reported lower
cortisol in FMS, whereas this study reported elevated cortisol, one can only
conclude that there is evidence of HPA axis disturbance in FMS but that it is
not very specific.
Gur, Cevik, Sarac, Colpan, and Em (2004) attempted to determine
whether depression, fatigue, and sleep disturbance affected follicle-stimulating
hormone, luteinizing hormone, estradiol, progesterone, prolactin, and corti-
sol concentrations. Thus, this is the only study that has examined the hypo-
thalamic-pituitary-gonadal and the HPA axes in the same patient. Sixty-
three women with FMS were compared with 38 matched healthy controls,
all of whom were less than 35 years old. Depression was assessed by the Beck
Depression Inventory (BDI), and patients with high and low BDI scores were
compared. Additionally, patients were divided according to sleep disturbance
and fatigue and were compared both with healthy controls and within the
group. No significant differences in follicle-stimulating hormone, luteinizing
hormone, estradiol, prolactin, and progesterone levels were found between
patients with FMS and controls, but cortisol levels were significantly lower
in patients than in controls. In particular, cortisol levels in patients with
high BDI scores, fatigue, and sleep disturbance were significantly lower than
in controls. Correlation between cortisol levels and the number of tender
points in all patients was significant. Despite low cortisol concentrations in
young women with FMS, there was no abnormality in HPA axis hormones.
Because fatigue, depression rate, sleep disturbance, and mean age of patients
affect cortisol levels, these variables should be taken into account in future
investigations.
Chronic widespread pain seems to result in either low or high cortisol;
the alteration in HPA regulation is the critical determinant rather than a
consistent directional pattern. McBeth, Morris, Benjamin, Silman, and
Macfarlane (2001) hypothesized that psychological distress and somatiza-
tion (rather than the pain) might explain HPA dysregulation in FMS. McBeth
et al. performed a population study of pain and psychological status in indi-

104 MEDICALLY UNEXPLAINED ILLNESS

viduals aged 25 to 65 years. Random samples were selected from the follow-
ing three groups: 131 persons satisfying criteria for chronic widespread pain;
267 free of chronic widespread pain but with strong evidence of somatization
("at risk"); and 56 controls. HPA axis function was assessed by measuring
early morning and evening salivary cortisol levels and serum cortisol after
physical (pain pressure threshold exam) and chemical (overnight dexam-
ethasone suppression test) stressors. Those in the chronic widespread pain
and at risk groups were, respectively, 3.1 and 1.8 times more likely to have a
saliva cortisol score in the lowest third. Yet, no psychosocial factors mea-
sured were associated with saliva cortisol levels. Furthermore, those in the
chronic widespread pain and at risk groups were also more likely to have the
highest serum cortisol scores. High poststress serum cortisol was related to
high levels of psychological distress. The researchers concluded that this was
the first population study to demonstrate that those with and those at risk of
chronic widespread pain demonstrate abnormalities of HPA axis function,
which is not fully explained by psychological stress.
Van Houdenhove and Egle (2004) proposed that FMS can be under-
stood as a stress disorder in many patients. A genetic predisposition causes
hyperresponsiveness to stress, which interacts with adverse developmental
experiences, leading to further sensitization of the stress system. Negative
affect and poor coping may follow. Accumulating stress caused by role strain,
exhaustion, and conflicts can precipitate the condition. They suggest that
illness onset may be prodded by a shift from chronic hyperfunction of the
stress response to hypofunction, giving rise to chronic disturbance in stress
regulation, pain processing, and immune functioning. This would also help
to explain why most studies of FMS have found hypocortisolism, yet several
have reported hypercortisolism; patients may be at different points on the
illness continuum.

Sleep Disturbance

Generalized sleep disturbance is an extremely prevalent feature of FMS.

Patients with FMS often report insomnia or light sleep as well as an increase
in FMS symptoms after disturbed sleep (Campbell et al., 1983). This is ex-
pressed in the common symptoms of awakening unrefreshed with intense
muscle stiffness, aching, and fatigue. Molodofsky and colleagues have hy-
pothesized that FMS may be due to nonrestorative deep sleep (Moldofsky,
1993; Moldofsky, Scarisbrick, England, & Smythe, 1975). They found that
FMS-like symptoms can be induced in healthy volunteers by depriving them
of deep sleep; this was not the case, however, with individuals who exercised
regularly (Moldofsky, Scarisbrick, England, & Smythe, 1975). Abnormal
amounts of alpha activity on the electroencephalogram (EEG) of FMS pa-
tients during deep sleep have been reported (Moldofsky, 1975), but these
early EEG findings have not been consistently replicated (Rizzi et al., 2004).

FIBROMYALGIA 105
Shaver et al. (1997) found no differences in sleep quality, depth, continuity,
efficiency, non-rapid eye movement arousal, or slow wave sleep variables.
Yet, women with FMS spent more time in Stage 1 sleep and had a higher
number of stage changes. These findings indicate that sleep is lighter and less
consolidated in the first half of the night for FMS women. On the stress
arousal measure, they found no differences in cardiodynamic stress indica-
tors, catecholamine, or cortisol urine concentrations. A more recent study
from this group compared 37 midlife women with FMS and 30 sedentary
women without pain on sleep-spindle (a burst of brain activity visible on an
EEC) incidence (number of spindles per minute of non-rapid eye movement
sleep) and spindle wave time, spindle frequency activity, and pain measures
(Landis, Lentz, Tsuji, Buchwald, & Shaver, 2004). The FMS group had fewer
sleep spindles and reduced spindle frequency compared with the control group.
The researchers contended that thalamocortical mechanisms of spindle gen-
eration might be impaired in FMS.
Rizzi et al. (2004) investigated the notion that the sleep fragmentation
observed in FMS could be due to cyclic alternating pattern. They had 45
patients with FMS and 38 healthy controls undergo polysomnography and
found the cyclic alternating pattern rate to be 29% higher in the FMS group
relative to controls. As other studies have found, the Rizzi et al. study con-
cluded that the microstructure of sleep is what is affected in FMS and that it
is associated with pain. The pain of FMS reduces sleep efficiency and causes
more light sleep, more cyclic alternating pattern, more arousals, and breath-
ing irregularities. Collectively, these studies indicate that nonrestorative sleep
in FMS is not due to marked abnormalities in sleep architecture but rather a
variety of alterations in the microstructure of sleep, most likely secondary to
the experience of pain.

Immunological Changes

The dysfunction in pain, mood, and sleep processes could be associated

with changes in immune system indicators in FMS. Landis et al. (2004) com-
pared pain, psychological variables, subjective and objective sleep quality,
lymphocyte phenotypes and activation markers, and natural killer activity in
midlife women (aged 37 to 53 years) with and without FMS. The women had
pain pressure tender points assessed, completed a psychiatric interview and
questionnaires (BDI, Symptom Checklist, Profile of Mood States, subjective
sleep), and underwent polysomnographic assessment for 2 consecutive nights.
Compared with controls, women with FMS had lower pain thresholds, more
psychological distress, higher depression scores, and reduced subjective and
objective sleep quality. Although they had fewer natural killer cells alto-
gether, they had more natural killer cells that expressed the interleukin-2
receptor; these differences were not statistically significant. Landis et al. found
little evidence to support the hypothesis that pain, mood, and sleep symp-

106 MEDICALLY UNEXPLAINED ILLNESS

toms are associated with changes in lymphocyte function in FMS. Zurowski
and Shapiro (2004) commented that it is possible both that FMS and sleep
problems could cause increased stress or that increased stress could contrib-
ute to FMS and sleep problems. The only thing they could conclude with
certainty is that these symptoms co-occur.

Psychosocial Issues

A contributing factor to FMS is stress; it may be early life stress such as

childhood sexual abuse or current stress such as workplace stress. The onset of
FMS often follows severe physical or psychological stress, although Cleare (2004)
cautioned that stress as a precipitating factor should not be overemphasized.

Childhood Trauma
Goldberg and Goldstein (2000) found that a chronic pain group (in-
cluding people with FMS) was more likely to have a history of physical, sexual,
and verbal abuse than a control group of hospital employees. Although child
abuse is reported to be as high as 25% in the general American population,
the statistics for chronic pain patients are generally twice as high as in the
general population. The risk factors for abuse include age, gender, and early
family environment. Finestone et al. (2000) found that women who had ex-
perienced childhood abuse reported a greater number of painful body areas,
visited health care providers more often, and had more surgeries and hospi-
talizations than nonabused controls.
Compared with other pain disorders, FMS is associated with a higher
prevalence of sexual abuse and childhood illnesses. Goldberg, Pachas, and
Keith (1999) examined the relationship between traumatic events in child-
hood in 91 patients with chronic facial pain, myofascial pain, and fibromyalgia
who had been consecutively recruited from the outpatient clinics of a reha-
bilitation hospital and a general hospital. FMS patients reported the highest
rates of abuse (65%). All patient groups had been exposed to a high degree of
family violence and alcoholism.
Walker, Keegan, Gardner, Sullivan, Bernstein, and Katon (1997) stud-
ied 36 patients with FMS and 33 with rheumatoid arthritis. The participants
with FMS had significantly higher rates of victimization, both in childhood
and adulthood. Sexual abuse did not have specific effects, whereas experi-
ences of physical assault in adulthood showed a strong and specific relation-
ship with unexplained pain. Trauma severity was correlated significantly with
measures of physical disability, psychiatric distress, illness adjustment, per-
sonality, and quality of sleep in patients with fibromyalgia but not in those
with rheumatoid arthritis.
However, several studies have not found significantly higher rates of
sexual abuse in FMS patients compared with healthy controls (Alexander et
al., 1998; M. L. Taylor, Trotter, & Csuka, 1995). Ciccone, Elliot, Chandler,

FIBROMYALGIA 107
Nayak, and Raphael (2005) attempted to resolve the inconsistent findings
on the role of childhood abuse by conducting a community-based study of
trauma in FMS. They recruited samples of women from a large community
with FMS and major depressive disorder (MDD; n = 36) and FMS without
MOD (n = 16) and compared them with controls with MDD only (n = 32) or
controls with no physical or psychiatric symptoms (n = 21). Women in the
FMS group were 3.1 times more likely to report having been raped. FMS and
control participants did not differ on the aggregate measure of abuse events.
Ciccone et al. did not find exacerbated FMS symptoms in the abused versus
nonabused women with FMS, although those in the abused group were more
likely to have MDD and have posttraumatic stress disorder (PTSD) symp'
toms. The risk of FMS in the rape victims was mediated by PTSD; therefore,
it is possible that rape and posttraumatic stress are implicated in the etiology
of FMS. Ciccone et al. concluded that future studies need to determine
whether the effects of specific abuse events (such as rape), which are more
violent and life threatening and may be pivotal, are being lost in aggregate
measures.
Workplace stress may also contribute to an increased risk of FMS.
Kivimaki et al. (2004) conducted a prospective study of 4,791 hospital em-
ployees to determine rates of newly diagnosed FMS from 1998 to 2000. The
mean age of this sample was 43.3 years, 88% were women, and respondents
with FMS at baseline were excluded. High workload, limited decision-mak-
ing opportunity, and especially being bullied at work were associated with a
twofold to fourfold risk of new FMS. These stress exposures did not predict
osteoarthritis or sciatica.

Psychiatric Disorders
FMS, headaches, IBS, and CFS share phenotypic and genotypic fea-
tures with mood disturbances (Goldenberg, 1999; Hudson et al., 2003). A
majority of patients with FMS have significant psychiatric illness. Depres-
sion is the most common psychiatric disorder associated with FMS (Hawley
& Wolfe, 1993; Hudson, Goldenberg, Pope, Keck, & Schlesinger, 1992;
Hudson, Hudson, Pliner, Goldenberg, & Pope, 1985; Okifuji, Turk, &
Sherman, 2000); explanations for the linkage between the two include the
following: (a) FMS is a symptom of depression, (b) FMS causes a reactive
depression, and (c) the two conditions share a common pathophysiology
(Goodnick & Sandoval, 1993). Psychologic distress is an intrinsic dimen-
sion of FMS with a likely bidirectional pathway.
Several studies have concluded that anxiety and depression are more
likely to be reactions to the pain and disability imposed by FMS rather than
the cause (Dunne & Dunne, 1995; Goldenberg, 1989). Yunus, Ahles, Aldag,
and Masi (1991) found that the central features of FMS (e.g., number of pain
sites, number offender points, fatigue, and poor sleep) were independent of

108 MEDICALLY UNEXPLAINED ILLNESS

psychological status. Meyer-Lindenberg and Gallhofer (1998) suggested that
a subgroup of FMS has somatized depression.
A number of psychiatric studies have compared FMS with rheumatoid
arthritis patients as well as healthy controls. The rheumatoid arthritis group
is meant to control for living with chronic pain in an organically explained
condition. Several studies have found no differences between FMS and rheu-
matoid arthritis in terms of psychopathology, although both were higher than
in controls (Ahles, Khan, Yunus, Speigel, & Masi, 1991; Ahles, Yunus, &
Masi, 1987; Kirmayer, Robbins, & Kapusta, 1988). Conversely, Hudson et
al. (1992) found higher rates of major depression in FMS compared with
rheumatoid arthritis patients and healthy controls. Walker, Keegan, Gardner,
Sullivan, Katon, and Bernstein (1997) found that 90% of the patients with
FMS had a prior psychiatric diagnosis compared with fewer than half of the
patients with rheumatoid arthritis.
Studies comparing FMS with a variety of rheumatic diseases have found
that depression is higher in FMS. In an analysis of 6,153 consecutive patients
of a rheumatic disease outpatient clinic, the rheumatoid arthritis group did
not differ from all other clinic patients on depressive symptoms and depres-
sion scores. Patients with FMS had significantly more abnormal scores (Hawley
& Wolfe, 1993).
Okifuji, Turk, and Sherman (2000) investigated the factors that differ-
entiate FMS patients with and without depressive disorders. A sample of 69
patients with FMS (96% were women) underwent a standardized tender point
examination and a semistructured psychological interview and completed a
set of self-report inventories; 39 met criteria for depressive disorder, and 30
did not. Those with depression were significantly more likely to live alone,
report elevated functional limitations, and display maladaptive thoughts,
whereas the nondepressed patients were significantly more likely to have
received prior physical therapy than depressed patients. Pain severity, num-
bers of positive tender points, and pain intensity of tender points and control
points did not differentiate the groups. These results indicate that concur-
rent depression appears to be independent of pain in FMS and, instead, to be
related to the cognitive appraisals of the effects of symptoms on daily life and
functional activities.
In most of the studies cited above, patients were recruited from rheu-
matology clinics, but Wolfe and colleagues investigated FMS symptoms in
the general population surrounding Wichita, Kansas. In the first report from
this survey, they found that depressive symptomatology had a stronger corre-
lation with tender point count than with pain threshold (Wolfe et al., 1995).
In the second report from this group, FMS was strongly associated with so-
matization, anxiety, past or current depression, and family history of depres-
sion (Wolfe, Ross, Anderson, Russell, & Herbert, 1995). The researchers
concluded that the level of distress seen in FMS in the general population

FIBROMYALGIA 109
was similar to that of patients seen in specialty clinics. These studies confirm
psychologic distress as an intrinsic dimension of FMS.
Although depression is the most common disorder observed in FMS,
anxiety may be the most disabling. For instance, S. A. Epstein et al. (1999)
sought to determine whether psychiatric comorbidity and psychological
variables were predictive of functional impairment in FMS using patients
from four tertiary-care centers. Seventy-three individuals were adminis-
tered the Structured Clinical Interview for DSM-III-R, the Rand 36-item
Health Survey (SF-36), and multiple self-report measures. The patients
with FMS were found to have a high lifetime and current prevalence of
major depression and panic disorder. The most common disorders were major
depression, dysthymia, panic disorder, and simple phobia. Self-report scales
revealed significant elevations in depression, anxiety, neuroticism, and
hypochondriasis and severe functional impairment on the SF-36. Multiple-
regression analysis found that current anxiety was the only variable that
predicted a significant proportion of the variance (29%) in SF-36 physical
functioning.
Individuals with FMS and PTSD also have impaired functioning.
Sherman, Turk, and Okifuji (2000) examined the prevalence of PTSD in a
sample of 93 consecutive FMS patients at an interdisciplinary pain center.
They found that 56% of the sample presented with PTSD symptoms. Those
with PTSD symptoms reported higher levels of pain, disability, and distress
than those without such symptoms. Several explanations are possible: Both
FMS and PTSD may be a consequence of poor coping, or alternately, the
burden of coping with PTSD increases the danger of a pain condition be-
coming chronic (Sherman et at, 2000). Although there is likely to be over-
lap between PTSD and affective distress, PTSD does present with a number
of distinct symptoms specific to the traumatic stress response, such as intru-
sive thoughts, intense fear, racing heart, and agoraphobia.
Brosschot and Aarsse (2001) showed that compared with healthy
women, women with FMS showed restrictive emotional processing tenden-
cies and a preponderance of somatic attributions for symptoms at the ex-
pense of psychological attributions. Hazlett and Haynes (1992) assessed the
correlation between daily stressors, cognitive rumination, and symptoms in
12 FMS patients. Although they found no relationship between previous-
day stressors and symptoms, cognitive rumination was associated with symp-
toms for one third of the patients. Gaston-Johansson, Gustafsson, Felldin,
and Sanne (1990) compared 31 individuals with FMS with 30 individuals
with rheumatoid arthritis on feelings, behaviors, and attitudes toward their
illness. Those with FMS reported more sickness, discussed and experienced
pain more often, and received more practical help from others than those
with rheumatoid arthritis. They were less satisfied by attention they received,
less sure of themselves, and felt that they were mistrusted or viewed as malin-
gering. Those with FMS were significantly less optimistic than rheumatoid

110 MEDICALLY UNEXPLAINED ILLNESS

arthritis patients regarding relief from pain, improved functioning, and em-
ployment prospects.
In a Swedish study, Hellstrom, Bullington, Karlsson, Lindqvist, and
Mattsson (1999) conducted qualitative interviews with 19 women and 1 man
recruited from local FMS group meetings. Interviews were 30 to 50 minutes
long and took place in patients' homes; the interviews started with the open-
ended question, "Please tell me a little bit about what it is like to live with
fibromyalgia." The dominant themes that emerged were a desire to have their
illness validated by physicians and significant others, a feeling that they had
been dramatically felled by an incapacitating yet invisible disease, and an
attempt to find biomedical explanations. FMS emerged as the sole problem
for these individuals; they felt that all would be well in their lives if not for
FMS. The researchers speculated that FMS may be a strategy to avoid de-
mands that patients have placed on themselves. This echoes the perfection-
ism issues documented in CFS—that is, the individual cannot tolerate re-
duced performance. Patients "choose" illness in order to come to terms with
difficult life situations. Hadler (2003) also posited that people choose to be-
come patients because they have exhausted their ability to cope with pain
and stress in the context of various psychosocial factors.
Overall, in most studies, persons with FMS exhibited marked functional
impairment, high levels of some lifetime and current psychiatric disorders,
and significant current psychological distress. Although it appears in many
cases to be reactive depression caused by living with chronic pain, the preva-
lence of psychiatric disorders remains high in subgroups of FMS.

Coping
Psychologically maladaptive responses to stress seem to characterize
FMS. Davis, Zautra, and Reich (2001) examined 50 women with FMS and a
chronic pain control group of 51 women with osteoarthritis and compared
the groups on vulnerability to negative social stress. They found that the
FMS group had fewer positive affective resources and used ineffective, avoidant
coping strategies to a greater degree than the osteoarthritis group. Those
with FMS also had a smaller social network and poorer quality social ties
than their osteoarthritis counterparts. Both pain groups had comparable lev-
els of pain and personality dispositions. The women with FMS appeared to
be more vulnerable to stress and to have made a poorer adaptation to stress.
Studies cited in the pain sensitivity section in this chapter provide evidence
that catastrophizing is a particularly poor coping response; it has been consis-
tently associated with heightened pain sensitivity. This could lead to a bidi-
rectional exacerbation of pain experience.
People with FMS recognize that they are coping poorly. Burckhardt
and Bjelle (1996) reported that only 13% of patients with FMS believed they
were coping successfully compared with 30% of those with rheumatoid ar-
thritis who thought so. In several studies Turk and others have used the West-

FIBROMYALGIA 111
Haven Yale Multidimensional Pain Inventory (WHYMPI) and identified
three subgroups of FMS patients. One group, labeled dysfunctional, had the
highest level of pain, emotional distress, and disability. The second group,
the interpersonally distressed, had significantly lower levels of pain, disability,
and marital satisfaction and more negative responses from significant others.
Adaptive copers made up the third group; they were characterized by lower
pain intensity and distress and less interference with daily activities (Turk,
Okifuji, Sinclair, & Starz, 1996; Walen, Cronan, Serber, Groessl, & Oliver,
2002). Researchers have also found that type of FMS onset affected coping.
Patients with a posttraumatic onset of FMS (following an accident, surgery,
or illness) reported significantly higher pain intensity, disability, interfer-
ence, and distress and lower activity levels than the 53% of patients who
could not identify a specific cause for their FMS (Turk, Okifuji, Starz, &
Sinclair, 1996).
Thieme, Turk, and Flor (2004) examined the relationship of somatic
and psychosocial variables to depression and anxiety in FMS. They also split
them into dysfunctional, interpersonally distressed, and adaptive copers ac-
cording to the WHYMPI. Overall, 75% of the participants had an Axis I
disorder, whereas only 8.7% had an Axis II disorder. The dysfunctional sub-
group was more likely to have anxiety disorders, PTSD-like symptoms, more
sexual and physical abuse, and low levels of depression. They reported more
physical symptoms, higher pain intensity and interference, and the most so-
licitous behaviors by significant others compared with the other two groups.
The interpersonally distressed group was most likely to have mood disorders.
Thieme et al. also reported fewer physical symptoms, lower pain intensity,
higher activity, and more negative behaviors from significant others. The
adaptive copers group had little psychiatric comorbidiry. Thieme et al. con-
cluded that psychiatric disorders were not directly associated with FMS, but
factors such as past trauma, coping, and spousal behaviors seem to mediate
the association between FMS symptoms and psychiatric disorder.
Zautra, Fasman, et al. (2005) asked whether in the overemphasis on
negative states, investigators have failed to perceive that FMS may entail an
inability to mobilize positive affect. They compared 87 FMS patients with 39
osteoarthritis patients from the community. The participants responded to
baseline questionnaires on demographic and personality factors and were
interviewed weekly for up to 12 weeks regarding pain, affect, fatigue, and
stress. The authors found no substantial differences between the groups on
neuroticism, depression, anxiety, or negative affect. However, those with FMS
did report lower levels of positive affect, joviality, and self-assurance. When
reporting more stress, the FMS group could not retain their positive affect as
well as the osteoarthritis group did. In an expansion of this study, Zautra,
Johnson, and Davis (2005) found that people with greater average positive
affect were less likely to show high negative affect during high pain and in-
terpersonal stress weeks. These data are consistent with Zautra and colleagues'

112 MEDICALLY UNEXPLAINED ILLNESS

dynamic model of affect (Davis, Zautra, & Smith, 2004), which postulates
that under conditions of pain and stress there is a strong inverse relationship
between positive and negative affect. Evidence is gradually accumulating that
indicates that rather than an excess of negative traits such as neuroticism,
FMS may involve difficulty in reducing negative affect and mounting a resil-
ient positive affect response. Future research may do well to reduce
psychology's traditional emphasis on distress and examine positive features
of psychological functioning and resilience resources.

CONCLUSION

FMS provides an exemplar of the biopsychosocial model of illness. A

broad, integrative approach that encompasses central sensitization mecha-
nisms affecting pain perception that is associated with cognitive and person-
ality vulnerabilities affords the best approach to understanding FMS (Masi,
White, & Pilcher, 2002; Meeus & Nijs, 2007; Shaver et al., 2006). Biologi-
cal factors such as genetics, central sensitization, lowered pain threshold, sex
hormones, and neuroendocrine dysfunction interact with sleep difficulties,
stress sensitivity, and psychosocial factors. Psychosocial vulnerabilities found
in FMS include trauma history, negative affect, and lack of coping resources.
Many of these factors may make women more vulnerable to FMS than men.
Negative affect combined with alterations of pain mechanisms may lead to
long-term neuroplastic changes that exceed the pain-coping capabilities of
people with FMS, resulting in a cycle of increasing pain sensitivity and re-
duced functioning (Price & Staud, 2005). Meeus and Nijs (2007) have sug-
gested that behavioral and cognitive treatments could affect descending path-
ways in the spinal cord and reverse these pain pathways.

F/BROMYALG/A 113
 7
CHRONIC FATIGUE SYNDROME

Chronic fatigue syndrome (CFS) affects people of all ages, racial and
ethnic backgrounds, and economic situations, although the typical patient is
a woman in her 30s or 40s. CFS is characterized primarily by unexplained
chronic fatigue as well as rheumatological, infectious, and neuropsychiatric
symptoms. Fatigue represents the chief complaint in 4% to 9% of all visits to
primary practice physicians (Manu, Lane, & Matthews, 1992). Fatigue is a
common symptom in community-based studies (Cope, 1992; Jason, Jordan,
et al., 1999; Lindal, Stefansson, & Bergmann, 2002; Pawlikowska et al., 1994)
and among primary care and hospital based studies of fatigue prevalence
(Cathebras, Robbins, Kirmayer, & Hayton, 1992; Cope, 1992; Fuhrer &
Wessely, 1995; Kroenke, Wood, Mangelsdorff, Meier, & Powell, 1988).
Prins, van der Meer, and Bleijenberg (2006) summarized the myriad
controversies surrounding discussion of CFS. Researchers, medical profes-
sionals, and patients do not agree on the name, the case criteria, the pur-
ported pathophysiology, the utility of further research into physiological eti-
ology, or the effectiveness of various treatment approaches.

DIAGNOSIS
CFS is characterized primarily by unexplained severe, persistent, dis-
abling fatigue lasting for at least 6 months. The diagnosis also includes a

115
number of rheumatological, infectious, and neuropsychiatric symptoms
(Fukuda et al., 1994). In addition to unexplained fatigue that results in sub-
stantially reduced functioning, an individual must report at least four of the
following minor symptom criteria: sore throat, tender lymph nodes, new head-
aches, myalgias, arthralgias, postexertional fatigue, sleep disturbance, and neu-
ropsychological complaints. It is a diagnosis of exclusion in that the persistent
fatigue cannot be accounted for by another medical or psychiatric condition. It
has been given numerous labels, including Epstein-Ban virus infection, chronic
mononucleosis, myalgic encephalomyelitis, postviral fatigue syndrome, postinfectious
neuromyasthenia, chronic fatigue immune deficiency syndrome, and yuppie flu
(Greenberg, 1990; Holmes et al., 1988; Sharpe et al., 1991); the labels tend
to reflect current explanatory trends more than research findings.
The first case definition for CFS was developed in 1988 by a number of
experts in the field (Holmes et al., 1988), subsequently revised in 1991
(Schluederberg et al., 1992) and again in 1994 (Fukuda et al., 1994; see Table
7.1). The 1988 definition required a history of 6 months of severe fatigue in
a previously healthy person (Holmes et al., 1988) and excluded a CFS diag-
nosis if "chronic psychiatric disease" was present. In 1992, the case definition
was modified such that nonpsychotic depression, anxiety, and somatoform
disorders could be present (Schluederberg et al., 1992). The 1994 definition
was crafted by the joint Centers for Disease Control and Prevention-
National Institutes of Health international working group. Conditions that
can coexist with a diagnosis of CFS are adequately treated hypothyroidism,
Lyme disease, asthma, syphilis, or fibromyalgia (FMS). Goldenberg (1989a)
found that most patients with CFS had a tender point examination similar to
that of patients with FMS. Concurrent diagnosis of anxiety, panic,
somatoform, or nonmelancholic depression is allowed, whereas depression
with psychotic or melancholic features, bipolar disorder, schizophrenia, de-
lusional disorder, dementia, anorexia nervosa, or bulimia nervosa would ex-
clude a person from CFS diagnosis. In general, the Fukuda et al. definition is
broader than earlier criteria; it reduces the number of symptoms required and
includes some concurrent psychiatric diagnoses, resulting in greater hetero-
geneity in study populations.
Although there are Australian (Lloyd, Wakefield, Boughton, &. Dwyer,
1990) and British (Sharpe et al., 1991) case definitions (which use the term
myalgic encephalomyelitis), the Fukuda et al. (1994) definition has become the
standard for clinical practice and research. Jason and others have criticized
the development of CFS case criteria by group consensus rather than through
empirically derived processes (King & Jason, 2005) and the importance of
subtyping on distinguishing characteristics such as severity of postexertional
fatigue or neurocognitive impairment (Jason, Corradi, Torres-Harding, Tay-
lor, & King, 2005; S. K. Johnson et al., 1999). Through the International
CFS Study Group, Reeves et al. (2003) recommended an empirical case defi-
nition using validated instruments to obtain standardized measures of the

116 MEDICALLY UNEXPLAINED ILLNESS

 TABLE 7.1
Centers for Disease Control and Prevention Case Definitions
for Chronic Fatigue Syndrome
1988 case definition 1994 case definition
Symptom criteria (Holmes etal., 1988) (Fukuda et al., 1994)
Major New onset of fatigue that Unexplained persistent or
results in at least a 50% relapsing fatigue that is of
reduction of daily new or definite onset that
activities for 6 months results in a substantial
Exclusion of other medical reduction of previous
conditions that produce levels of functioning
similar symptoms
Minor Fever
Muscle weakness
Sore throat Sore throat
Tender lymph nodes Tender lymph nodes
Headaches of new type Headaches of new type
Myalgia Myalgia
Arthralgia Arthralgia
Postexertional fatigue Postexertional fatigue
Sleep disturbance Sleep disturbance
Neuropsychologic Neuropsychologic
complaints complaints
Physical Low-grade fever
Nonexudative pharyngitis
Palpable lymph nodes
Note. The 1988 definition requires satisfying the major criteria plus eight signs and symptoms to diagnose
chronic fatigue syndrome. The 1994 definition requires major criteria plus four symptoms. Dashes in cells
indicate no applicable data. From Fatigue as a Window to the Brain (p. 138), by J. DeLuca (Ed.), 2005,
Cambridge, MA: MIT Press. Copyright 2005 by MIT Press. Reprinted with permission.

major dimensions of CFS. In a study applying this system, Reeves et al. (2005)
found that the empirical case definition was less affected by day-to-day fluc-
tuation of the illness and allowed more precision in case ascertainment.

PROGNOSIS

A review of prognosis in CFS (Cairns & Hotopf, 2005) extracted 28

studies (14 studies included individuals with operationally defined CFS, 14
included individuals with CFS and chronic fatigue ) and found that for de-
fined CFS the median full recovery rate was 5%, whereas 39.5% had some
improvement during follow-up periods. Recovery was more likely in those
who did not meet full CFS criteria. The strongest predictors of improved
outcome were less severe fatigue at baseline, lack of physical attribution, and
less psychiatric disorder (Cairns & Hotopf, 2005). Despite some level of im-
provement, the majority of persons with CFS remain disabled over time.
Age, comorbid depressive disorders, and somatic attributions are asso-
ciated with outcomes in CFS. Older age has been associated with better (Bom-

CHRONIC FATIGUE SYNDROME 117

hardier & Buchwald, 1995; Hartz et al., 1999) and worse (Kroenke et al.,
1988; Russo et al., 1998; Schmaling, Fiedelak, Katon, Bader, & Buchwald,
2003; Tiersky et al., 2001) outcomes. Depressive disorders have been linked
to poorer outcomes in some (Bombardier & Buchwald, 1995; M. R. Clark et
al., 1995; Schmaling et al., 2003) but not all (Ciccone, Busichio, Vickroy, &
Natelson, 2003; Tiersky et al., 2001) studies. Somatic attributions have been
associated with poorer outcomes in longitudinal studies (Hartz et al., 1999;
Sharpe et al., 1992; Schmaling, Fiedelak, et al., 2003; Tatllefer, Kirmayer,
Robbins, & Lasry, 2002; Wilson et al., 1994), and patients who improved
over an approximate 3-year period were more likely to endorse both physical
and psychological causes than patients whose fatigue persisted, but these dif-
ferences did not achieve statistical significance (R. R. Taylor, Jason, & Cu-
rie, 2002). One U.K. population based incidence study of chronic fatigue
found that baseline fatigue score predicted subsequent chronic fatigue, and
when controlled for baseline fatigue, subsequent fatigue levels were not pre-
dicted by psychological morbidity and somatic attribution (Lawrie, Manders,
Geddes, & Pelosi, 1997). Van der Werf, de Vree, Alberts, van der Meer, and
Bleijenberg (2002) found that people with a relatively short duration of CFS
had a more favorable outcome, whereas those with duration longer than 15
months rarely recovered. More social support and a stronger psychosocial
explanation for symptoms also predicted better outcomes. The majority of
studies have found that depressive disorders and somatic attributions were
associated with poorer outcomes in CFS.

PREVALENCE

Bierl et al. (2004) conducted a random-digit-dialing survey to estimate

the prevalence of fatiguing illnesses in diverse areas of the United States.
This investigation estimated that nearly 2.2 million American adults suffer
from CFS-like illness. Although women had much higher prevalence of
chronic fatigue and CFS-like illness than men, the differences between male
and female incidence rates were not significant. The prevalence of chronic
fatigue was significantly higher in Whites than non-Whites, in the 40- to 69-
year-old age group than in the 18- to 29-year-old age group, and in individu-
als with lower incomes and education.
Only a small minority of patients presenting to their physicians with
problematic fatigue receive a diagnosis of CFS. The prevalence of CFS has
been estimated to be from 0.24 to 0.4% (Jason et al., 1999; Steele et al.,
1998) in community based studies, but these studies had a low participation
rate in the clinical examination phase. In a large population based study of
members of the Swedish Twin Registry, the preceding 6 months' prevalence
rate of CFS was 2.4% (Evengard, Jacks, Pedersen, & Sullivan, 2005). This is
closer to the 2.6% prevalence of patients in primary care (Wessely, Chalder,

] ]8 MEDICALLY UNEXPLAINED ILLNESS

Hirsch, Wallace, & Wright, 1997). CFS is a heterogeneous condition, fluc-
tuating in terms of symptoms and severity. Although the level of disability
varies widely (Carrico, Jason, Torres-Harding, & Witter, 2004; Cox &. Findley,
2000), people with CFS have a markedly higher degree of impairment com-
pared with other chronically ill people (Anderson & Ferrans, 1997). In the
United States, approximately 400,000 to 900,000 people have CFS (Reeves
et al, 2005), and the illness is estimated to cost about $9 billion per year in
lost productivity (Reynolds, Vernon, Bouchery, & Reeves, 2004).

NEUROPSYCHOLOG1CAL PERFORMANCE

Cognitive complaints are one of the most frequent and debilitating symp-
toms of CFS (Christodoulou et al., 1998; Komaroff, 1994; Komaroff &
Buchwald, 1991). A number of studies have documented objective, albeit
modest, neuropsychological impairments in CFS (Tiersky, Johnson, Lange,
Natelson, & DeLuca, 1997). The most consistently documented impairments
are in the areas of complex information processing speed and efficiency, work-
ing memory, and initial learning (Caseras et al., 2006; DeLuca et al., 2004;
Michiels & Cluydts, 2001); higher order cognitive abilities are usually in-
tact. Neuropsychological impairments are more likely in CFS persons who
do not have a comorbid psychiatric condition or history of a psychiatric con-
dition (DeLuca, Johnson, Ellis, & Natelson, 1997). Objective cognitive im-
pairments appear to be related to functional decline (Christodoulou et al.,
1998), employment status (Tiersky et al., 2001), and brain involvement
(Lange et al., 1999, 2005; Schmaling et al., 2003).
Emotional factors (Wearden & Appleby, 1996) and self-reported fa-
tigue (Cope et al., 1995; S. K. Johnson, Lange, DeLuca, Korn, & Natelson,
1997; Vercoulen et al., 1998) are related to an increase in subjective report
of cognitive difficulty, with little evidence for a relationship between com-
plaints and objective neuropsychological findings (Tiersky et al., 1997; Short,
McCabe, & Tooley, 2002). Neither objective impairments nor subjective
complaints can be explained by depression or fatigue levels.

ETIOLOGY

A biopsychosocial model is clearly required to explain the etiology of

CFS (for reviews, see S. K. Johnson et al., 1999; Sharpe, 1996); CFS clearly is
a multidimensional illness experience that cannot be conceptualized as a
single diagnostic entity (Afari 6k Buchwald, 2003; Wessely, 1996). Although
some researchers have expressed doubts regarding any biologic basis, there
do appear to be neurophysiolological disturbances in a subset of persons with
CFS.

CHRONIC FATIGUE SYNDROME I19

Pathophysiology

Several recent studies have attempted to explore the molecular basis of

CFS through gene expression analysis. Although these studies are very pre-
liminary, several different laboratories indicate that gene expression profiles
show some promise in distinguishing a genetic component of CFS, and ge-
netic analysis may help elucidate pathogenesis of CFS (Fang et al, 2006;
Fostel, Boneva, & Lloyd, 2006; Goertzel, Pennachin, de Souza Coehlo,
Gurbaxani, et al., 2006).
Many of the symptoms of CFS such as myalgias, sore throat, swollen lymph
nodes, and fatigue resemble symptoms seen in viral infections. Immune system
abnormalities have been a productive area of research. In reviewing this work,
Natelson and Lange (2002) concluded that although the CFS can occur after
severe infection, no convincing evidence exists to support an immunologic
process in disease maintenance. They proposed several possible etiologic pro-
cesses: an encephalopathy, an impaired physiological capability to respond to
stress, psychological fears about effort exacerbating symptoms, or environmen-
tal agents eliciting chronic fatigue states. Glaser et al. (2005) have argued that
proinflammatory cytokines may play a role, but heterogeneity produces so much
variability that it has been difficult to tell a consistent story. Glaser et al. pro-
posed that a nonstructural Epstein-Barr virus-encoded protein can cause im-
mune dysfunction and symptoms of CFS and may be an etiological agent.
The immune, endocrine, and nervous systems interact, and psychologi-
cal stress may dysregulate immune responses by affecting these interactions.
Hypothalamic-pituitary-adrenal (HPA) axis abnormalities have been widely
studied in CFS, and some studies show a mild hypocortisolism of central
origin suggesting an altered physiological response to stress. Deficits in corti-
sol have been linked to lethargy and fatigue in many conditions.
In summarizing studies of basal HPA axis function in CFS, A. J. Cleare
(2003) noted that in about half of CFS studies, evidence has been found for
lowered cortisol levels. In the pioneering study by Demitrack et al. (1991),
low levels of basal cortisol were found in individuals with CFS, possibly be-
cause of a deficit in corticotropin-releasing hormone (CRH). Altemus et al.
(2001) measured the adrenocorticotropin (ACTH) and cortisol response to
infusion of vasopressin in patients with CFS and matched healthy volun-
teers. Persons with CFS had a reduced ACTH response and a more rapid
cortisol response to a vasopressin infusion. They interpreted this as evidence
of reduced hypothalamic CRH secretion in patients with CFS.
A study examining endocrine hyporesponsiveness to a maximal tread-
mill exercise test found that in CFS patients, the stress-responsive hormones
were less than half the level of those in sedentary healthy controls 4 minutes
after exercise (Ottenweller, LaManca, Sisto, Guo, & Natelson, 1997).
Racciatti et al. (2001) found an altered cyclicity of HPA axis hormones (par-
ticularly ACTH and prolactin) in a circadian rhythm study.

120 MEDICALLY UNEXPLAINED ILLNESS

 Glucocorticoids can have an inhibitory effect on serotonin function,
and CRH release is modulated by serotonin. Reduced glucocortocoid secre-
tion would therefore result in higher serotonin levels. A number of studies
(Bakheit, Behan, Dinan, Gray, & O'Keane, 1992; A. J. Cleare et al, 1995;
Vassallo et al., 2001) have provided evidence that serotonin neurotransmis-
sion is increased in CFS patients compared with both healthy and depressed
individuals.
Several studies have found evidence for subtle abnormalities in HPA
function. A. J. Cleare et al. (2001) examined ACTH and cortisol responses
to challenge agents in patients with CFS without comorbid psychiatric dis-
order compared with healthy controls. They found a similar ACTH response
to all challenges, suggesting that central control of the HPA axis is intact in
CFS, although they did find impaired adrenal response. Gaab, Huster, Peisen,
Engret, Heitz, et al. (2002) have suggested that CFS patients are capable of
mounting a sufficient cortisol response to a psychosocial stressor, a standard-
ized exercise test, and an insulin tolerance test. Yet, these authors also found
moderate HPA axis dysfunction with enhanced sensitivity of the adrenals to
ACTH, indicative of secondary or tertiary origin. In a follow-up study, Gaab,
Huster, Peisen, Engret, Schad, et al. (2002) found more suppression of sali-
vary free cortisol in CFS patients compared with healthy controls after ad-
ministration of dexamethasone. This pattern is the opposite of that generally
found in depression; depressed patients generally do not suppress cortisol in
response to dexamethosone. Rather, this exaggerated suppression of cortisol
in response to dexamethasone is similar to what has been reported in post-
traumatic stress disorder, chronic pelvic pain, and burnout syndrome (Gaab,
Huster, Peisen, Engret, Schad, et al., 2002).
Crofford et al. (2004) studied underreactivity of the HPA axis in CFS
patients by assaying blood samples across a 24-hour hormonal cycle. For all
patient and control groups, there was an interaction between hormone levels
and time period for both ACTH and cortisol. In the early morning periods,
there were several hours during which patients with CFS had lower (but not
significantly lower) cortisol levels compared with controls. There were no
significant differences between patient and control groups for mean ACTH
or cortisol over the entire 24-hour period. Jerjes et al. (2006) found that
urinary free cortisol levels were significantly lower in CFS across a 3-day
time period, whereas indices of cortisol metabolism showed no differences
from controls. Future research needs to take into account the circadian cycle
that can be seen with cortisol and ACTH. The neuroendocrine patterns in
CFS resemble those observed in atypical depression. Van Hoof, Cluydts, and
De Meirleir (2003) noted that in persons with CFS attending their clinic,
the most common affective disorder diagnosed was atypical depression.
Overall, persons with CFS show subtle abnormalities in the HPA axis
function, hormonal stress responses, and serotonin neurotransmission, which
are in the opposite direction from the pattern observed in patients with clini-

CHRONIC FATIGUE SYNDROME 121

cal (melancholic) depression. Although dysfunction is mild and is not found
consistently in all studies, a blunted HPA stress response is generally observed.
The recurrent stress responses and prolonged activation of cardiovascu'
lar and neuroendocrine systems have been termed allostatic load. Several studies
have found that CFS was associated with a high level of allostatic load
(Maloney et al., 2006) and that CFS patients with a high allostatic load had
the worst functioning and most severe illness (Goertzel, Pennachin, de Souza
Coelho, Maloney, et al., 2006).

Neuroimaging

Numerous studies have used brain imaging technology to examine

whether there are structural and functional abnormalities in persons with
CFS. Several studies have reported significantly more abnormalities on mag-
netic resonance imaging (MRI) among CFS patients relative to controls
(Buchwald, Cheney, et al., 1992; D. B. Cook, Lange, DeLuca, & Natelson,
2001; Lange et al., 1999; Natelson, Cohen, Brassloff, & Lee, 1993); others,
however (Cope, Fernet, Kendall, & Davis, 1995; R. B. Schwartz, Garada, et
al., 1994), have not found significant differences. Lange et al. (1999) and
Greco, Tannock, Brostoff, and Costa (1997) found brain abnormalities clus-
tered in the nonpsychiatric rather than the psychiatric CFS cases. D. B. Cook,
Lange, DeLuca, and Natelson (2001) reported that CFS participants with
MRI abnormalities reported significantly more impairments in physical func-
tional activity compared with CFS participants without MRI abnormalities.
Overall, structural MRI studies of the brain in persons with CFS have
been inconsistent in demonstrating significant abnormalities. When they do
occur, abnormalities are more likely in the subcortical white matter and in
persons with CFS who do not have concurrent psychopathology. This is con-
sistent with the neuropsychological data (presented above) suggesting greater
neuropsychological impairment in persons with CFS without concurrent psy-
chopathology.
In terms of functional neuroimaging, studies using single photon emis-
sion computed tomography (SPECT) technology have also been inconclu-
sive. Some SPECT studies have reported cerebral abnormalities in CFS pa-
tients compared with healthy controls. (D. C. Costa, Tannock, & Brostoff,
1995; Ichise et al., 1992; Machale et al., 2000; R. B. Schwartz, Garada, et al.,
1994; R. B. Schwartz, Komaroff, et al., 1994). In a co-twin control study of
cerebral perfusion on SPECT of monozygotic twins discordant for CFS, no
significant difference in cerebral blood flow was observed (D. H. Lewis et al.,
2001).
Tirelli et al. (1998) used 18-fluorodeoxyglucose positron emission to-
mography to study cerebral metabolism and found that both the CFS and
depression groups showed significant hypometabolism in the frontal lobes
relative to controls. However, CFS patients showed significant brain stem

122 MEDICALLY UNEXPLAINED ILLNESS

hypometabolism relative to the depression group, a finding consistent with
what has been reported in SPECT but not replicated more recently using
positron emission tomography (Siessmeier et al, 2003). Regions activated
in prior studies (e.g., brain stem [D. C. Costa et al., 1995; Tirelli et al.,
1998]; thalamus [Machale et al., 2000]) were not observed by Siessmeier et
al. (2003). SPECT findings remain inconclusive, with no consistent pat-
tern of abnormality.
A few studies have attempted to relate neuropsychological performance
(or complaints) with cerebral perfusion. Schmaling, Lewis, Fiedelak, Mahurin,
and Buchwald (2003) conducted SPECT scans during rest and while per-
forming a complex and speeded working memory task (the Paced Auditory
Serial Addition Test [PASAT]). CFS patients showed a pattern of more dif-
fuse regional blood flow compared with a more focal pattern in controls. CFS
patients also showed more widespread and diffuse activation in frontal and
temporal lobes and thalamus, indicative of increased recruitment of cerebral
regions needed to perform the challenging cognitive task. These results were
not attributed to group differences in mood, cognitive performance, or effort.
Using blood oxygen level dependent functional MRI (fMRI), Lange et
al. (2005) examined persons with CFS without concurrent psychopathology
while performing the PASAT. A select group of CFS patients with low
PASAT scores displayed more diffuse and bilateral cerebral activation on
fMRI while performing the complex working memory task relative to the
healthy group. These studies (Lange et al., 2005; Schmaling et al., 2003)
suggest that individuals with CFS need additional cerebral resources to per-
form the same amount of mental work.
Several studies have reported cerebral metabolic dysfunction in CFS
using a variety of spectroscopy methods (Chaudhuri & Behan, 2000; Kuratsune
et al., 2002; Puri et al., 2002; Tanaka, Matsushima, Tamai, & Kajumoto,
2002). Overall, evidence of brain pathology in CFS continues to accumu-
late, particularly among persons without comorbid psychiatric disorders. Struc-
tural neuroimaging studies show white matter hyperintensities in persons
with CFS. Functional neuroimaging shows hypometabolism in the frontal
lobes and basal ganglia most consistently in persons with CFS. Collectively,
these findings suggest that central nervous system mechanisms may be in-
volved in the pathophysiology of CFS. However, this work needs to be repli-
cated and extended and developed into a cohesive theory (e.g., DeLuca, 2005).
Many of the studies cited have a small number of participants and have not
been consistently replicated.

Gender and Fatigue

Many studies have examined the role of gender in predicting fatigue.

Studies have found gender differences in fatigue, with women tending to be
more likely to report having both fatigue and chronic fatigue (Chen, 1986;

CHRONIC FATIGUE SYNDROME 123

Jason, Jordan, et al., 1999; Loge, Ekeberg, & Kaasa, 1998; Nelson et al., 1987;
Nisenbaum, Reyes, Mawle, & Reeves, 1998). Lindal et al. (2002) found that
78% of people in a random population study in Iceland who met criteria for
CFS were women. Some researchers have also found that women tend to
report more severe fatigue (Chen, 1986; Jason, Jordan, et al., 1999; Kroenke
et al., 1988; Loge et al., 1998; Nisenbaum et al., 1998; Pawlikowska et al.,
1994). In a general practice study, women were more likely to complain of
fatigue than men, even after adjustment for psychological distress
(Pawlikowska et al., 1994), and the most commonly cited reasons for fatigue
were psychosocial (40% of patients). Women are more than twice as likely
to seek medical help for their fatigue (Cope, 1992). For example, in one
study, two thirds of the people who presented with fatigue in a primary care
practice were women (Nelson et al., 1987). However, some primary care and
hospital studies have not found statistically significant differences in fatigue
according to gender (Cathebras, Robbins, et al., 1992; Kirk, Douglass, Nelson,
Jaffee, & Lopez, 1990).
In a population based study of chronic fatigue, Evengard et al. (2005)
found that when respondents were asked about the symptom of feeling "ab-
normally tired" during the past 6 months, there was no gender difference,
and after excluding possible medical causes, 17% of the population reported
this symptom. As the requirements for a CFS-like illness became more rigor-
ous, however, the gender prevalence became skewed. Using the Fukuda et al.
(1994) definition brought the prevalence down to 2.36% of the population;
more than 80% were women. This is reminiscent of irritable bowel syndrome
(IBS) and FMS in that when more symptoms are included in the diagnostic
criteria, the patient population becomes predominantly female. Using the
same sample from the Swedish Twin Registry, P. F. Sullivan, Evengard, Jacks,
and Pedersen (2005) investigated whether there were differences according
to zygosity in chronic fatigue. They found that from a less refined symptom of
chronic fatigue to the Fukuda et al. definition, there was no difference in
genetic contribution. Using the more restrictive definition did not make the
illness more genetic. The modest genetic influences were similar in both
genders. Despite differences in prevalence, the relative importance of genes
and environment did not differ between genders.
Buchwald, Pearlman, Kith, and Schmaling (1994) examined differences
between 348 male and female CFS patients from a university-based referral
clinic devoted to chronic fatigue. Clinical variables included symptoms, physi-
cal examination findings, and laboratory results. Psychosocial assessment
consisted of a structured psychiatric interview; the Medical Outcomes Study
Short'Form General Health Survey to assess functional status; the General
Health Questionnaire to ascertain psychological distress; the Multidimen-
sional Health Locus of Control; and measures of attribution, social support,
and coping. Overall, few gender-related differences were identified. Women
had a higher frequency of tender or enlarged lymph nodes and FMS and

124 MEDICALLY UNEXPLAINED ILLNESS

lower scores on the physical functioning; men more often had pharyngeal
inflammation and reported a higher lifetime prevalence of alcoholism. In a
subclassification of CFS study, Jason et al. (2003) found that people with
high symptom frequencies were more often female and older and had greater
disability and more children.
Tseng and Natelson (2004) examined differences in symptom presen-
tation and functional and psychiatric status between 43 men and 78 women
with CFS only who were patients at their research center. They found no
differences in severity of CFS or functional status, although women had sig-
nificantly higher endorsement of infectious-type symptoms. There was no
significant difference in the rates of lifetime psychiatric disorders, although
they were somewhat higher in men (64.3% vs. 47.5%). Collectively, these
studies indicate that demographic, clinical, and psychosocial factors do not
clearly differ in male and female CFS patients.
Soderlund and Malterud (2005) performed a qualitative interview study
of causal attributions in 8 women with CFS. Some gendered factors recurred
in the interviews, such as living in a culture where women are overburdened
without sufficient relaxation time, having emotional conflicts, having more
self-inflicted pressure than men, and having weaker immune systems than
men.
Clark (1999) examined gender differences in CFS using qualitative in-
terview methods and found no differences in terms of mode of onset, dura-
tion, symptom variability, least and most commonly reported symptoms, and
level of activity prior to illness. Women were more likely to attribute their
illness to stress, whereas men were more likely to believe the illness resulted
from working with chemicals. The biggest differences emerged in the medi-
cal encounter. Compared with women, men were more likely to report that
their doctors took them seriously and were more likely to be sent to a special-
ist; women reported more negative experiences with doctors and were more
likely to be sent to a psychiatrist.

Abuse

Unlike IBS and FMS, there is little research on the prevalence of abuse
history in CFS. R. R. Taylor and Jason (2001) used a randomly selected com-
munity sample to compare fatigue groups with healthy controls regarding
history of childhood sexual, physical, or death threat abuse. Childhood sexual
abuse was significantly associated with idiopathic chronic fatigue and chronic
fatigue caused by a psychiatric or medical condition, but it was not associated
with CFS. Van Houdenhove et al. (2001) examined emotional, physical,
and sexual victimization throughout the life span in patients with CFS or
FMS compared with rheumatoid arthritis patients, multiple sclerosis patients,
and healthy controls. There were no significant differences in victimization
experiences between the CFS and FMS groups. CFS and FMS patients re-

CHRONIC FATIGUE SYNDROME 125

ported more emotional neglect and emotional and physical abuse than rheu-
matoid arthritis or multiple sclerosis patients or healthy controls. When
separated into childhood only, adult only, and lifelong victimization, sig-
nificantly more CFS and FMS patients belonged to the lifelong victimiza-
tion group (40.0% vs. 7.6% in the rheumatoid arthritis and multiple scle-
rosis group and 11.6% in the controls). There were no significant differences
in sexual abuse and sexual harassment among groups. The CFS and FMS
groups also reported significantly greater emotional impact from emotional
neglect, emotional abuse, physical abuse, and sexual harassment compared
with the rheumatoid arthritis, multiple sclerosis, and healthy control groups.
There was no significant difference in terms of impact of sexual abuse. Van
Houdenhove et al. (2001) suggested that CFS and FMS patients remain
entangled in problematic relationships, without marshalling protective fac-
tors to reduce the emotional impact of these burdens. These studies indi-
cate that sexual abuse is not a specific risk factor for CFS or FMS but rather
that victimization takes the form of neglect, violence, chaos, and unpredict-
able family life.

Psychiatric Disorder

Elevated rates of psychiatric comorbidity or indicators of psychological

disorder have been found among chronic fatigue patients in primary care
settings (Cathebras et al., 1992). Community based studies have also found
that persons suffering from chronic fatigue were more likely to have psychi-
atric symptoms or to be diagnosed with psychiatric disorders (Lawrie et al.,
1997; Pawlikowska et al., 1994).
High levels of somatization in individuals with depression and anxiety
suggest that CFS may be a somatic form of depression. Alternatively, high
rates of depression and anxiety in CFS may result from overlapping symp-
tomatology, reaction to disability imposed by fatigue, or viral or immune
changes affecting the central nervous system. Although CFS patients may
meet diagnostic criteria for depressive disorder or score in the depressed range
on a self-report inventory, they report significantly lower levels of dysphoria
and self-reproach symptoms than clinically depressed patients (S. K. Johnson,
DeLuca, & Natelson, 1996a). Patients with CFS are significantly less likely
than either depressed individuals, multiple sclerosis patients, or healthy con-
trols to interpret symptoms in terms of negative emotional states (Dendy,
Cooper, & Sharpe, 2001). Unlike depressed patients' cognitions, which are
dominated by a negative view of the self, CFS patients are primarily preoccu-
pied with symptoms for which they make physical attributions, which helps
maintain self-esteem (Moss-Morris & Petrie, 2001).
CFS patients generally demonstrate greater impairment than depressed
individuals on various measures of functional disability (Buchwald, Pearlman,
Umali, Schmaling, & Katon, 1996; Natelson et al., 1995). Antidepressants

12 6 MEDICALLY UNEXPLAINED ILLNESS

have not been efficacious in CFS (Dzurec, 2000; Dzurec, Hoover, & Fields,
2002; Vercoulen et al., 1996). Converging evidence suggests that CFS can
be separated from most subtypes of depression, although it resembles atypical
depression in neuroendocrine responses. Physiologically and in symptom pre-
sentation, CFS looks much more like atypical depression than melancholic
depression, but no research to date has addressed these similarities directly
by comparing the two patient groups (S. K. Johnson & DeLuca, 2005).
Prevalence of depression in CFS studies spans a wide range, from a low
of 5% to as high as 80%. S. K. Johnson, Gil-Rivas, and Schmaling (2006)
found that only 5% of patients met criteria for a current depressive disorder.
(This was probably attributable to the coding assumptions applied to the
psychiatric interview in that study.) Specifically, previous studies
(Henningsen, Zimmerman, & Sattel, 2003; Skapinakas, Lewis, & Mavreas,
2003; Skapinakas, Lewis, & Meltzer, 2000; Tiersky et al., 2001) have not
adjusted for the symptom overlap between psychiatric disorders and CFS symp-
toms, potentially overestimating the prevalence of psychiatric disorders among
this population. Clearly, it is hard to estimate consistent levels of depression
or somatization disorder when there are so many overlapping symptoms that
can be attributed to organic or psychiatric causes, depending on coding as-
sumptions made by the researcher or clinician.

Personality Factors

Although early studies of personality in samples of persons with CFS

found histrionic and emotional type traits overrepresented compared with
their base rates in the population, these studies suffered from methodologi-
cal flaws (Blakely et al., 1991; C. Millon et al., 1989; Stricklin, Sewell, &
Austad, 1988). Studies with improved methodology have also found evi-
dence of personality pathology. The most commonly reported personality
disorders have been obsessive—compulsive, histrionic, borderline, and de-
pendent (Henderson & Tannock, 2004; S. K. Johnson, DeLuca, & Natelson,
1996b; Pepper, Krupp, Friedberg, Doscher, & Coyle, 1993). S. K. Johnson
et al. (1996b) found that personality dysfunction in the CFS group was ac-
counted for by comorbid depression, whereas Henderson and Tannock (2004)
did not find an association.
Thus, across studies, obsessive-compulsive and histrionic personality
pathology was most common among persons with CFS, with dependent and
borderline features found less consistently. Two studies have examined the
association between personality disorders and functioning. Ciccone et al.
(2003) found that neither Axis I nor Axis II disorders predicted physical
functioning or physical role functioning. Conversely, in a 5-year follow-up
study of adolescents with CFS, Rangel, Garralda, Levin, and Roberts (2000)
found that adolescents with personality dysfunction were less likely to have
recovered from CFS.

CHRONIC FATIGUE SYNDROME 127

 Subjectively reported symptoms have been shown to be systematically
biased by neuroticism, which is strongly correlated with health complaints
but not actual health status (P. T. Costa & McCrae, 1987). S. K. Johnson et
al. (1996c) also examined the personality trait of neuroticism, which is asso-
ciated with a tendency to experience emotional distress, including anxiety,
anger, sadness, and other emotions with negative valence (P. T. Costa &
McCrae, 1992). In that study, participants with CFS and multiple sclerosis
had neuroticism scores that were significantly higher than those of healthy
controls yet significantly lower than those of depressed participants. This
finding was replicated by Buckley et al. (1999); the sample with CFS scored
in between participants who were depressed and healthy controls on the mea-
sure of neuroticism.
Neuroticism appears to play a role in poorer prognosis in CFS. Higher
neuroticism scores were associated with lower vitality over time (S. K. Johnson
et al., 2006). Taillefer, Kirmayer, Robbins, and Lasry (2003) found that neu-
roticism, somatic attribution, depression, and age contributed to illness worry
in CFS. They hypothesized that illness worry leads to restriction of activity
and physical deconditioning, contributing to the chronicity of fatigue, con-
sistent with S. K. Johnson et al.'s (2006) finding of increased suppression of
competing activities being associated with worse functioning. Likewise, the
cognitive-behavioral model of CFS posits a vicious cycle of suppressing and
avoiding activity that results in deconditioning, further reduction of activ-
ity, and illness perpetuation (Surawy, Hackman, Hawton, & Sharpe, 1995).
A Belgian study found that CFS patients described themselves as sig-
nificantly more "action-prone" premorbidly than comparison groups (Van
Houdenhove, Onghena, Neerinckx, & Hellin, 1995), and a later study found
that this was not due to idealistic appraisal of premorbid traits (Van
Houdenhove et al., 2001). Clinical observations of more than 100 CFS pa-
tients revealed a typical premorbid characterization of perfectionism, high
achievement orientation and work performance standards, high valuation of
the opinions of others, and suppression of emotions (Surawy et al., 1995).
White and Schweitzer (2000) found that CFS patients had higher perfec-
tionism and lower self-esteem scores than did healthy controls, although they
did not differ on a measure of emotional control. The results obtained by
Wood and Wessely (1999) did not support the view of CFS sufferers as per-
fectionists with more negative attitudes toward psychiatry compared with a
rheumatoid arthritis group.
Indications of defensiveness among persons with CFS were reported by
Creswell and Chalder (2002) using the Emotional Stroop Test to determine
whether participants with CFS were different from those with diabetes and a
healthy group in "covert" self-esteem. Individuals with CFS were slower to
name negative words than positive words compared with the other two groups.
The authors maintained that this result reveals higher levels of self-esteem
than expected from the level of depression, anxiety, and self-esteem that was

128 MEDICALLY UNEXPLAINED ILLNESS

overtly reported. In another study the same authors found participants with
CFS frequently used "defensive high anxious" coping styles (Creswell &
Chalder, 2001). The low levels of overt psychopathology suggest defensive-
ness regarding psychological contributions to illness.
In a prospective design, Kato, Sullivan, Evengard, and Pedersen (2006)
investigated the relationship between self-perceived stress, extraversion, and
emotional instability assessed from 1972 to 1973 and chronic fatigue assessed
from 1998 to 2002 in 19,192 twins from the population based Swedish twin
registry. Kato et al.'s analysis showed strong support for premorbid stress and
emotional instability to predict chronic fatigue several decades later. The
role of emotional instability in chronic fatigue was found to be mediated by
genetic and family environment factors, whereas stress had exogenous, di-
rect effects on the later appearance of chronic fatigue.

CONCLUSION

CFS can be conceptualized as a stress disorder along the same lines as

FMS. Stressful life events, infectious illness, autonomic and HPA axis func-
tioning, and cognitive biases interact at the biopsychosocial level and ini-
tiate symptoms of fatigue, myalgias, and sleep difficulties. Research on brain
pathology and genetic abnormalities are ongoing, but a consistent story has
yet to emerge. Women may be more vulnerable to CFS because of pressure
from role expectations, stressful experiences, and neuroendocrine vulnerabili-
ties; further research is needed to explore these possible explanations for the
greater prevalence of the condition in women.

CHRONIC FATIGUE SYNDROME 129

 8
MULTIPLE CHEMICAL SENSITIVITY

Multiple chemical sensitivity (MCS) is a syndrome in which multiple

disabling symptoms are reported in response to low-level chemical exposure.
MCS has been described by a number of labels: environmental illness, chemical
hypersensitivity syndrome, universal reactor syndrome, universal allergy, total al-
lergy syndrome, 20th century disease, chemical AIDS, and ecologic illness (Grav-
eling, Pilkington, George, Butler, & Tannahill, 1999; Kroll-Smith & Floyd,
1997; Mooser, 1987; Simon, Katon, & Sparks, 1990). Some have proposed
calling the condition idiopathic environmental intolerance (IEI) because mul-
tiple chemical sensitivity implies that the cause of these disorders is known,
even though no relation between exposure and symptoms has thus far been
substantiated (Wiesmuller, Ebel, Hornberg, Kwan, & Friel, 2003, p. 420).
However, because multiple chemical sensitivity is the term most widely used in
the scientific literature, I use it in this chapter. In discussions of specific
studies, however, I use the nomenclature used by the study authors.
Of the medically unexplained illnesses (MUls) discussed in this vol-
ume, MCS is the most controversial and the least recognized by the medical
profession. The U.S. government has directed little research attention to-
ward chemical sensitivities or toward adverse effects associated with toxic
chemicals in general. There is considerable scientific skepticism regarding
the existence of MCS as a distinct disorder. For example, the Journal of the

131
American Medical Association and the New England Journal of Medicine pub-
lish articles on chronic fatigue syndrome (CFS), irritable bowel syndrome
(IBS), and fibromyalgia (FMS), but they have not published studies investi-
gating MCS (Zavestoski et al., 2004). Zavestoski et al. (2004) commented
that there is really no better understanding today of the physiological dys-
function and prevalence of MCS than when it was first identified.

DEFINING MULTIPLE CHEMICAL SENSITIVITY

A growing number of individuals have presented with symptoms of

MCS since the 1980s. A range of symptoms are reportedly precipitated and
then exacerbated by exposure to commonly occurring chemical substances
such as petroleum products, synthetics, and food additives. The most com-
mon symptoms of MCS appear to be headache; shortness of breath; dizzi-
ness; weakness; pain in joints, muscles, back, or abdomen; neuropsycho-
logical problems; fatigue; congestion; sore throat; and nausea or vomiting
(Fiedler, 1996; Ziem & McTamney, 1997). No group of core symptoms
that are common to all individuals with MCS has been identified
(Wiesmuller et al., 2003).
The term chemical in MCS is used broadly to refer to a range of natural
and man-made chemical agents, some of which have multiple chemical con-
stituents. The most commonly reported substances that elicit MCS symp-
toms are perfumes and colognes, spray paint, perfumes in cosmetics, cigarette
smoke, gasoline, garage fumes, diesel exhaust, hair spray, restroom deodor-
izer, and air fresheners (Fiedler, 1996). This list is notable for the predomi-
nant presence of everyday substances rather than industrial chemicals or pol-
lutants. The toxic responses of MCS sufferers are occurring at extremely low
(generally considered safe) levels.
Clearly, there is the potential for large costs to be incurred by industry
if a direct connection could be made between manufactured chemicals and
serious illness. The economic and regulatory implications of accepting MCS
as a medical disorder caused by common chemicals and the built environ-
ment are enormous. News media have generally portrayed people with MCS
as histrionic and psychologically disturbed rather than legitimately sick from
chemical products; this view downplays the effects of pollutants and toxins
on health (Lipson, 2004). MCS sufferers and their advocates maintain that
people with MCS may be akin to "canaries in a coal mine"; that is, only the
most sensitive harbingers of a toxic industrial environment that may eventu-
ally affect the health of the general population. More than with other MUIs,
people with MCS request that other people modify their behaviors to ac-
commodate them. People with MCS may require coworkers, friends, and
family to avoid scents, soaps, and cleaners to avoid exacerbating the MCS
symptoms (Kroll-Smith & Floyd, 1997).

13 2 MEDICALLY UNEXPLAINED ILLNESS

 The broad and baffling array of symptoms associated with sensitivity to
chemicals has made many doctors wary of treating MCS patients. Indeed,
many in the medical community see MCS as a faulty set of beliefs rather
than a disease. In MCS, the biomedical model does not allow patients to
assume the sick role and the doctor to assume the expert healer role (Kroll-
Smith & Floyd, 1997). As a consequence, doctor shopping occurs because
patients are not taken seriously by doctors. However, a group of physicians,
formerly called clinical ecoiogists and now called environmental medicine physi-
cians, specialize in MCS. These specialists tend to cast a wide net and at-
tribute many diseases such as cancer, arthritis, and vasculitis to chemical
exposures (Fiedler & Kipen, 1997). The specialty of clinical ecology is not
recognized by conventional medicine.
The first definition of MCS was developed by Cullen (1987), and it
described the following characteristics: Initial symptoms are acquired from
identifiable environmental exposure, symptoms involve more than one or-
gan system, symptoms occur and abate in response to predictable stimuli,
symptoms are elicited by low-level exposures, and symptoms cannot be ex-
plained through standard medical testing. Known organ system dysfunction
and disease are excluded from Cullen's definition. Ashford and Miller (1997)
have postulated that MCS develops through a two-stage process of sensitiza-
tion and triggering. Sensitization occurs as the result of one massive exposure
or following low-level chronic exposures to common toxins, such as in sick
building syndrome. Symptoms are then triggered by a variety of chemicals
and, in some individuals, electromagnetic exposures, foods, light, sound, or
natural substances such as pollen or molds.
Other researchers have noted that no consensus exists regarding case
criteria; some studies include patients with gradual onset of symptoms, rather
than requiring an identifiable initial exposure. The lack of agreement on an
empirically validated symptom profile prevents standardized diagnostic rec-
ommendations (Fiedler, 1996; Lacour, Zunder, Schmidtke, Vaith, & Scheidt,
2005). Lacour et al. (2005) performed a systematic literature review of 1,429
MEDLINE references of MCS-related terms and found 36 articles, which
included symptom profiles, clinical overlap with other conditions, quality of
life indices, and diagnostic procedures. From this review, Lacour et al. con-
cluded that central nervous system complaints, such as headaches, fatigue,
and cognitive deficits, were the most frequently reported symptoms, followed
by musculoskeletal and gastrointestinal complaints. They recommended that
diagnostic procedures exclude any diseases that might account for nonspe-
cific central nervous system symptoms, as is done in CFS. Food or alcohol
intolerance is not an exclusion for MCS (i.e., they may coexist with it).
Lacour et al. also found significant overlap of MCS, CFS, and FMS.
In their review of MCS, Graveling et al. (1999) used a broad definition
of MCS, requiring symptoms in more than one organ system elicited by vari-
ous chemicals at very low levels of exposure. Like Kipen and Fiedler (2002),

MULTIPLE CHEMICAL SENSITIVITY 133

they conceded that MCS raises many questions about the nature of illness.
Some have suggested that MCS is an olfactory preference to be protected
from noxious scent and not a pathological condition. There appears to be no
resolution to this debate, partly because of the paucity of funding and peer-
reviewed research on this topic. Because MCS often occurs with other MUIs,
it is unclear whether MCS is a distinct malady. This question continues to be
debated (Fiedler, Maccia, &Kippen, 1992).

PREVALENCE

Very little research into the prevalence of MCS has been attempted,
largely because there is no consensus definition. Fiedler and Kipen (1997)
summarized the literature on patients who report a symptomatic intolerance
for low-level chemical exposures, express symptoms in multiple organ sys-
tems, and have no other medical illnesses. Fiedler and Kipen found 10 stud-
ies meeting these criteria. Despite some discrepancies in selection criteria,
they found striking consistencies in the demographic profiles. The ratio of
women to men was 8:2. The average age was mid-40s, and the average educa-
tional level was at least 2 years of college.
Kreutzer, Neutra, and Lashuay (1999) conducted a population-based
telephone survey of 4,046 people in California and found that 15.9% re-
ported being allergic or unusually sensitive to everyday chemicals, and an
even more astounding 6.3% were diagnosed with "environmental illness" or
MCS by their physician. Hispanic ethnicity was associated with physician-
diagnosed MCS. Female gender was associated with individual self-reports of
sensitivity. Marital status, employment, education, geographic location, and
income were not predictive of reported chemical sensitivities or diagnosis of
MCS. Kreutzer et al. believed that the homogeneity of responses across
ethnicity, geography, education, and marital status was compatible with a
physiologic response or with widespread societal apprehensions in regard to
chemical exposure.
Caress and Steinemann (2003, 2004b) found that MCS affected 12.6%
of the population, and 3.1% of these had been diagnosed medically in a ran-
domly selected sample from the Atlanta, Georgia, metropolitan area. In
follow-up questioning of the respondents who reported hypersensitivity, the
most commonly reported triggers for the onset of symptoms were pesticides
and solvent exposure. Only 1.4% reported experiencing depression, anxiety,
or other emotional problems before the onset of their symptoms, yet 38%
said they experienced these problems after developing hypersensitivity (Ca-
ress & Steinemann, 2004b).
In another study, Caress and Steinemann (2004a) conducted a tele-
phone survey of 1,054 randomly selected individuals within the continental
United States to determine the prevalence of chemical hypersensitivity and

134 MEDICALLY UNEXPLAINED ILLNESS

the medical diagnosis of MCS in the U.S. population. They found that 11.2%
of Americans reported an unusual hypersensitivity to common chemical prod-
ucts such as perfume, fresh paint, pesticides, and other petrochemical-based
substances, and 2.5% reported that they had been medically diagnosed with
MCS. Additionally, 31.1% of those sampled reported adverse reactions to
perfumed products, and 17.6% experienced breathing difficulties and other
health problems when exposed to air fresheners. Although chemical hyper-
sensitivity was more common in women, it affected individuals in all demo-
graphic groups studied. Although only based on self-reports, it does appear
that an MCS-like condition that impairs quality of life is common in the
general U.S. population.
One might wonder why MCS does not appear more often in groups
that are occupationally exposed to petrochemicals and pesticides. It is pos-
sible that self-selection and reporting biases play a role. Reid et al. (2002)
performed an epidemiological health survey of U.K. military personnel, which
included an assessment of chemical sensitivities. They received responses
from 3,531 veterans of the Gulf War, 2,614 veterans in active service but
not deployed to the Gulf, and 2,050 veterans from Bosnian peacekeeping
operations. Most demographic profiles show MCS as occurring predominantly
in females and do not measure occupational exposures, so the fact that the
sample was 92% male and included occupational exposures such as diesel
fumes and pesticides that have been frequently reported in military cohorts
makes this survey different from previous studies. Sensitivity to at least one
common chemical was reported by 28% of the Gulf War veterans, 14% of
those not deployed to the Gulf, and 13% of the Bosnian conflict group.
These results show, rather surprisingly, that a significant proportion of U.K.
veterans appeared to have sensitivity to various chemicals, although they
were clearly not typical of the MCS demographic profile.
C. S. Miller (1999) described diverse demographic groups with MCS-
like conditions, ranging from radiology workers exposed to X-ray developer
solution, Environmental Protection Agency employees exposed to carpet
building materials, German log home owners exposed to pentachlorophenol
wood preservative, sheep dippers in Great Britain exposed to organophos-
phate pesticides, and Gulf War veterans exposed to a variety of substances
during military service.

PROGNOSIS
Black, Okiishi, and Schlosser (2001) performed a 9-year follow-up on
18 persons with MCS from an original sample of 26. Overall, there was little
change in psychological and functional status, and the individuals remained
strong in their illness conviction and resistant to psychological explanations.
Eighty-five percent of the sample met criteria of the Diagnostic and Statistical
Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Asso-

MULTIPLE CHEMICAL SENSITIVITY 135

elation, 1994) for Lifetime Mood Disorder, 56% for Lifetime Anxiety, and
56% for Lifetime Somatoform Disorder. Other than this report, there are few
data on longitudinal outcomes for people with MCS.

OVERLAP WITH OTHER MEDICALLY UNEXPLAINED ILLNESSES

Several studies have documented the co-occurrence of MCS with CFS

and EMS according to self-reports of symptoms (Buchwald & Garrity, 1994;
Kipen & Fiedler, 2002); about 30% to 50% of individuals with one illness
also met criteria for one of the others. MCS also has substantial overlap with
Gulf War illness (Kipen, Hallman, Kang, Fiedler, & Natelson, 1999). In
their population-based study, Caress and Steinemann (2003, 2004b) found
that 26% of those with MCS also reported gastrointestinal problems, 22%
said they also had FMS, and 19% reported CFS.
One of the important distinctions between MCS and other MUIs is
that MCS purportedly results from a chemical insult. Therefore, toxic expo-
sures in the environment are a more prominent issue, both for theoretical
explanations of this illness and for clinical management. As with other MUIs,
rates of disability and functional impairment are very high in MCS. People
with MCS often significantly alter their behavior in an attempt to avoid
presumed precipitants of symptoms. They often withdraw from activities,
friends, and family in an attempt to eliminate chemical exposures. In a study
of 35 patients with occupationally related MCS evaluated in an occupational
medicine clinic (Lax & Henneberger, 1995), 97% of the patients had stopped
activities outside the home, 91% had limited travel, 89% had limited their
contact with friends, and 77% had left their jobs. Additionally, many pa-
tients changed their home life drastically: 97% had stopped using cleaning
compounds, 69% removed home furnishings, and 63% limited their contact
with family members. In their personal care, 94% stopped using fragrances,
91% changed their diet, and 86% changed the type of clothing they wore. As
with other MUIs, MCS results in significant disruption of everyday life and a
heavy burden of disability.

GENDER

As with the other MUIs explored in this book, gender is a consistent,

robust predictor of MCS. Middle-aged, educated women make up 60% to
80% of samples in clinical studies (Black, 2000; Fiedler & Kipen, 1997).
Bell, Baldwin, and Schwartz (2001) have suggested that "chemical intoler-
ance" may be more sensitizable in some individuals, driven by differences in
genetic and gender-related vulnerability of various target organs and the pre-

136 MEDICALLY UNEXPLAINED ILLNESS

vailing environmental context. We have seen the evidence for increased life
stress and childhood trauma in various MUIs. Bell et al. suggested that these
stressors could provide an initiating stimulus for sensitization that subsequent
stressors such as low-level chemical exposure could later elicit. Allostatic
load from adapting to amplified stress reactivity should lead to chronic health
problems sooner in more sensitizable than in less sensitizable individuals.
Middle age may be the point where allostatic load impairs adaptability. Bell
et al. also suggested that women who have a family history of substance abuse
have inherited an enhanced capacity for sensitization, one that leads to chemi-
cal intolerance and food cravings and intolerances.
Mooser (1987) noted that the most common statistical finding in MCS
is female predominance and speculated that this may be due to innate height-
ened allergic sensitization and food sensitivities in females. There is also evi-
dence that women of reproductive age have enhanced sensitivity to odors;
women's olfactory sensitivity increases faster and to a significantly greater
degree than that of men (Dalton, Doolittle, & Breslin, 2002). This sensitiv-
ity may be hormone mediated; it was not found in girls (ages 8 to 10 years) or
postmenopausal women. Dalton et al. (2002) suggested that this enhanced
sensitivity may account for the greater prevalence of MCS in women, al-
though there may be adaptive benefits conferred on reproductive age women
in increased ability for olfactory-based kin recognition and mother-infant
bonding. Lipson (2004) speculated that MCS is more prevalent in reproduc-
tive age women because their hormonal systems may be more vulnerable to
the large number of endocrine-disrupting chemicals in pesticides and plas-
tics that mimic estrogen. Estrogen load may be one reason that females (both
human and animal) are more susceptible than males to metabolic disorders,
sensitization, and MCS.
Compared with men, women appear to have more health concerns about
the effects of toxins, pollutants, and dangerous chemicals such as pesticides.
Petrie et al. (2005) found that worries about modernity, including concerns
about the health effects of toxins, pollution, tainted food, and radiation, pre-
dicted symptom complaints after a pesticide-spraying program in New Zealand.
In this study, Petrie et al. assessed worries about modernity before the spray-
ing program and found that higher levels of modern health worries and baseline
symptoms were associated with a higher number of symptoms being attrib-
uted to the spray program. Petrie et al. corroborated previous findings that
modern health worries are associated with increased somatic complaints and
medical utilization and that such concerns and complaints are more com-
mon in women (S. K. Johnson & Blanchard, 2006; Kaptein et al., 2005).
Kaptein et al. specifically reported in samples of medical students from New
Zealand and Holland that modern health worries were related to the use of
health care services and that the relationship was mediated by subjective
health complaints.

MULTIPLE CHEMICAL SENSITIVITY 13 7

 ETIOLOGY

A number of theories have been articulated to explain MCS symp-

tomatology. The earliest theory of MCS proposed immune dysfunction; this
theory is most popular among clinical ecologists who posit a chemical
overload-induced immune dysregulation. Clinical ecologists believe that
chemical exposure causes the development of allergy to low levels of many
chemicals, not just the initiating one. Although some abnormalities have
been found in patients with MCS, there are many problems with these tests,
such as wide natural variation in the test results, few reference standards to
determine what is statistically "normal," and lack of reproducibility (Magill
& Surada, 1998). Controlled studies have not supported any consistent pat-
tern of immune dysfunction or deficiency (Graveling et al, 1999; Simon,
Daniell, Stockbridge, Claypoole, & Rosenstock, 1993).
Although much MCS research has focused on an immune system mecha-
nism, most MCS symptoms cannot be immune system mediated because they
occur too quickly on exposure. With the exception of a histamine response
and some IgE-mediated responses such as anaphylactic shock, the immune
system is not generally capable of reacting as quickly as the symptoms ap-
pear. This has led some researchers to look at central nervous system re-
sponses, which would be consistent with the time frame most patients report.
The proposed mechanism is that affected persons develop increasing neuro-
logic sensitivity to the adverse effects of chemicals (Bell, 1994; Bell et al.,
2001).
Bell and her colleagues have published a number of reports supporting a
neurogenic mechanism for MCS wherein connections between the olfactory
nerve, limbic structures (particularly amygdale and hippocampus), and hy-
pothalamus develop sensitization. The neurological phenomenon known as
time-dependent sensitization (TDS), which has been studied primarily in ani-
mals for the last 20 years, has shown some similarity to MCS. TDS is the
progressive amplification of response to intermittent exposure to stimuli.
Animals repeatedly exposed to seizure-inducing chemicals or electrical stimu-
lation have been found to develop lower thresholds for seizure induction
than the thresholds observed before exposure. With other stimuli, animals
have been found to have an amplification of the response to the stimulus
over time, as well as cross-sensitization to unrelated chemicals (Bell, 1994;
Bell, Miller, Schwartz, Peterson, & Amend, 1996; Friedman, 1994). TDS
may explain how the brain becomes sensitized to low-level chemical expo-
sures and the role that stress plays in adverse reactions. Cross-sensitization
can turn chemical sensitivity into a progressive condition. After a person is
sensitized to one chemical, the sensitivity can spread to include other unre-
lated compounds. Then repeat exposures reduce the body's tolerance level
by an as yet unknown mechanism, so the body becomes more easily reactive
to more and more chemicals at lower and lower levels until it finally reaches

] 38 MEDICALLY UNEXPLAINED ILLNESS

the point where the person is sick all the time. Besides animal models, Bell
has studied cacosmic college students (cacosmia is a negative response and
illness from common chemical odors) and found evidence for increased sen-
sitivity in some individuals (Bell et al., 1996).
A related theory involves altered function of respiratory passages, a
neurogenic inflammation (Bascom et al., 1997). Meggs (1995) has proposed
a reactive upper airway dysfunction syndrome, essentially a chronic rhinitis
developing from inhalation exposure to a toxic substance. Meggs (1999) has
also argued that allergy and chemical sensitivity are closely related disorders
in which environmental exposures produce inflammatory reactions. Both the
allergic and chemical irritant responses may be subjected to conditioning so
that the response is triggered by other stimuli and becomes chronic. The
problem with neurogenic theories is that they cannot account very well for
the multisystem nature of MCS symptoms.
The finding that some MCS sufferers have increased urinary
coproporhyrin levels led to speculation that MCS is an acquired form of por-
phyria (Donnay & Ziem, 1995). The porphyrias are a group of rare metabolic,
enzyme deficiency disorders involving the production of heme (a component
of blood) and liver or bone marrow damage; some of the symptoms are simi-
lar to those for MCS. Disorders of porphyrinopathy have also been claimed
for people with CFS, FMS, amalgam problems, and silicone implants. This
theory has been widely disseminated by advocates for MCS patients but has
not held up under scientific scrutiny (Hahn &: Bonkovsky, 1997; McDonagh
& Bissell, 1998).
Claudia Miller (1999) has proposed a mechanism called toxicant in-
duced loss of tolerance to explain MCS. This mechanism involves two steps:

1. Exposure to certain chemicals causes vulnerable individuals

to lose their previous tolerance for common chemicals, food,
or drugs.
2. Previously tolerated exposures trigger symptoms in sensitive
individuals at everyday low levels.

Controlled exposure studies allow an empirical approach to determin-

ing the concentrations of substances that produce symptoms. Fiedler and
colleagues (Fiedler, 2000; Fiedler et al., 2004; Fiedler & Kipen, 2001) main-
tained a controlled environment facility where they tested different chemi-
cally sensitive groups. They found that MCS and individuals sensitive to
methyl tertiary butyl ether (MTBE) do not consistently respond with symp-
toms differently from healthy controls. Individuals with MCS responded dif-
ferently from controls only to suprathreshold levels of a rose-scented chemi-
cal (phenyl ethyl alcohol) but not to a noxious odorant (pyridine).
MTBE-sensitive individuals responded symptomatically to gasoline with 15%
MTBE but not to gasoline alone or gasoline with 11% MTBE. Controlled

MULTIPLE CHEMICAL SENSITIVITY 139

exposure studies also found that chemically sensitive individuals did not de-
tect or identify odors better than healthy controls. However, in a single,
controlled diesel vapor exposure that Fiedler et al. (2004) conducted with
chemically sensitive Gulf War veterans compared with healthy Gulf war
veterans, the chemically sensitive veterans reported significantly increased
symptoms of disorientation, dizziness, reduced end-tidal CO2, respiratory dis-
comfort, and malaise as exposure increased. Fiedler et al. concluded that both
psychologic and physiologic mechanisms contribute to symptomatic responses
in ill Gulf War veterans.
Staudenmayer, Binkley, Leznoff, and Phillips (2000) reviewed toxico-
genic theories of MCS to determine whether such explanations held up, us-
ing Bradford Hill's (1965) nine criteria for causation (strength, consistency,
specificity, temporality, biological gradient, biological plausibility, coherence,
response to intervention, and analogy). Staudenmayer et al. concluded that
toxicogenic theories do not meet any of the nine criteria, rendering such
theories invalid. This skepticism and lack of scientifically validated etiologic
evidence help explain why MCS remains a controversial diagnosis.

Psychological Factors

Because the relationship between chemical exposures and symptoms in

MCS does not fit well into current toxicological paradigms for such relation-
ships, the psychiatric explanation for symptoms has been investigated more
than any other. Lipson (2004) commented on the "psychologization" of MCS
as a women's disease. Except in the cases of a defined toxically exposed co-
hort, close to 80% of those with MCS are women. As in the other MUIs,
patients are often told that their medical tests are normal and that their
illness must be caused by stress or depression. Lipson referred to this bio-
medical viewpoint, which finds that female-predominant illnesses are dis-
proportionately attributed to psychiatric causes, as male oriented.
Fiedler and Kipen (1997) summarized the early psychiatric explana-
tions of MCS, which tended to emphasize an anxiety response; typical or
atypical posttraumatic stress disorder; or modern expressions of anxiety, de-
pression, or somatization. Numerous studies have found elevated rates of de-
pression and anxiety traits in MCS; about one half of the patients in various
studies have met the criteria for depressive and anxiety disorders (Fiedler et
al., 1992; Simon, 1994)
Simon et al. (1990) examined plastics workers at an aerospace manu-
facturing plant who reported symptoms attributed to chemical exposure in
the workplace. Thirty-seven workers filed compensation claims. Subsequently,
Simon et al. measured the development of "environmental illness" with a
four-item survey and found 13 individuals with high scores—in other words,
they could be considered cases—and compared them with 13 noncases. The
13 cases scored higher on all measures of psychiatric symptoms, particularly

140 MEDICALLY UNEXPLAINED ILLNESS

on prior history of anxiety and depressive disorder and of medically unex-
plained symptoms before exposure.
Fiedler, Kipen, DeLuca, Kelly-McNeil, and Natelson (1996) found a
significantly higher rate of psychiatric disorders in individuals who did not
report a date of onset for their chemical sensitivities. This same finding has
been reported in CFS (DeLuca, Johnson, & Natelson, 1997)—that is, indi-
viduals who developed CFS after an acute flu-like illness had lower rates of
psychiatric disorder than those who reported a gradual onset of symptoms.
Caccappolo-van Vliet, Kelly-McNeil, Natelson, Kipen, and Fiedler
(2002) compared 30 individuals with MCS according to Cullen's (1987) cri-
teria with 19 individuals with asthma and 31 healthy controls on psychiatric
disorders and personality traits associated with symptom reporting. Relative
to controls, individuals with MCS and asthma demonstrated a significantly
greater proportion of lifetime anxiety disorders. In terms of current psychiat-
ric disorders, a higher proportion of those with MCS met criteria for depres-
sion and somatization disorder than either individuals with asthma or con-
trols. There were no significant differences on alexithymia, but individuals
with MCS and asthma reported significantly higher anxiety sensitivity than
controls. As in many similar studies, approximately 50% of individuals with
MCS did not meet criteria for any psychiatric disorder.
A Japanese study compared 46 individuals with MCS meeting Cullen's
(1987) criteria with a control group with various opthalmologic diseases using
the State-Trait Anxiety Inventory, the Self-Rating of Depression scale, and
the Hamilton Depression Scale. They found higher levels of current anxiety
and depression among the MCS group than the controls (Tonori et al., 2001).
Bell, Peterson, and Schwartz (1995) conducted a study of women with
cacosmia, some of whom also had MCS and some of whom did not, and
compared them with healthy controls on medical and psychological mea-
sures. The MCS group reported high rates of disability and much more ex-
tensive medical histories than the other two groups; the MCS group also had
increased psychopathology on the Symptom Checklist-90—Revised.
Black (2000) summarized the reported prevalence of psychiatric disor-
der in published studies as ranging between 42% and 100%. Mood, anxiety,
somatoform, and personality disorders are the most commonly diagnosed
conditions. He also made the interesting point that substance use disorders
are rarely linked with MCS, which appears to be true of other MUIs as well.
Black suggested that personality factors or health beliefs of people predis-
posed to MCS might preclude the development of substance abuse.
Anxiety disorders and symptoms appear to be very prevalent psychiat-
ric problems in MCS. Several groups have looked specifically at inducing
panic attacks in individuals with MCS. Poonai et al. (2000) compared re-
sponses in 36 individuals with MCS (according to Simon criteria; Simon et
al., 1990) with those of 37 healthy controls. Although individuals with MCS
had to be free of psychiatric history and medication use, 71% of them met

MULTIPLE CHEMICAL SENSITIVITY 141

criteria for a panic attack after CO2 inhalation compared with 26% of con-
trols. In another study of the same cohort (Poonai et al., 2001), MCS pa-
tients also scored significantly higher than controls on self-report measures
of anxiety and agoraphobia. Tarlo, Poonai, Binkley, Anthony, and Swinson
(2002) observed that not all individuals with MCS experience panic responses
to CO2 challenges. The symptoms of MCS have been called a "toxic agora-
phobia," with panic attacks and avoidance behavior manifested through con-
finement to clean, safe environments and avoiding contact with any situa-
tion that might involve toxins (Black, 2000; Simon, Katon, & Sparks, 1990).
Bailer's group in Germany has investigated the association between
MCS, somatization, and somatoform disorders to explore the possibility that
MCS could be conceptualized as an atypical somatoform disorder. Bailer,
Rist, Witthoft, Paul, and Bayerl (2004) compared individuals with moderate
and high MCS intensity with nonsensitive controls. The high-MCS group
scored significantly higher than the other two groups on depression and
somatoform scales and on diagnosed somatoform disorder; it also reported
significantly more trait anxiety, chemical triggers, avoidance behavior, doc-
tor visits, sensitivity to chemical substances and environmental stimuli, and
dysfunctional beliefs about environmental threat than the other two groups.
In another study, Bailer, Witthoft, Paul, Bayerl, and Rist (2005) examined
four comparison groups using the Structured Clinical Interview for DSM-
IV: IEI only, IEI and somatoform disorder, somatoform disorder only, and a
nonsomatoform control group. Although 57% of the individuals with IEI
met the DSM—IV criteria for at least one somatoform disorder, the medi-
cally unexplained symptoms attributed by the participants to environmen-
tal chemicals were counted by the interviewer as somatoform symptoms.
This explains the high percentage of somatoform diagnoses. The people
who met criteria for both IEI and somatoform disorders had a more severe
type of IEI; they had more symptom complaints and more doctor visits.
The lEI-only group still had multiple unexplained symptoms, but the symp-
toms were less likely to cause significant distress or impairment. All groups
were higher on depression, anxiety, and self-reported allergic diseases than
the control group.
Gupta and Home (2001) assessed 85 patients in a tertiary clinic who
were exposed to chemicals that included pesticides, wood preservatives, vola-
tile organic compounds, metals, and gases. Fifty-seven patients reported mod-
erate to severe symptoms following the exposure, whereas 26 patients did not
suffer from physical symptoms. There were no differences between the groups
on meeting criteria for depression, MCS, or CFS. Furthermore, the research-
ers did not find any differences in beliefs about chemicals. This suggests that
patients who suffer from documented and validated chemical exposures do
not appear to show psychological complications.
Bornschein, Hausteiner, Konrad, Forstl, and Zilker (2006) examined
psychiatric disorders and toxic burden through blood and urine samples in

142 MEDICALLY UNEXPLAINED ILLNESS

309 outpatients with IEI compared with 59 semiconductor workers. Psychi-
atric disorders were significantly higher in individuals with IEI than the con-
trols (75% vs. 24%), particularly in somatoform, mood, and anxiety disor-
ders. Furthermore, the industry workers had higher metal and solvent
concentrations in their blood and urine samples. This is further evidence
that objective measures of chemical exposure are not closely linked to IEI,
whereas psychiatric morbidity is high.

Associative Learning

Schottenfeld (1987) proposed a learning model in which patients be-

lieve that their nonspecific symptoms are the result of disease. These pa-
tients become increasingly anxious about being diseased, experience more
symptoms, and consequently become more anxious and more entrenched in
disease conviction. Some investigators have posited an associative learning
process contributing to MCS symptoms. The initial toxic exposure is the
unconditioned stimulus that results in symptoms (the unconditioned re-
sponse). The odorous context becomes the conditioned stimuli, and condi-
tioned responses are symptoms elicited by subsequent exposures at lower lev-
els. Through stimulus generalization, completely different odors can also
become conditioned stimuli leading to the same conditioned response sys-
tems (Bolla-Wilson, Wilson, & Bleeker, 1988).
Winters et al. (2003) investigated whether warnings about environ-
mental pollution would produce symptoms in 32 healthy volunteers, regard-
less of the noxiousness of the smell. Half of the study participants received a
leaflet describing the "widespread chemical pollution of our environment"
(p. 334) as a potential cause for MCS and a MCS case description. Then
they received ammonia mixed with CO2 or with room air, or niaouli (a pleas-
ant smell) mixed with CO2 or with room air. The researchers found that the
group that read the leaflet prior to exposure learned symptoms in response to
both odors more readily than the group that did not receive information.
These results echo Petrie et al.'s (2005) findings in regard to pesticide spray-
ing reported above: People who are primed to believe in the dangers of chemi-
cals (i.e., have more modern health worries) report more symptoms after
exposure.
Bailer et al. (2005) proposed a cognitive-behavioral model of IEI. People
predisposed to develop IEI possess the characteristic of hypersensitivity to
common chemical agents. IEI develops when an interaction occurs between
this predisposition and environmental stress (trauma, stressful life events,
overwhelming hassles); physiological changes caused by asthma or allergy;
beliefs about the harm from chemicals; and other traits such as negative af-
fectivity, suggestibility, or a schema of sickliness. IEI is then maintained by a
self-perpetuating cycle of increased attention to exposures and sensations,
which are interpreted as symptoms of IEI.

MULTIPLE CHEMICAL SENSITIVITY 143

 Lipson (2004) performed an ethnographic interview study of 36 people
with MCS to try to understand the experiences and beliefs of people with
MCS. Most participants had become chemically sensitive from remodeling,
sick buildings, or workplace exposures. Lipson found that economic, medi-
cal, and social contexts increase the stigma experienced in MCS, such as
corporate motives to delegitimize MCS and the hyperindividualistic values
of wearing scents even if they harm others. The social suffering often exceeds
the physical suffering.
In a qualitative study, Gibson, Placek, Lane, Brohimer, and Lovelace
(2005) asked 178 women and 25 men with MCS an open-ended question
about how MCS had affected their identities. The themes that emerged in-
cluded loss of stable personality, loss of self-positioning, emotional suppres-
sion, redesigning plans, forced growth, struggling with support, discovering
the spiritual self, and identity reconsolidation. The difficulties encountered
by those with MCS are shared with other delegitimized illnesses and include
negative effects on employment, finances, social relations and roles, mental
health, and quality of life (Gibson et aL, 2005).

CONCLUSION

MCS sits at the lower rungs of the credibility ladder compared with the
other MUIs examined in this volume. Although a variety of theories favor a
pathophysiological etiology, that etiology remains elusive. It may be that
beliefs, expectations, and poor coping responses are more viable explana-
tions for MCS than toxic insult. The more likely explanation is that a height-
ened sensitivity to toxins combined with psychosocial factors contribute to
the development of MCS in vulnerable individuals. The lack of sufficient
research on this condition makes it difficult to develop consistent explana-
tory theories.

144 MEDICALLY UNEXPLAINED ILLNESS

 TREATMENT APPROACHES TO
9
IRRITABLE BOWEL SYNDROME

Recent developments have led to improvement in the care of irritable

bowel syndrome (IBS). If a patient meets Rome II criteria for IBS and does
not have alarm factors, treatment should be initiated as soon as possible.
There is evidence for differential response to treatment in subtypes of IBS. In
some studies, individuals with diarrhea-predominant IBS responded better
to treatment with tricyclic antidepressants (Whitehead, 1999). Interpersonal
psychotherapy is also more effective for the diarrhea and pain symptoms of
IBS, presumably because therapy helps patients understand the connection
between stress and gastrointestinal symptoms and helps them control stress
(Guthrie, Creed, Dawson, & Tomenson, 1993). A connection between stress
and constipation symptoms is not as obvious.
In treating IBS, it is important to remember that IBS represents a spec-
trum of symptoms that tend to fluctuate over time. An IBS patient with an
alternating pattern of constipation and diarrhea may be treated for diarrhea
only to have the symptom pattern shift to constipation, making drug treat-
ment unhelpful. This suggests that symptom-directed treatment may not be
useful as a global approach to the problem. Additionally, because IBS is of-
ten a chronic condition, medication should be used cautiously and tempo-

149
rarily. This chapter summarizes the findings regarding both drug and psycho-
logical treatments for IBS, recognizing that multimodal therapy will be the
most effective approach for most patients.

DRUG TREATMENTS

Several reviews have evaluated the efficacy of various drug treatments

for IBS (Brandt et al, 2002; Jailwala, Imperiale, & Kroenke, 2000). A meta-
analysis of antispasmodic medications found that they were superior to pla-
cebo as treatment for IBS (Poynard, Regimbeau, 6k Benhamou, 2001). The
American College of Gastroenterology task force reviewed the available
evidence for the usefulness of bulking agents, such as wheat bran, corn
fiber, and psyllium, and found that they were no more effective than place-
bos at relieving overall IBS symptoms, although they could be helpful spe-
cifically for constipation (Brandt et al., 2002). The antidiarrheal agent
loperamide was found to be helpful in relieving IBS-related diarrhea, but it
was no better than placebo at relieving global symptoms of IBS (Efskind,
Bernklev, & Vatn, 1996).
Antidepressants' impact on anticholinergic, serotonergic, and norad-
renergic receptors that affect gastrointestinal motility makes these drugs good
candidates for the treatment of IBS (Clouse & Lustman, 2005; Talley, 2003).
However, a systematic review performed by the American College of Gas-
troenterology concluded that evidence did not support the effectiveness of
tricyclic antidepressants in ameliorating global IBS symptoms (Brandt et al.,
2002). SSRIs appear to have a more efficacious profile. Evidence suggests
that both desipramine (Drossman et al., 2003) and paroxetine (Creed et al.,
2003) may be more effective than standard medical treatment in IBS.
The presence of a significant number of 5-HT3 receptors in the gut has
led to the development of a number of agents specific to this receptor site.
Antagonism of the 5-HT3 receptor causes significant slowing in colonic
transit and a decrease in visceral sensation and should help the diarrhea-
predominant form of IBS. The first agent developed in this class was alosetron,
which has been found effective in relieving abdominal pain, discomfort, and
rectal urgency and improving well-being in patients with IBS (Camilleri,
2001; Camilleri et al., 1999). Viramontes et al. (2001) found that the reduc-
tion in colonic transit was significantly greater in women than in men.
Alosetron was withdrawn from the market in November 2000 because a small
number of patients experienced severe constipation and ischemic colitis. The
drug was re-released by the U.S. Food and Drug Administration under a re-
stricted prescribing program for women with severe diarrhea-predominant
IBS who did not respond to conventional IBS therapy. Careful patient edu-
cation and monitoring can reduce adverse events associated with this agent
(Camilleri, 2001; Camilleri et al., 1999).

150 MEDICALLY UNEXPLAINED ILLNESS

 Stimulation of the 5-HT4 receptors in the gut appears to increase the
rate of intestinal colonic transit, reduce the firing rate of colonic visceral
afferent nerves, and in turn, to reduce visceral sensitivity. The 5-HT4 partial
agonist tegaserod is the only drug in this class approved by the U.S. Food and
Drug Administration. Currently approved for the treatment of IBS with con-
stipation in women, this drug has been shown in trials, when compared with
a placebo, to increase the number of bowel movements, decrease bloating,
reduce abdominal pain or discomfort, and improve stool frequency and con-
sistency (Camilleri, 2001; Muller-Lissner et al., 2001).
To summarize the findings for prescription drug treatment for IBS, some
antidepressants and antispasmodic agents are more effective than placebos
for treating IBS, although the studies are small and poorly designed. There
are no randomized controlled trials examining the efficacy of laxatives for
managing IBS. Gender appears to play an important role in the serotonin
receptor specific drugs; research reveals that they are significantly more ef-
fective in women than in men. Tegaserod is more effective than placebo at
improving global IBS symptoms in women with non-diarrhea-predominant
IBS. Alosetron is more effective than placebo in women with diarrhea-
predominant IBS, although its use should be limited to patients who have
not improved with conventional therapy because of its adverse event profile
(Schoenfeld, 2005; Talley, 2003).
No single drug therapy has proved to be beneficial for the majority of
people with IBS (Tan, Corydon Hammond, & Gurrala, 2005). There is a
clear trend in the literature showing that behavioral treatment of IBS, as
well as "combined treatment" consisting of medical management, psycho-
logical treatment, and judicious use of antidepressants, can be more effective
than standard medical treatment alone in treating such patients, particularly
patients with severe IBS symptoms (Brandt et al., 2002).

DIETARY ISSUES

Recent studies suggest that although individual patients may have "food
triggers," there is no definitive evidence that food allergies or food intoler-
ance to large food groups, such as meats or grains, are associated with either
the development or the exacerbation of IBS symptoms. Dietary triggers re-
ported include caffeine, citrus, corn, dairy lactose, wheat, and wheat gluten.
Lactose and caffeine may be associated with diarrhea-predominant IBS
(H. R. Mertz, 2003). Patients should be encouraged to eat a healthful diet
and to avoid foods that can trigger their symptoms. Extensive testing for gut-
based food allergies is usually nonproductive in IBS patients, although Zar,
Kumar, and Benson (2001) have argued that a subgroup of IBS could benefit
from therapeutic dietary manipulation. For example, increasing dietary fiber
has long been recommended as a treatment for constipation-predominant

TREATMENT APPROACHES TO IRRITABLE BOWEL SYNDROME 151

IBS (Floch & Narayan, 2002). A systematic review of 13 randomized con-
trolled trials found no convincing evidence that bulking agents relieve glo-
bal symptoms of IBS (Brandt et al., 2002); another systematic review (Jailwala
et al., 2000) found significant improvement in the ease of stool passage and
in general satisfaction with bowel movements. Using fiber is reasonable for
constipation-predominant patients. Partially hydrolyzed guar gum has report-
edly been successful in alleviating constipation. A nonblinded randomized
controlled trial found that symptoms of IBS were improved equally by diets
supplemented with fiber or guar gum, but more patients preferred guar gum
(Parisi et al., 2005).
Monsbakken, Vandvik, and Farup (2005) advocated a general thera-
peutic approach in the management of IBS and documented its effect. They
assessed the abdominal symptoms, musculoskeletal pain, and mood disorders
of 65 individuals with IBS identified in a public screening. A doctor pre-
sented IBS as a positive diagnosis and offered information, reassurance, and
lifestyle advice but no pharmacotherapy. A dietician gave dietary advice. At
6-month follow-up, 20 individuals (31%) had satisfactory relief of symptoms.
Dietary advice was effective only in those with diarrhea-predominant IBS.
Previous consultations for the complaints, visits for psychiatric disorders, and
presence of mood disorders were predictors of persistent complaints. Although
this study reported significant relief of symptoms after 6 months, those with
psychological comorbidity were not as responsive as the others. The sections
that follow describe approaches that may benefit individuals with treatment-
resistant IBS.

STRESS REDUCTION

Stressful life events and difficulty in coping with stress play important
roles in MUIs, and IBS is paradigmatic of this connection (Monnikes et al.,
2001; Sagami et al., 2004). Although not a direct cause of illness, stress can
clearly influence outcomes and severity of IBS (Whitehead, Bosmajian,
Zonderman, Costa, & Schuster, 1988) and interfere with treatment. E. J.
Bennett, Tennant, Piesse, Badcock, and Kellow (1998) prospectively exam-
ined the relation of chronic life stress threat to IBS symptom intensity over
time in a sample of 117 consecutive outpatients who satisfied the modified
Rome criteria for IBS (66% with one or more concurrent functional disorder
syndromes) participated. The life stress and symptom intensity measures were
determined 6 months prior to study entry and at 6 and 16 months after entry;
these measures assessed the potency of chronic life stress threat during the
prior 6 months or more and the severity and frequency of symptoms during
the following 2 weeks. Chronic life stress was a powerful predictor of subse-
quent symptom intensity, explaining 97% of the variance on this measure
over 16 months. No patient exposed to even one chronic highly threatening

152 MEDICALLY UNEXPLAINED ILLNESS

stressor improved clinically (by 50%) over the 16 months; all patients who
improved did so in the absence of such a stressor. This shows the importance
of identifying and managing stressors in a patient's life.
Developing more effective coping strategies and relaxation training can
be key to improving symptomatology. Patients who can make a clear associa-
tion between their symptoms and stress or anxiety benefit the most from
stress management and relaxation training (Palsson & Drossman, 2005). Shaw
et al. (1991) randomized 35 patients with IBS to receive treatment either in
a stress management program or with the antispasmodic drug Colpermin.
The stress management program involved a median of six 40'minute sessions
with a physiotherapist, during which patients were helped to understand the
nature of their symptoms and the relationship of those symptoms to stress
and were taught relaxation exercises. Two thirds of those in the stress man-
agement program found it effective in relieving symptoms and experienced
fewer attacks of less severity. This benefit was maintained for at least 12
months. The drug group reported no benefit.
Keefer and Blanchard (2001) used a relaxation response meditation
program group compared with a wait-list control group (symptom monitor-
ing only) in a 6-week crossover design. IBS patients were paired on the basis
of presence of Axis I disorders, primary IBS symptoms, age, and gender. One
member of the pair was randomly assigned to either treatment or wait list.
Both groups were required to monitor symptoms in a daily diary. Relaxation
group members met once a week for 30 minutes, and they were instructed to
practice relaxation techniques twice a day for 15 minutes. Most participants
managed to practice only once per day. Immediately after treatment, 77% of
the relaxation group members had improved. At 3-month follow-up, im-
provement was maintained. The control group also received treatment after
6 weeks of wait list, but in the wait-list condition, only 28% improved. Re-
laxation is often an important component of other psychological treatments
such as cognitive-behavioral therapy, hypnotherapy, and meditation.

PSYCHOLOGICAL APPROACHES

The literature supporting the efficacy of psychological approaches to

treating IBS is positive. Psychosocial treatments have generally been found
to be more effective than medication alone or various control conditions.
Cognitive-behavioral therapy, hypnosis, pure cognitive therapy, and relax-
ation therapy have all been effectively applied to the treatment of IBS, espe-
cially in patients with severe symptoms (Blanchard, Schwarz, & Neff, 1988;
Drossman et al., 2003; Galovski & Blanchard, 1998).
Behavioral treatments are based on a biopsychological model of IBS.
The biological disturbance in gut sensitivity or motility interacts with emo-
tional regulation problems and disturbed central nervous system processing.

TREATMENT APPROACHES TO IRRITABLE BOWEL SYNDROME 153

Emotional disturbance or early encoded childhood traumas might increase
ascending visceral signals, thus producing more intense pain experiences.
Psychological interventions or antidepressant drugs can intervene with these
stimulus pathways and decrease the pain experience (Halpert & Drossman,
2005). Psychological treatments can help individuals regulate emotions more
adaptively and develop coping skills that can affect central processing, which
in turn reduces gastrointestinal and other symptoms.
Because such varied psychological approaches have yielded positive re-
sults, they all have some key factors in common. The critical factor addressed
by all of these treatments is the patient's belief system: providing the patient
with a more thorough understanding of the disorder and an enhanced sense
of control by learning new coping approaches. Teaching the individual that
IBS is a biobehavioral disorder, illuminating the role of stress and coping in
symptom maintenance, teaching positive self-management strategies, and
discouraging excessive health care seeking behaviors are critical (Naliboff,
Chang, Munakata, & Mayer, 2000). Naliboff et al. (2000) recommended a
psychoeducational approach that alters the patient's beliefs and understand-
ing of the disorder so that he or she can benefit from a variety of approaches.
As in other MUIs, organic disease conviction can be tenacious in IBS.
Toner and Akman (2000) have suggested that the feminine gender role can
affect illness attributions. This disease conviction could come from focusing
on others' needs, which leads to neglect of self, and lack of self-nurturance
exacerbates stress. The distressing symptoms of IBS cannot be ignored, but
IBS patients who go to specialists tend to selectively attend to physiological
symptoms and are less likely to acknowledge stress than those who do not see
gastrointestinal specialists (Toner, 1994). Strong disease convictions also
contribute to high levels of doctor shopping. Thus, the cognitions may go
something like this: "I have it all under control, I'm doing just fine, but please
cure my embarrassing symptoms with some medication or procedure." Ex-
amples of dysfunctional cognitions typical of IBS are presented in Exhibit
9.1. These cognitions do not help patients to cope with chronic symptoms
and must be addressed through cognitive-behavioral therapy. Toner and
Akman (2000) have noted that bowel functioning is more of a source of
embarrassment for women than for men. For women with IBS, the shame
associated with bowel function may contribute to feelings of isolation.
Greene and Blanchard (1994) laid out an intensive cognitive therapy
system that consisted of ten 1-hour individual sessions. Cognitions were
emphasized as the determining factors in IBS symptoms. Treatment was aimed
at increasing patients' awareness of the association between stress, thoughts,
behaviors, and bowel symptoms; training patients in the identification and
modification of appraisals of situations, thoughts, and behaviors; and chang-
ing dysfunctional schemas. The researchers randomized 20 people with IBS
to either cognitive therapy or a symptom monitoring condition in a cross-
over design. Of those receiving cognitive therapy, 80% experienced clini-

J 54 MEDICALLY UNEXPLAINED ILLNESS

 EXHIBIT 9.1
Cognitive Scale for Functional Bowel Disorders

Theme Example of statements endorsed

Bowel performance "I worry there might not be a toilet available."
anxiety
Pain "I often feel this abdominal pain will never go away."
Control "My bowel symptoms make me feel out of control."
Self-efficacy "I feel my bowel symptoms are too much for me to
handle."
Embarrassment/shame "I worry that other people will hear my stomach
noises."
Anger/frustration "I am constantly frustrated by my symptoms."
Disease conviction "I feel I am always sick with my bowel symptoms."
Perfectionism "It's important to do my absolute best at everything."
Social approval "I hate the thought of making a fool of myself."
Social rules/norms "The idea of being late upsets me."
Self-nurturance "I often give up my own wishes to make others happy."
Note. Statements are rated on a scale that ranges from 1 (strongly disagree) to 7 (strongly agree).
Adapted from "Cognitive Change in Patients Undergoing Hypnotherapy for Irritable Bowel Syndrome," by
W. M. Gonsalkorale, B. B. Toner, and P. J. Whorwell, 2004, Journal of Psychosomatic Research, 56,
p. 273. Adapted with permission from Elsevier.

cally significant improvement compared with only 10% in the symptom

monitoring condition. Payne and Blanchard (1995) sought to extend these
findings by using a support group condition to control for patient expecta-
tions and therapist contact. They randomized 34 people to three conditions:
cognitive therapy, self-help support, or wait list (controls). The support group
met weekly with a therapist who led discussions of IBS issues such as stress
and diet. All three groups kept gastrointestinal symptom diaries for 8 weeks.
The wait-list control was contacted at 4 weeks to check on diary keeping.
Results replicated Greene and Blanchard's, with an average reduction in pri-
mary gastrointestinal symptoms of 67% in the cognitive therapy condition,
compared with 31% for the support group condition and 10% for the wait-
list condition. This improvement was sustained at 3 months posttreatment.
Boyce, Gilchrist, Talley, and Rose (2000) assessed 8 participants undergoing
cognitive-behavioral therapy for IBS. They found significant improvement
in the distress and disability associated with bowel symptoms and alleviation
of anxiety and depression. Frequency of bowel symptoms remained unchanged.
Payne and Blanchard (1995) indicated that in cognitive therapy, par-
ticipants learned to alter their distorted thinking and change fundamental
beliefs and to reduce behavioral avoidance and physiological reactivity. They
argued that the crucial ingredient is interrupting the cognitive pathway that
links the physiological, behavioral, and cognitive aspects of IBS.
Heymann-Monnikes et al. (2000) compared behavioral treatment with
drug treatment alone in patients consulting a tertiary gastrointestinal refer-
ral center. IBS outpatients were randomly assigned to the combination of
standardized multicomponent behavioral therapy plus standard medical treat-

TREATMENT APPROACHES TO IRRITABLE BOWEL SYNDROME 155

ment or standard medical treatment alone. The behavioral treatment group
received IBS information and education, progressive muscle relaxation, train-
ing in illness-related cognitive coping strategies, problem solving, and
assertiveness training in 10 sessions over 10 weeks. Standard medical treat-
ment included symptom-oriented medical treatment and regular visits to a
gastroenterolegist every 2nd week. Follow-ups were conducted at 3- and 6-
month intervals. Compared with the group receiving standard medical treat-
ment alone, the behavioral treatment group showed significantly greater IBS
symptom reduction and improved quality of life and overall well-being as
measured by daily symptom diaries. Heymann-Monnikes et al.'s data provide
evidence that medical treatment alone is not especially effective, whereas the
combination of medical treatment plus multicomponent behavioral treatment
is superior in the therapy of IBS. Although all of these studies involved rela-
tively small numbers of participants, they show consistently that cognitive-
behavioral approaches are effective in IBS.
Boyce, Talley, Balaam, Koloski, and Truman (2003) randomized 105
people recruited from gastroenterology clinics and advertisements to three
treatment arms. All participants received routine clinical care, and the other
two groups received weekly sessions of either relaxation or cognitive-
behavioral therapy for 8 weeks. Only individuals with no psychiatric diagno-
sis and with gastroenterologist-diagnosed IBS were included. Routine care
consisted of three 15- to 30-minute sessions with a gastroenterologist, during
which individuals received recommendations for a high-fiber diet along with
the bulking agent psyllium husk in a standard dose. The relaxation treat-
ment consisted of 30-minute instructional sessions using a variety of relax-
ation techniques. Cognitive-behavioral therapy sessions consisted of strate-
gies to manage anxiety, incorporate realistic symptom appraisal, enhance
coping strategies, teach relaxation skills, and restructure cognition. Partici-
pants were assessed at baseline and at 4, 8, 26, and 52 weeks. All three groups
demonstrated significant improvement over time in IBS severity, anxiety,
depression, and quality of life. Gender was not associated with outcome. There
was a high attrition rate in the treatment groups. Although this study might
indicate that good clinical care and support are sufficient for many individu-
als with IBS, these findings have limited generalizability because Boyce et al.
(2003) excluded those with psychiatric disorder.
A randomized study of 431 women with moderate to severe functional
bowel disorders (including IBS, functional abdominal pain, painful constipa-
tion, and unspecified functional bowel disorder) compared cognitive-
behavioral therapy, education, desipramine, and placebo in a multicenter
treatment trial (Drossman et al., 2003). Cognitive-behavioral therapy con-
sisted of 12 weekly hour-long sessions aimed at modifying the influence of
attention, appraisal, gender-related cognitive schemas, and illness attribu-
tion related to participants' gastrointestinal symptoms to develop more ef-
fective coping strategies. Examples of gender-related cognitions include the

15 6 MEDICALLY UNEXPLAINED ILLNESS

belief that girls and women must always be in control of bodily functions and
that they must always be fresh, clean, and socially desirable; that bodily func-
tions must be kept hidden and private; and that social approval can be se-
cured by pleasing others. The education control sessions were conducted with
the same therapist over the same time frame but consisted of reviewing symp-
tom diaries and reading and discussing educational materials. The remaining
participants were randomized to desipramine or placebo and visited a nurse
weekly over the 12 weeks for monitoring. Outcome measures were satisfac-
tion with treatment, well-being, diary card scores, and quality of life.
Cognitive-behavioral therapy was significantly more effective than educa-
tion on a composite outcome measure. Desipramine was more effective than
placebo but only in secondary analysis. Participants in the placebo drug group
had a higher response rate than those in the education control group.
Drossman et al. (2003) also found that desipramine was more effective for
those with less severe illness and a history of abuse, whereas cognitive-be-
havioral therapy was effective regardless of those factors. Surprisingly, par-
ticipants with depression were not more likely to benefit from active treat-
ment than those who were not depressed.
Given that cognitive-behavioral therapy has proved effective for IBS,
Kennedy et al. (2006) sought to determine whether it could be delivered by
primary care nurses to patients with moderate or severe IBS that was resis-
tant to the antispasmodic drug mebeverine. They concluded that this type of
therapy had more benefit than mebeverine for up to 6 months, but that after
12 months, most of the benefit had dissipated.
A systematic review of the effectiveness of psychological interventions
in patients with IBS, chronic fatigue syndrome (CFS), and chronic back pain
was conducted to determine whether psychological treatment was as effica-
cious in a primary care setting as in specialty settings (Raine et al., 2002).
They identified 61 randomized controlled studies and two meta-analyses; 20
of these studies assessed patients in primary care. Although cognitive-
behavioral therapy and cognitive treatments were generally effective for CFS
and IBS, greater improvements were seen in the specialty settings. Raine et
al. cautioned that their conclusions are qualified because of many method-
ological weaknesses in the studies reviewed. Patients in specialty care tended
to be sicker, had longer treatment times, and had more supervised interven-
tions than patients in primary care, which may explain the greater improve-
ments in specialty care settings. Raine et al. also reported that although an-
tidepressants were not helpful in CFS, they were found to be effective for IBS
in both primary and specialty care settings.
Toner, Segal, et al. (1998) discussed the usefulness of group cognitive-
behavioral therapy in IBS. A group setting helped reduce the stigma of the
condition, and participants gained support from others experiencing the same
difficulties. Clinicians often endorse same-gender groups, because women
may be more willing to disclose shame-related issues or sexual and physical

TREATMENT APPROACHES TO IRRITABLE BOWEL SYNDROME 15 7

abuse in same-gender groups. The common themes that emerge and should
be addressed in group therapy are associations between thoughts, feelings,
and bowel symptoms; the specific cognitions associated with bowel symp-
toms; pain management; and "bowel performance" anxiety. Important issues
that commonly require addressing in therapy with IBS are perfectionistic
beliefs, need for approval, social desirability, anger, and control (Toner,
Koyama, Garfinkel, Jeejeebhoy, &Gasbarro, 1992; Toner, Segal, et al., 1998).
Below are several therapy excerpts from Karen,1 a 32-year-old married
woman, that exemplify several common themes addressed by Toner et al.
(1992; Toner, Segal, et al., 1998). Karen had no children and worked as an
accountant, a job she enjoyed but found "pretty stressful." She had had IBS
symptoms for 3 years and described the embarrassment of unpredictable diar-
rhea and the loss of libido affecting sexual activity. These were her most
troubling presenting symptoms.
I just finished having a huge array of tests to confirm IBS as a diagnosis.
My sex drive was huge before I got this, and now I have nothing, and
simply make an effort for [my] husband's sake, but not as often as he
would like. He is really understanding, but if I can't stop how bad I'm
feeling enough to get back to a relatively normal life (I'm still coming to
terms with diagnosis) then how long will he continue to put up with
this? We had been married for five years before my symptoms started, but
I feel so bad for him. I'm afraid I'll have an accident if I lose control
during sex. I just feel disgusting and disgusted about it.
There is an emphasis on her partner's needs and on letting him down by
not being an enthusiastic sexual partner. After several months of cognitive-
behavioral therapy, a theme of acceptance arose in the therapy dialogue with
Karen. Her therapist worked with her on relaxation techniques and avoiding
self-blame. Another important theme was accepting that embarrassing events
will occur but avoiding a catastrophizing response.
Things are going much better now. Part of this involved my journey to
accepting that I had a chronic illness. And realizing eventually that if I
waited [to have sex] till I felt "well" or even "good" ... it just wouldn't
happen most of the time. And once I realized that sometimes it actually
made me feel better. And once I had a few positive experiences, and a
few negative ones and my husband didn't leave the room running or
screaming . . . nor did he love me any less.. . things improved a lot.
Karen reported that using relaxation techniques helped reduce the in-
tensity of some of her symptoms. The last several sessions of therapy focused
on not letting IBS control her life yet accepting that she may have to live
with the symptoms. Karen was still having difficulty moving toward accep-
tance.

'This case study is a fictionalized amalgam of typical patients.

158 MEDICALLY UNEXPLAINED ILLNESS

 I know that it's best to just keep on keeping on, I definitely don't freak
out and obsess about my symptoms as much as I used to.... I think I am
still having trouble accepting I have this illness, and am always hoping I
will wake up one day and be cured ... but I'm not letting it overrun my
life.

HYPNOTHERAPY

Hypnosis has emerged as an especially effective treatment for IBS.

Galovski and Blanchard (1998) randomly assigned 6 matched pairs of IBS
patients to either a gut-directed hypnotherapy condition or to a symptom
monitoring wait-list control condition. Those assigned to the control condi-
tion were later crossed over to the treatment condition. Patients were matched
on concurrent psychiatric diagnoses, susceptibility to hypnosis, and various
demographic features. Results from the entire treated sample indicate that
the individual symptoms of abdominal pain, constipation, and flatulence
improved significantly. State and trait anxiety scores were also seen to de-
crease significantly. Results at the 2-month follow-up point indicated good
maintenance of treatment gains. A positive relationship was found between
the incidence of psychiatric diagnosis and overall level of improvement.
Gonsalkorale, Houghton, and Whorwell (2002) established a hypno-
therapy unit devoted to IBS in the United Kingdom. The technique involved
hypnotic induction using relaxation procedures to deepen the hypnotic state,
followed by suggestions and imagery tailored to each individual, such as in-
duced warmth in the patient's abdomen aimed at controlling and normaliz-
ing gut function. Hypnotherapy consisted of weekly 1-hour sessions for 12
weeks, and people were required to practice techniques between sessions.
They were able to audit 250 patients who participated in this hypnotherapy
treatment and found marked improvement in IBS symptoms, anxiety, de-
pression, and quality of life, with 71% responding favorably. Only gender
was significantly associated with responder status; men with diarrhea-
predominant IBS were the least likely to respond. The authors speculated
that these nonresponsive men may have had somewhat lower imaginative
abilities or differing pathophysiologic mechanisms that made them less suited
to a hypnotherapeutic approach. Gonsalkorale, Miller, Afzal, and Whorwell
(2003) then followed up with these patients to determine whether improve-
ment was maintained as much as 6 years after the original hypnotherapy
treatment. They found that 81% of responders maintained their improve-
ment over time. Responders also reported a reduction in medical consulta-
tion rates and medication use.
Palsson, Turner, Johnson, Burnett, and Whitehead (2002) were inter-
ested in determining the mechanism for the success of hypnosis treatment
for severe IBS. They examined whether hypnosis was effective by normaliz-

TREATMENT APPROACHES TO IRRITABLE BOWEL SYNDROME 159

ing interpretation of aversive intestinal stimuli, reducing rectal smooth muscle
tone, reducing autonomic arousal, and reducing somatizing. They found that
hypnosis was effective in reducing symptoms of IBS, replicating previous stud-
ies. However, hypnosis treatment did not change rectal pain thresholds, rec-
tal muscle tone, or cardiovascular responses. The only physiological response
that improved was skin conductance, which could reflect a slight reduction
in sympathetic autonomic activity after hypnosis. Conversely, somatization
and general distress were significantly reduced. Palsson et al. hypothesized
that hypnosis may improve IBS symptoms by altering the patient's attentional
and belief systems about the meaning of sensations arising from the gastrointes-
tinal tract.
Gonsalkorale, Toner, and Whorwell (2004) were interested in deter-
mining whether the cognitive changes were related to the success of hypno-
therapy. They assessed 78 patients with IBS who underwent a course of hyp-
notherapy. As in other studies, hypnotherapy significantly reduced IBS
symptoms and improved psychological well-being and quality of life. IBS'
related cognitions were assessed with the Cognitive Scale for Functional Bowel
Disorders, which yields a total cognitive score (Toner, Stuckless, et al., 1998).
The score was made up of statements derived from diaries of IBS patients.
Exhibit 9.1 summarizes the themes and statements found on the scale. The
total cognitive score was associated with symptom severity and interference.
These cognitions improved after hypnotherapy, and this change was corre-
lated with improvement in symptoms. In particular, bowel-related cogni-
tions improved after hypnotherapy, but there was less change in cognitions
relating to perfectionism, self-nurturance, and social norms.
Tan et al. (2005) reviewed 14 studies of the efficacy of hypnosis in
treating IBS. They concluded that hypnosis consistently produces improve-
ment in IBS symptoms as well as in psychological states and quality of life
and that these improvements last over a number of years. They summarized
the possible mechanism of action for hypnotherapy as improving abnormal
pain perception, normalizing rectal sensitivity, altering electroencephalo-
gram activity, or, alternatively, working through psychological mechanisms
by reducing somatization and distress or increasing placebo analgesia. Tan et
al. found that hypnosis for IBS qualifies for the highest level of acceptance;
they noted that the Clinical Psychology Division of the American Psycho-
logical Association guidelines regard hypnosis as both efficacious and spe-
cific for this condition.

PSYCHOTHERAPY

The effectiveness of psychotherapy in patients with chronic, refractory

IBS was demonstrated by Guthrie, Creed, Dawson, and Tomenson (1993),
who conducted a randomized controlled trial of psychotherapy versus sup-

160 MEDICALLY UNEXPLAINED ILLNESS

portive listening with a sample of 102 patients. Physical and psychological
assessments were carried out at the beginning and end of the 12-week trial.
For women, psychotherapy was found to be superior to supportive listening
in terms of improving both physical and psychological symptoms. There was
a similar trend for men, but this did not reach significance. Following comple-
tion of the trial, patients in the control group were offered psychotherapy; 33
accepted and after treatment experienced a marked improvement in their
symptoms; 10 declined. At 1-year follow-up, those patients who had received
psychotherapy remained well, patients who had dropped out of the trial were
unwell with severe symptoms, and most of the controls who declined psy-
chotherapy had relapsed. This study shows that psychotherapy is effective in
the majority of IBS patients with chronic symptoms unresponsive to medical
treatment.
Individuals with IBS who have a history of being physically or sexually
abused or are patients with psychiatric disorders such as depression or panic
disorder often benefit from psychotherapy. Not surprisingly, it is individuals
with the greatest psychological comorbidity who appear to benefit the most
from psychological approaches. These patients may be more motivated. Creed,
Guthrie, et al. (2005) found that the association between abuse history and
impaired functioning was mediated by somatization tendencies. In a 15-month
trial of psychotherapy and paroxetine, Creed et al. (2003) found the greatest
beneficial response in those with abuse history, particularly those with a re-
ported history of rape. Psychotherapy allowed the patients to discuss and
resolve previous and current interpersonal difficulties, which argue for a treat-
able component in functioning with IBS. Somatization processes were also
decreased after psychotherapy (Creed et al., 2003).
New pharmacological treatments may hold some promise for treating
IBS, but it appears likely that multimodal approaches are more likely to be
the most effective. This chapter has presented evidence that in controlled
trials approaches that incorporate stress reduction, relaxation, imagery, and
more effective coping techniques have significantly improved IBS symptoms.
Psychotherapy is also helpful, particularly to patients with an abuse history.
The most well-researched and impressive improvements in symptoms and
quality of life come from trials of cognitive-behavioral therapy and hypno-
therapy. Cognitive-behavioral therapy that includes strategies to manage
anxiety, learning realistic symptom appraisal, enhancing coping strategies
and relaxation skills, and restructuring cognitions has proven effective in
IBS. Similarly, hypnotherapy works to improve coping and to change mal-
adaptive cognitions and shows great promise for treating IBS.

TREATMENT APPROACHES TO IRRITABLE BOWEL SYNDROME 161

 TREATMENT APPROACHES
10
TO FIBROMYALGIA

Fibromyalgia (FMS) treatment must be guided by the biopsychosocial

model. The interaction between neurally mediated nociceptive activity,
anxiety, depression, catastrophizing, and decreases in physical activity level
can result in increased pain experiences. Some patients experience signifi-
cant relief of symptoms after treatment, some find moderate improvement,
and others report little or no relief. Only about 5% of FMS patients be-
come symptom free. Most treatment regimens include medication, lifestyle
changes, exercise, physical therapy, and behavior modification (Millea &
Holloway, 2000). R. M. Bennett (1996) recommended multidisciplinary
group programs to treat FMS patients, including physiatrists, psychologists,
and rheumatologists.
Successful management of FMS is more likely if patients have suffi-
cient information and skills to deal with it. In randomized clinical trials,
educating FMS patients about their condition resulted in improvements in
pain, sleep, fatigue, self-efficacy, quality of life, and exercise ability (Burckhardt
& Bjelle, 1994). Most education trials range from 6 to 17 weekly sessions,
but even a Wi day multidisciplinary education program was found to be suc-
cessful (Pfeiffer et al., 2003).

163
 MEDICATION

No medical therapies have been specifically approved by the U.S. Food

and Drug Administration for the management of FMS. Antidepressants ap-
pear to be the most effective class of medications used. In addition to their
potential side effects, their analgesic effect has been demonstrated in many
chronic pain disorders and may be related to increasing the spinal concentra-
tions of serotonin and norepinephrine. Tricyclic antidepressants are one of
the few classes of medications proven to be effective in randomized clinical
trials (Arnold & Keck, 2001; O'Malley et al, 2000; Rao & Bennett, 2003).
Another class of antidepressants used in FMS is that of the SSRIs, which
tend to improve mood but not physical symptoms. These inhibitors have
been effective as monotherapy (Arnold et al., 2002) or in combination with
tricyclic antidepressants in FMS (Goldenberg, Mayskiy, Mossey, Ruthazer,
& Schmid, 1996).
Trigger point injections involve injecting a local anesthetic into a ten-
der point. Local anesthetic increases blood flow to the muscle, and cortico-
steroids reduce inflammation. Although the injections are used commonly
in clinical practice, few studies of their efficacy have been conducted. The
injections can be painful and take several days to show results. However,
because of the complicated nature of pain management in some patients,
injections should not be ruled out as an alternative treatment. Further study
of this treatment is warranted (Goldenberg, Burckhardt, & Crofford, 2004).
The negatives of drug treatments are that they treat only certain symp-
toms, their long-term benefits have not been well established, and improve-
ment with drugs seems to fade over time. Because FMS is usually a chronic
disorder, a multimodal approach with lifestyle changes is likely to confer the
most benefit.

REVIEWS OF TREATMENT STUDIES

A number of reviews and meta-analyses have examined treatment effi-

cacy in FMS. A meta-analysis of 49 FMS treatment outcome studies assessed
the efficacy of pharmacological and nonpharmacological treatment across
four types of outcome measures: physical status, self-report of FMS symp-
toms, psychological status, and daily functioning (Rossy et al., 1999). Antide-
pressant drugs resulted in improvements on physical status and self-report of
symptoms, whereas nonpharmacological treatments were associated with sig-
nificant improvements in all four categories of outcome measures, with the
exception that physically based treatment (primarily exercise) did not signifi-
cantly improve daily functioning. Additionally, nonpharmacological treatment
appeared to be more efficacious in improving self-reported FMS symptoms
than pharmacological treatment alone. This meta-analysis suggests that op-

1 64 MEDICALLY UNEXPLAINED ILLNESS

timal intervention for FMS would include nonpharmacological treatments,
specifically exercise and cognitive-behavioral therapy, with appropriate
medication management only as needed for sleep and pain symptoms.
Goldenberg, Burckhardt, and Crofford (2004) used the major citation
indexes to identify and review 505 randomized controlled trials and meta-
analyses of randomized controlled trials of FMS. Although they noted major
limitations to the FMS literature, with many trials compromised by short
duration and lack of controls, they found support for the efficacy of low-dose
tricyclic antidepressants, cardiovascular exercise, cognitive-behavioral
therapy, and patient education. Goldenberg et al. recommended a stepwise
program emphasizing education, certain medications, exercise, cognitive-
behavioral therapy, or a multimodal combination of all four.
Several reviews have specifically examined nonpharmacological and
complementary and alternative medicine (CAM) approaches to FMS treat-
ment (Hadhazy, Ezzo, Creamer, & Berman, 2000; Holdcraft, Assefi, &
Buchwald, 2003; Rossy et al., 1999). Holdcraft et al. (2003) performed a
database citation review using the National Institutes of Health classifica-
tion of complementary and alternative medicine. They found evidence of
the efficacy for these therapies: acupuncture, some herbal and nutritional
substances (e.g., magnesium, S-adenosyl-L-methionine), and massage therapy.
Limited evidence (at least one randomized controlled trial) supports relax-
ation, biofeedback, and chorella (green algae; Holdcraft et al., 2003).
Hadhazy et al. (2000) reviewed mind-body therapies and found 13 con-
trolled trials involving 802 participants (92% women, 8% men). Therapies
included biofeedback, exercise, education, relaxation, stress management,
and hypnotherapy. According to these authors, mind-body therapies did not
significantly improve pain and function over wait-list or treatment as usual
conditions, although when combined with exercise, they were moderately
more effective. These therapies were most successful in enhancing self-
efficacy and quality of life. People who responded to these therapies tended
to have shorter disease duration, less depression, and higher premorbid activ-
ity levels, suggesting that mind-body therapies should be initiated early to be
effective. Illness behaviors may become less amenable to change as FMS
progresses. This is in contrast to the meta-analysis by Rossy et al. (1999),
which found that nonpharmacological treatments were generally superior to
pharmacological treatment.
Sim and Adams (2002) built on the review of Rossy et al. (1999) by
reviewing 25 randomized controlled trials of nonpharmacological interven-
tions, including exercise, education, relaxation, cognitive-behavioral therapy,
acupuncture, and hydrotherapy. They concluded that most studies were of
low methodological quality and underpowered and that no single interven-
tion was especially effective. Aerobic exercise did emerge as the most effica-
cious intervention, and the authors suggested that exercise should be incor-
porated into any management strategy for FMS.

TREATMENT APPROACHES TO FIBROMYALGIA ] 65

 EXERCISE

Exercise has been one of the most consistently robust and effective treat-
ments for FMS. Exercise has also been shown to decrease the perception of
central pain, which appears to be high in FMS patients. Routine low-impact
aerobics and strength-building exercise may help reduce pain, tender point
counts, depression, and sleep disturbance. Exercise increases time spent in
deep sleep, perhaps a mechanism for its therapeutic effect.
Several of the reviews cited above indicated that exercise combined
with other treatments improved outcomes. Aerobic exercise has consistently
led to improvements in FMS symptoms and function as well as in physical
fitness (Burckhardt, Mannerkorpi, Hedenberg, & Bjelle, 1994; Mannerkorpi,
Ahlmen, & Ekdahl, 2002; Mannerkorpi, Nyberg, & Ekdahl, 2000; McCain,
Bell, Mai, &Halliday, 1988). Busch, Schacter, Peloso, and Bombardier (2002)
identified 16 controlled trials of exercise interventions and found that par-
ticipants experienced significant improvements in aerobic performance, re-
duced tender point pain thresholds, and decreased pain reports relative to
controls. However, these studies were plagued by poor descriptions of exer-
cise programs; insufficient information regarding the intensity, duration, fre-
quency, and mode of exercise; and adverse events. Sufficient descriptions of
measures and outcomes would make them more useful to clinicians.
Gowans et al. (2001) described an intensive 3-day-per-week aerobic
exercise regime over 23 weeks that ameliorated depression (measured by Beck
Depression Inventory) and improved physical function (measured by 6-minute
walk distances). P. T. Costa et al. (2001) evaluated self-reported activity and
depression in 70 Canadian women with FMS at baseline and 3 years later.
Women who engaged in more physical activity reported lower depressed mood
at follow-up after controlling for baseline depression, socioeconomic status,
age, and changes in daily functioning.
Still, not all studies have found that exercise is effective. Van Santen et
al. (2002) randomized 143 women with FMS into three groups: a fitness pro-
gram, biofeedback training, or no active treatment control. The women were
assessed at baseline and at 24 weeks for pain, tender points, myalgia, physical
fitness, functioning, distress, and fatigue. No significant differences in change
scores were found for any of the groups.
Because most exercise intervention studies show benefits from exer-
cise, FMS patients should attempt to exercise if it is not contraindicated
(Mannerkorpi & Daly Iverson, 2003). Exercise should be introduced gradu-
ally and incrementally, targeting at least 30 minutes of cardiovascular fitness
training three times each week. Daily, gentle, low-impact aerobic exercise
appears to be of central importance in the treatment of FMS (McCain et al.,
1988), but too much or the wrong kind of exercise may exacerbate FMS
symptoms. Patients who are deconditioned should start out with just 3 to 5
minutes of exercise every day and gradually increase as tolerated, usually up

166 MEDICALLY UNEXPLAINED ILLNESS

to 20 to 30 minutes a day. The benefit of the exercise seems to be from its
systemic effects rather than any direct effect on the exercised muscles (Sim
& Adams, 2002). Patients should choose an exercise program they enjoy and
stick with it, because exercise must be routine to be beneficial. Recommended
methods of exercise and pain control are cardiovascular fitness training and
muscle strengthening and stretching (Gowans & deHueck, 2004; Quisel, Gill,
& Walters, 2004). Multidisciplinary programs using cognitive-behavioral
therapy in combination with exercise have been the most effective
(Karjalainen et al., 2000).
FMS patients often respond to physical modalities including physical
therapy, massage, tissue manipulation, soft-tissue injections, and acupuncture
(B. M. Berman, Ezzo, Hadhazy, & Swyers, 1999) or chiropractic (Blunt, Rajwani,
& Guerriero, 1997). Tender point thresholds have been increased with exer-
cise and external muscle stimulation through massage (Hadhazy, Bausell,
Berman, Creamer, & Ezzo, 2005) and spa therapy (Evcik, Kizilay, & Gokcen,
2002). Therefore, a consultation with a rehabilitation team, including
physiatrists and physical therapists, can be a helpful adjunct to treatment.

COGNITIVE-BEHAVIORAL THERAPY

A specific goal of cognitive-behavioral therapy in FMS treatment is to

change the idea that patients are helpless against their pain (Turk, 2003).
Gaston-Johansson et al. (1990) found that individuals with FMS were sig-
nificantly less optimistic than rheumatoid arthritis patients regarding relief
from pain, improved functioning, and employment prospects. Cognitive ru-
mination and pessimism reported in FMS (Gaston-Johansson et al., 1990;
Hazlett & Haynes, 1992) have implications for treatment. Catastrophizing is
common in women with FMS and chronic pain conditions and appears to
contribute to poorer outcomes (I. Jensen et al., 1994). Catastrophizing re-
sponses and other dysfunctional cognitions can be addressed in cognitive
therapy.
Patients' initial beliefs about the success of treatment can have an im-
portant influence on the treatment outcome. Goosens, Vlaeyen, Hidding,
Kele-Snijders, and Evers (2005) examined the extent to which treatment
expectancy predicts the short-term and long-term outcomes of cognitive-
behavioral treatment of chronic pain. This study used the data of two pooled
randomized clinical trials evaluating the effectiveness of cognitive-
behavioral interventions for 171 patients with FMS and chronic low back
pain. Pretreatment and posttreatment expectancy were measured by a short
questionnaire before and after the intervention and at 12-month follow-up.
Patients with higher treatment expectancies were significantly less fearful
and received less disability compensation. Pretreatment expectancy signifi-
cantly predicted outcome measures immediately after treatment as well as at

TREATMENT APPROACHES TO FIBROMYALGIA 167

 12-month follow-up. This study corroborates the importance of evaluating
treatment expectation before attempting cognitive-behavioral intervention
with FMS patients.
I. Jensen, Bergstrom, Ljungquist, Bodin, and Nygren (2001) evaluated
the outcome of behavioral approaches compared with a treatment-as-usual
control group in chronic pain patients on sick leave in Sweden. The results
showed that the risk of full-time early retirement was significantly lower for
women in behavior-oriented physical therapy and cognitive-behavioral
therapy compared with the control group during the 18-month follow-up
period. However, the total absence from work in days over the 18-month
follow-up period was not significantly different in the control group com-
pared with the treatment groups. On the Short Form-36 (SF-36), women
receiving cognitive-behavioral therapy either exclusively or in conjunction
with physical therapy reported a significantly better health-related quality of
life than women in the control group at the 18-month follow-up. No signifi-
cant differences for men were found on the SF-36 scales. The results revealed
gender differences in the outcome of the treatments and that the compo-
nents of behavioral programs yielded results as effective as the comprehen-
sive program. The authors speculated that the women may have benefited
more than the men from pain management techniques because women have
a greater need for the specific coping strategies presented or are able to apply
the strategies more effectively. Because many women have a higher total
workload than men (paid plus unpaid work), they may be able to apply more
effective coping strategies to their home environment (I. Jensen et al., 2001).
Behavior modification is an important component of cognitive-
behavioral therapy. Behavior modification involves learning coping skills,
relaxation exercises, and self-hypnosis. Nielson and Jensen (2004) examined
the relationship between changes in coping and treatment outcome after a
multicomponent treatment. The treatment program was a 5-day-a-week, 4-
week outpatient program aimed at improving pain management and physi-
cal and psychological functioning. It included cardiovascular, strengthening,
and stretching exercises; a graded activity program; group cognitive-behav-
ioral therapy; assertiveness and relaxation training; group pain education;
and tapering of pain medications. Regression analyses revealed that the fol-
lowing beliefs and coping strategies were most likely to be associated with
improved outcomes at 3- and 6-month follow-up: increased sense of control
and belief that FMS is not disabling and that pain is not necessarily a sign of
damage, decreased guarding, increased exercise, seeking support, activity pac-
ing, and use of coping self-statements.
Disclosure writing has shown benefits in chronic illness groups such as
rheumatoid arthritis and cancer as well in psychological disorders (R. S.
Campbell & Pennebaker, 2003). Broderick, Junghaenel, and Schwartz (2005)
investigated the effect of written emotional expression in FMS. Ninety-two
women were randomized to a trauma writing group, a control writing group

168 MEDICALLY UNEXPLAINED ILLNESS

that wrote about time management, or a usual care control group. At the 4-
month follow-up, pain and fatigue measures were significantly lower in the
trauma writing group compared with the control groups, and there was a
slight improvement in psychological well-being. However, at the 10-month
follow-up, none of the measures reflected that improvement.
The problem of not sustaining benefits in FMS treatment is not surpris-
ing given the high level of attrition and nonadherence to regimes. Meaning-
ful improvement rarely occurs without active participation by patients in
their treatment (Clauw & Crofford, 2003). It may be more efficacious for
treatment to be tailored to subgroups within FMS. For example, dysfunc-
tional patients might benefit from an operant behavioral approach to reduce
the solicitous behaviors of significant others, whereas interpersonally dis-
tressed patients might benefit from interpersonal problem-solving and com-
munication skills and treatment for depression. The adaptive coper group
may benefit the most from exercise regimes (Thieme, Turk, & Flor, 2004;
Turk, Okifuji, Sinclair, & Starz, 1998).

CASE STUDY
This case study1 illustrates a fairly typical picture of an FMS patient
beginning cognitive-behavioral therapy. Well illustrated here is the tortu-
ous route toward obtaining a diagnosis of FMS, which, although providing
some validation, does not provide any efficacious treatment avenues.
Abigail was a 39-year-old mother of 8-year-old twins. She had been
amicably divorced for 3 years, although her ex-husband had moved 350 miles
away so saw the children only for vacations. She had her 72-year-old parents
living with her. She had trouble enjoying family life because of constant pain
and exhaustion. When she arrived for psychological therapy, she seemed pleas-
ant and soft-spoken yet somewhat anxious as she told her therapist that she
had had headaches all her life. Abigail was also struggling with sleeplessness,
depression, nervousness, panic attacks, and constant exhaustion, all while
trying to raise her family and tend to her parents' needs. Her mother was in
good health but her father had suffered a stroke and had many health prob-
lems. Pain would wake Abigail two to three times a night. She was taking St.
John's wort for depression.
Along with her health, her personal freedom and family life were dete-
riorating. "1 was really irritable with my Mom and Dad for anything, and
with the kids. I would get really upset over anything." Ordinary daily activi-
ties like driving caused great distress and pain. She described headaches causing
tension that
pulled my muscles so much that it was painful to stretch my arms or to
turn my head. I would do an aerobics class and get a strong headache.

'This case study K a fictionalized amalgam of typical patients.

TREATMENT APPROACHES TO FIBROMYALGIA 169

 Eventually I stopped exercising completely because I didn't even have
the energy to go.

Abigail didn't know what was wrong with her. One doctor told her she
had tension headaches; another, muscle spasms. Subjecting herself to many
tests and treatments, she still didn't get a clear answer or any relief.
Abigail described one visit to her primary care physician:
He put me in a dark room and gave me a shot in the arm. We waited for
10 minutes to see if my headache would go away, but I still had it. The
doctor told me I'm not suffering from migraines. Then they put iodine in
the vein to find out if I had some kind of brain tumor. A CAT scan was
negative.
Her doctor prescribed Tylenol with codeine and then Valium. The pain
returned. After 3 days on a higher dose, still in pain, she decided to stop
taking the drug because it didn't seem to be helping. He referred her to an
orthopedic physician, who reported a narrowing of the spaces in the cervical
spine, but the MRI came back negative for abnormalities. For pain relief and
muscle spasms, the doctor performed an infiltration of the spine with pain
medication and corticosteroids. Abigail didn't like taking the steroid shots.
She knew it wasn't a cure. "With the shots, I felt so scared. I knew he wasn't
on the right track."
Visits to a chiropractor and a massage therapist provided pain relief for
only an hour or so. Going from doctor to doctor to try to find a cure, with
minimal results, Abigail lamented, "I felt afraid because I didn't know what
was going on with me. I didn't know if the problems were from allergies, age,
or my hormone system. I thought it could be my thyroid or too much stress."
When she went back to her primary care physician, he decided she was suf-
fering from FMS. He told her there was no real treatment for it except anti-
depressant drugs and muscle relaxants. He suggested that she see a psycholo-
gist and referred her to a clinician who specialized in patients with MUIs.
The psychologist explained to Abigail that when positive states of mind
are restored, the physical body responds. Troublesome feelings such as fear,
frustration, loss, anger, anxiety, sadness, depression, and hopelessness often
chronically surround a physical illness and hamper healing, undermining the
ability to feel in control of the outcome. Abigail understood the limits of
biomedical treatment for her FMS, and she expressed willingness to try
cognitive-behavioral therapy. Her therapist outlined the goals of treatment
as follows:
The primary goals of [cognitive-behavioral therapy] in FMS are to change
distorted perceptions and self-defeating behaviors. Using specific tasks
and self'observation, you will learn to think of pain as something other
than a negative factor that dominates your life. Over time, the idea that
you are helpless against pain will recede and you will learn that you can
manage your FMS.

170 MEDICALLY UNEXPLAINED ILLNESS

 Cognitive therapy is especially helpful in defining and setting lim-
its—a behavior that is extremely important for FMS patients. Abigail,
you are like many FMS patients who are trying to do everything for ev-
eryone. People with FMS often doggedly push themselves past the point
of endurance until they collapse and withdraw. This inevitable backlash
reverses their self-perception, and they then view themselves as com-
plete failures, unable to cope with the simplest task. One important aim
of cognitive-behavioral therapy is to help you find a middle route, where
you can prioritize your responsibilities and drop some of the less impor-
tant tasks or delegate them to others. Learning these coping skills can
eventually lead to a more manageable life and to less of an absolutist
perspective on yourself and others.
Abigail's therapy lasted for 16 sessions, 1 hour each week. She was also
given homework: keeping a diary, attempting tasks that she had been avoid-
ing, and practicing relaxation. Her program included the following tasks:
• Keeping a diary: A diary is often a key component of cognitive
therapy. The diary serves as a general guide for setting limits
and planning activities. Patients use the diary to track any stress
factors, such as a job or a relationship that may be making the
pain worse or better.
• Cognitive restructuring of negative thoughts: Abigail was taught
to challenge and reverse negative beliefs ("e.g., I'm not good
enough to control this condition, so I'm a total failure") to us-
ing coping statements ("Where is the evidence that I cannot
control this illness?").
• Graded activation and setting limits: Limits are designed to
keep both mental and physical stress within a manageable frame-
work so that patients do not get discouraged by forcing them-
selves into situations in which they are likely to fail. For ex-
ample, tasks and exercise are broken down into small,
incremental steps, and patients focus on one at a time.
• Seeking out pleasurable activities: List a number of enjoyable
low-energy activities that can be conveniently scheduled.
• Prioritizing: Learn to drop some less critical tasks or delegate
them to others.
• Relaxation training: Abigail was taught several relaxation tech-
niques to use throughout the day.
• Accepting relapses: Accomplishing too much too soon can of-
ten cause a relapse of symptoms. Patients should respect these
relapses and back off. They should not consider them a sign of
treatment or self-failure.
Abigail's beliefs in her ability to control pain were strengthened as she
gained success in using self-management skills. She was exercising for 20

TREATMENT APPROACHES TO FfBROMYALGIA 171

minutes every other day, and her mood was considerably improved. She was
no longer taking St. John's wort, because she didn't believe that it had helped
her. Beliefs in her ability to control pain also appeared to be stable; a follow-
up visit 4 months after the end of therapy revealed that she had maintained
her progress. Cognitive-behavioral therapy assumes that beliefs in control
evolve from successful use of cognitive skills, and Abigail's case provides a
clear example of this principle.
Because FMS involves a range of symptoms, different treatment mo-
dalities that target different symptoms are required. Exercise can help reduce
hypersensitivity to pain and improve mood. Low-dose antidepressants may
improve sleep and reduce pain. Cognitive-behavioral therapy can help modify
maladaptive thoughts and improve depressed mood, activity levels, and so-
cial relationships. A person-centered multimodal approach tailored toward
the individual's most pressing needs should enhance the patient—provider
relationship and help prioritize patients' goals (Masi et al., 2002). Although
FMS is difficult to treat, the studies reviewed in this chapter indicate that
tailored approaches, often involving a team of health professionals, can be
effective in reducing suffering and disability.

172 MEDICALLY UNEXPLAINED ILLNESS

 TREATMENT APPROACHES TO
11
CHRONIC FATIGUE SYNDROME

Given the diagnostic evolutions and heterogeneity of the chronic fa-

tigue syndrome (CFS) population, it is hardly surprising that there are no
firmly established treatment recommendations for CFS. This chapter reviews
some of the approaches that have been studied with this population.

PHARMACOLOGICAL APPROACHES

A number of pharmacological approaches have been attempted with-

out notable success. Many pharmacological treatments, including antivirals,
immune modifiers, essential fatty acids, antifungal agents, vitamins, and min-
erals, have been reported anecdotally to be helpful, but they have not dem-
onstrated efficacy in double-blind, placebo-controlled clinical trials (Blondel-
Hill & Shafran, 1993). A randomized, placebo-controlled, double blind,
multicenter study of a ribonucleic acid drug—Poly(I):Poly(C12U),
Ampligen—with antiviral and immunomodulatory properties was conducted
on 92 participants with severe CFS (Strayer et al., 1994). After 24 weeks of
treatment, participants receiving Ampligen reported a significantly reduced

173
disability score, enhanced ability to perform activities of daily living, and
reduced cognitive impairment, and they were able to tolerate a greater
workload during treadmill testing. However, Ampligen has not yet been ap-
proved for use in treating CFS. Despite frequent use of antidepressants for
fatigue, Dzurec (2000; Dzurec, Hoover, & Fields, 2002) concluded that anti-
depressants provide little long-term amelioration of fatigue for patients with
normal laboratory values. In a double-blind, placebo-controlled study,
fluoxetine had no beneficial effect in patients with CFS, with and without
depression (Vercoulen et al., 1996).
Given that hypocortisolism has been found in some persons with CFS,
treatment with hydrocortisone has been attempted. Cleare et al. (1999) found
that CFS patients reported significant reductions in self-rated fatigue and
disability compared with a placebo group after 28 days of treatment with
low-dose hydrocortisone, which led to a rise in circulating cortisol. A group
using a higher dose found adrenal suppression indicating that risks outweighed
benefits (McKenzie et al., 1998). Cleare et al. (2001) found that about 28%
of CFS patients responded to hydrocortisone treatment with reduced fatigue
levels (similar to the percentage found in the previous two studies). In those
who responded to treatment, there was a corresponding normalization of the
blunted cortisol response to human corticotropin-releasing hormone chal-
lenge. Although molecular biology advances are promising, pharmaceutical
approaches do not appear to offer significant benefits to the majority of indi-
viduals with CFS.

Beliefs and Coping Styles

Several studies have found that people with CFS have negative coping
styles such as escape-avoidance and denial (Blakely et al., 1991; Cope, Mann,
Pelosi, & David, 1996). Similarly, people with CFS tend to make external
attributions for their illness, maintaining organic illness convictions over
psychological explanations (Cope et al., 1996; S. K. Johnson, Lange, Tiersky,
DeLuca, & Natelson, 2001; R. Powell, Dolan, & Wessely, 1990; Schweitzer,
Robertson, Kelly, & Whiting, 1993; Surawy, Hackman, Hawton, & Sharpe,
1995); only one study has found that psychological morbidity and physical
attribution were not risk factors for chronic fatigue (Lawrie et al., 1997). In a
study of Gulf War veterans with CFS, Fiedler et al. (2000) found that life
stressors after the war, environmental exposures, neuroticism, defensiveness,
and negative coping style were predictors of low physical functioning on the
Short Form-36.
S. K. Johnson, Gil-Rivas, and Schmaling (2006) found that the use of
instrumental social support, which includes seeking information, advice, and
assistance, was negatively associated with vitality. Although it may seem
counterintuitive, studies have found that membership in a self-help group is
a robust predictor of poor treatment response to a graded exercise trial (Bentall,

174 MEDICALLY UNEXPLAINED ILLNESS

Powell, Nye, & Edwards, 2002) and poor outcomes over time (Sharpe et al,
1992). Involvement in self-help groups may represent illness conviction and
stronger attachment to the illness as well as involve information and advice
seeking, which may be counterproductive in CFS. Similarly, religious in-
volvement has usually been associated with positive health outcomes (L. H.
Powell, Shahabi, & Thoresen, 2003) but greater CFS symptom severity. The
COPE scale items tapping religious coping are turning to God, praying, and
finding comfort in religion, which imply a passive, internal process that might
involve more rumination than being engaged in religious activities; seen in
this light, it is perhaps not surprising that religious coping techniques are
used by the more symptomatic and disabled participants. These studies indi-
cate that addressing beliefs and coping styles could improve outcomes in
CFS.

COGNITIVE-BEHAVIORAL THERAPY

Cognitive-behavioral therapy is designed to alter a patient's cognitive

focusing on bodily symptoms and somatic attribution. This type of therapy
designed for CFS patients usually consists of challenging fatigue-related cog-
nitions, diminishing strong somatic attributions, improving sense of control
over symptoms, and facilitating increased levels of physical activity (Prins et
al., 2001; Sharpe et al., 1996). Cognitive-behavioral therapy and graded ex-
ercise therapy are the primary interventions that have been found to be ef-
fective in CFS (Prins, van der Meer, & Bleijenberg, 2006). Surawy et al.
(1995) have proposed that although infection and/or severe stress are pre-
cipitating factors, cognitive and behavioral factors are central in perpetuat-
ing illness. Thus, effective approaches need to break the cycle of decondi-
tioning, avoidance, and depression through graded activity and cognitive
restructuring. The therapist's goal should be recovery, which means that the
client with CFS strives to discard the "patient label" (Prins, Bleijenberg, &
van der Meer, 2002). This does not mean that the client returns to premorbid
functioning, which was often an extremely active life. Rather, individuals
with CFS must accept limitations but work toward lifestyle goals that make
them feel healthier.
Before considering cognitive-behavioral therapy, therapists should as-
sess a CFS patient's complaints. Responses to the following questions (adapted
from Bleijenberg, Prins, & Bazelmans, 2003) can be illuminating:
How does the patient spend the day?
What are the patient's views on the causes of complaints?
Does the patient have a tendency to catastrophize the complaints?
Is the patient afraid to undertake activities?
What effects do the patient's complaints have on his or her social
environment?

TREATMENT APPROACHES TO CHRONIC FATIGUE SYNDROME 175

 Has their work situation been affected by CFS?
Typical problematic cognitions encountered in therapy with CFS pa-
tients include statements along these lines:
"I'll never get better."
"I used to be able to do it all. I'd be cleaning the kitchen floor
while watching Late Night with David Letterman."
"I hate to have to ask others to do things for me. I've always been
the one doing for other people."
These themes of interference with previous high-activity levels or
nurturant roles, a reversal of the caregiving role, can result in guilt-tinged
cognitions, especially for women with CFS. It is important for the therapist
to guide their patients into more accepting and adaptive cognitions:
"I don't have to be perfect; everyone has limits."
"I can still achieve some goals; I have to set realistic limits."
Several early cognitive-behavioral therapy studies reported benefits in
improving disability outcomes (Bonner, Ron, Chalder, Butler, & Wessely,
1994; Butler, Chalder, Ron, & Wessely, 1991), whereas others have not
(Freidberg & Krupp, 1994; A. Lloyd et al., 1993). Bonner et al. (1994) con-
ducted a 4-year follow-up study of 47 patients diagnosed with CFS and of-
fered cognitive-behavioral therapy and found that 87% of the 23 partici-
pants who successfully completed therapy remained well 4 years later. In a
nonblind, nonrandomized study, Butler et al. (1991) found that 70% of par-
ticipants who started treatment rated themselves as "better" or "much bet-
ter" at the end of treatment and remained better at 3-month follow up. From
their initial pool of 50 patients who were offered cognitive-behavioral therapy,
18 declined and 5 withdrew after the start of treatment. Conversely, a ran-
domized, double-blind comparison of treatment and routine clinic attendance
found neither cognitive-behavioral therapy alone or in combination with
immunologic therapy of dialyzable leukocyte extract provided any benefit
greater than nonspecific treatment (A. Lloyd et al., 1993). However,
cognitive-behavioral therapy in this study comprised only six sessions over
10 weeks and may not have been intensive enough to sustain improvement.
Freidberg and Krupp (1994) found that cognitive-behavioral therapy (their
intervention emphasized coping skills) benefited only those individuals with
both CFS and depression; fatigue severity remained unaffected, although
catastrophic thinking, stress, and symptom magnification were reduced.
Deale, Chalder, Marks, and Wessely (1997) performed a study that con-
trolled for nonspecific treatment factors such as therapist time, attention,
support, and homework practices by using a relaxation comparison group.
They found that 70% of CFS patients showed improvement (on a physical
functioning scale) after 13 sessions over 4 to 6 months, whereas only 19% of

176 MEDICALLY UNEXPLAINED ILLNESS

a relaxation group improved. A total of 21% of eligible participants either
declined participation or dropped out before the 4 months were complete. In
a follow-up interview 5 years later (Deale, Kaneez, Chalder, & Wessely, 2001),
68% of the patients who received cognitive-behavioral therapy and 36% of
those who received relaxation therapy rated themselves as "much improved"
or "very much improved." Significantly more patients who received cogni-
tive-behavioral therapy met criteria for complete recovery, were free of re-
lapse, and experienced symptoms that had steadily improved or were consis-
tently mild or absent since treatment ended; they also worked significantly
more hours per week. Another randomized controlled trial of 16 weekly ses-
sions of cognitive-behavioral therapy showed that 73% improved to a level
of normal daily functioning compared with 27% of those given only medical
care (Sharpe et al, 1996). Only 2 out of 62 refused to participate, and all
participants completed treatment. At 12-month follow-up, work status had
improved for 63% of the cognitive-behavioral therapy group but for only
20% of the control group.
Prins et al. (2001) compared cognitive-behavioral therapy with guided
support groups and a no-intervention control in a multicenter randomized
trial. Ninety-three individuals with CFS were randomly assigned the
cognitive-behavioral treatment (administered by 13 therapists trained in this
technique for CFS), 94 were assigned the support-group approach, and 91
the control group. At 8 months, 83 in the treatment group, 80 in the support
group, and 78 in the no-intervention group had complete data. At 14 months,
cognitive-behavioral therapy was significantly more effective than both con-
trol conditions for fatigue severity and for functional impairment measures.
Support groups were not more effective for CFS patients than the no-
intervention condition. Among the cognitive-behavioral group, clinically
significant improvement was seen in fatigue severity for 20 of 58 (35%), in
Karnofsky performance status1 for 28 of 57 (49%), and in self-rated improve-
ment for 29 of 58 (50%). Those who improved with cognitive—behavioral
therapy had a higher sense of control, whereas a passive activity pattern and
focusing on bodily symptoms predicted less improvement.

EXERCISE

Graded exercise has shown effectiveness in CFS. Treatment should be

gradual, starting at a low level of activity or exercise and increasing incre-
mentally under controlled conditions (Sharpe & Wessely, 1998). In a ran-
domized controlled trial of graded aerobic exercise compared with flexibility

'The Karnofsky Performance Status Scale has the following anchors: 0 = Dead; 50 = Requires
considerable assistance and medical care; and 100 = Normal, no complaints, no evidence of disease (Mor,
Laliberte, Morris, & Weiman, 1984).

TREATMENT APPROACHES TO CHRONIC FATIGUE SYNDROME I77

and relaxation treatment, CFS participants reported significantly greater
improvements in fatigue, functional capacity, and fitness after exercise treat-
ment (Fulcher & White, 1997). Wearden et al. (1998) performed a 6-month
prospective randomized placebo and therapist-contact-time controlled trial
with allocation to one of four treatment conditions: exercise and 20 milli-
grams of fluoxetine, exercise and placebo, appointments with a therapist and
20 milligrams fluoxetine, and appointments and placebo. Results showed that
exercise was effective in reducing fatigue and improving health perception 6
months after the intervention, although patients were more likely to drop
out of exercise than nonexercise treatment and disability levels remained
unaffected. Fluoxetine had a significant effect on depression at Week 12 only
but had no effect on fatigue or disability.
P. Powell, Bentall, Nye, and Edwards (2004) performed an educational
intervention designed to encourage graded activity. At 2-year follow-up, 63
of the treated patients (55%) no longer fulfilled trial criteria for CFS. This
was similar to the percentage at 1-year follow-up and showed that the ben-
efits of the intervention were maintained. Wallman, Morton, Goodman,
Grove, and Guilfoyle (2004) also performed a randomized controlled trial
of graded exercise with pacing (32 patients) compared with relaxation-
flexibility therapy (29 patients) performed twice a day over 12 weeks. Fol-
lowing the graded exercise intervention, scores were improved for resting
systolic blood pressure, work capacity, perceived exertion after exercise,
net blood lactate production, depression, and performance on a modified
Stroop color-word test. No such changes were observed in the relaxation-
flexibility condition. The authors suggested that improvements may be as-
sociated with the abandonment of avoidance behaviors.
Moss-Morris, Sharon, Tobin, and Baldi (2005) were interested in de-
termining the mechanism underlying effectiveness of graded exercise therapy.
Do individuals with CFS improve with exercise interventions because of
improved physical fitness, which reduces symptoms caused by decondition-
ing, or does an exercise program increase patients' sense of control, reduce
focus on symptoms, and alter fears about the consequences of exercise? Forty-
nine CFS patients were randomized to a 12-week graded exercise program or
to standard medical care. At the end of treatment, the exercise group rated
themselves as significantly more improved and less fatigued than the control
group. The authors concluded that a decrease in focus on symptoms rather
than an increase in fitness mediated the treatment effect.
Bleijenberg et al. (2003) recommended different approaches for rela-
tively active versus low-active CFS patients. Relatively active patients need
help in building up their activity levels in a graded fashion without exacer-
bating symptoms. Low-active patients have fears that any activity may ag-
gravate symptoms. These patients typically spend a lot of time in supine po-
sitions and daytime napping. For these patients, the following cognitions
should be encouraged:

178 MEDICALLY UNEXPLAINED ILLNESS

 "I need to stop looking for explanations and do something about
my symptoms."
"I know I will feel bad when I exercise, but my body needs to get
used to being active."
Graded activity with low-active patients should start with about six
exercise bouts per day for 1 minute each, and then they should be increased
by 1 minute each day. The therapist needs to reassure the patient that it is all
right to feel tired. Social support that maintains the patient's complaints
must be curtailed.
These studies present evidence that both graded exercise and
cognitive-behavioral therapy may be effective through reducing avoidance
behavior, decreasing symptom focusing, and increasing efficacy through in-
creased functioning and return to work, supporting the validity of a
biopsychosocial model of CFS. Some have argued that cognitive-behavioral
therapy or graded exercise would benefit only subgroups of CFS who attend
tertiary clinics, because they tend to have greater functional impairment and
more psychological disorder (Jason, Richman, et al., 1997). On the other
hand, exercise treatment may be limited to a high functioning subgroup of
individuals with CFS. Risdale, Darbishire, and Seed (2004) addressed these
issues by randomizing primary care patients with unexplained fatigue for 3
months or longer to 6 weeks of either cognitive—behavioral therapy or exer-
cise treatment. They found that the two treatments were roughly equivalent
in reducing fatigue scores. However, fewer patients took up the offer of graded
exercise therapy, and more dropped out of that treatment arm. Overall, Risdale
et al. found cognitive-behavioral therapy to be more palatable to these pri-
mary care patients. Fairly high refusal and drop-out rates for cognitive-be-
havioral therapy and exercise also indicate that one treatment will not fit all
cases, and the heterogeneity of CFS requires individualized treatment pro-
grams.
Treatment strategies should focus on strategies such as effective coping
skills and reducing catastrophic thinking as well as addressing decondition-
ing effects through increasing activity, all of which have been shown to in-
crease levels of functioning. To be effective, treatment must be collaborative
and consistent with the explanatory models relevant to the individual with
CFS. Future research should determine what individual characteristics pre-
dict success for various interventions and what treatments are most cost-
effective and efficient in improving health outcomes and reducing disability
in CFS.

TREATMENT APPROACHES TO CHRONIC FATIG UE SYNDROME 179

 12
TREATMENT APPROACHES TO
MULTIPLE CHEMICAL SENSITIVITY

There is little research examining the efficacy of treatment for multiple

chemical sensitivity (MCS). Yet, many of the approaches shown to be effec-
tive for other medically unexplained illnesses (MUIs) should be helpful in
MCS as well. Therapists must consider the pain, loss, and estrangement of a
debilitating chronic illness that is not explained and often not recognized by
the medical profession. Somatization processes can result in amplification of
bodily sensations to the point where symptoms are painful and disabling. It
then becomes difficult to separate effects induced by beliefs from physiologic
responses. For the therapist who wants to help an individual with MCS achieve
better functioning and quality of life, it is important to understand the patient's
belief system. This can help elucidate irrational cognitions that may be ame-
nable to change through cognitive-behavioral therapy.
Because individuals with MCS generally encounter a high degree of
skepticism from the medical community, they are likely to develop defensive
responses to direct questioning. Appreciation for this defensive posture led
Gomez, Schvaneveldt, and Staudenmayer (1996) to develop an indirect route
to understanding beliefs surrounding MCS using the Pathfinder networking
scaling algorithm. They examined persons with allergies, persons with MCS,

181
asymptomatic controls, and allergists. The participants were given a list of
14 MCS symptoms and 10 causal factors and asked to rate every possible
pairwise combination on a 9-point relatedness scale. They found marked dif-
ferences in the network organization, with the MCS group placing multi-
chemical exposure at the center of their belief system and all other groups
placing multichemical exposure at the periphery.
An issue for individuals with any MUI, but perhaps even more so in
MCS, is the perceived illegitimacy of the illness. The lack of medical and
cultural validation increases a sense of stigma (Chircop & Keddy, 2003).
People will challenge biomedical precepts because conventional medicine
cannot explain their body's reduced ability to function in the face of chemi-
cal exposures. There is often an antipsychological stance in people with MCS.
Individuals with MCS and other MUIs are often hostile to any theories that
include psychological causation. In Poonai et al.'s (2001) study of the 26
individuals who had panic responses, only one was agreeable to a referral to a
psychologist or psychiatrist.
Although psychological approaches have been shown to be effective in
various MUIs, it is worth considering evidence of selection bias in these stud-
ies. It is likely that people who are amenable to cognitive-behavioral ap-
proaches are only a subset of the MUI patient populations; they may be those
who are more flexible in their attitudes and more open to change.
Haller (1993) described inpatient psychiatric treatment for 3 women
who had been severely disabled by MCS. Each improved significantly from a
nonjudgmental, comprehensive approach and tapering off of aggressive medi-
cations. The women reported that their experiences were validated in the
hospital, and they substantially reduced their symptoms and described im-
proved ability to cope.
Desensitization training has been reported to be effective anecdotally,
but few studies have examined this approach. Guglielmi, Cox, and Spyker
(1994) described cognitive-behavioral treatment of phobic avoidance in 3
women with severe MCS. They hypothesized that the incapacitating sever-
ity of MCS is similar to agoraphobia. Some evidence in their cases was a
significant increase in electrodermal activity during a review of chemical
exposure and description of the test exposure, whereas actual exposure to
stimuli described by the patient as particularly noxious produced a decrease
in physiological arousal. Thus, all 3 patients exhibited anticipatory anxiety.
The cases were treated with an intensive desensitization program consisting
of biofeedback-assisted relaxation training, in vivo exposure to a hierarchy
of the offending chemicals, and cognitive restructuring. All 3 patients showed
significant improvement; 1 woman returned to work and continued to do
well, but the others were lost to follow-up.
Although approaches such as behavioral desensitization, cognitive-
behavioral therapy, cognitive therapy, and psychotropic medications can be
useful, Staudenmayer (2000) warned that the greatest challenge in treat-

182 MEDICALLY UNEXPLAINED ILLNESS

ment is to overcome the patient's disabling belief in a toxicogenic etiology
for symptoms. Many of the recommendations of clinical ecologists to avoid
all chemicals even to the point of remodeling the home or moving to cleaner
locales may be counterproductive, because they further insulate the indi-
vidual with MCS and encourage avoidance. This will likely increase phobic
behaviors. Approaches that emphasize increasing activity and decreasing
symptom focusing are probably the most effective in treating individuals with
MCS.

TREATMENT APPROACHES TO MULTIPLE CHEMICAL SENSITIVITY 183

 CONCLUSION: UNDERSTANDING
13
MEDICALLY UNEXPLAINED ILLNESS

This book has presented a vast amount of information about the most
common medically unexplained illnesses (MUIs). Although diagnostic tech-
nology has become increasingly sophisticated, MUIs still remain largely un-
explained by organic factors. There are many reasons for this: heterogeneity
of groups, fairly recent case definitions, inconsistent research findings, and
an etiology that appears to be multidetermined. The biopsychosocial model
helps illuminate a contextual perspective to account for the interaction of
biological, psychological, social, and cultural factors. Biopsychosocial com-
ponents play a role in disease perception, symptom generation, and health
care seeking (Mayer, 1999).
Biological vulnerabilities may encompass genetics, hypothalamic-
pituitary-adrenal axis dysregulation, neuronal sensitization and hyperexcit-
ability, visceral hypersensitivity, immune suppression, and autonomic dysreg-
ulation. These vulnerabilities are aggravated by psychosocial stress, includ-
ing childhood abuse, work, role strain, and interpersonal stress. Cognitive
factors that increase the experience of symptoms are hypervigilance,
catastrophizing, and amplification. All of these processes are bidirectional
(Wilhelmsen, 2005). The pathophysiology of MUIs is heavily influenced by

185
psychosocial factors, particularly chronic stress. Much of the research reviewed
in this volume suggests that the physiological systems of people with MUIs
do not respond normally to physical and psychological stresses.
It is well established that virtually all of the MUIs are much more com-
mon in women. So, what more have we learned about MUI by focusing on
gender? Women's symptoms are more likely to be multidetermined than men's
symptoms, and because the most-established finding regarding MUIs is that
they are multidetermined, it is not surprising that MUIs are more prevalent
in women. Factors that occur more commonly in women—abuse, neglect,
role strain, depression, anxiety, and emotional coping styles—have been
shown to influence the precipitation and chronicity of MUIs. Women have
lower thresholds for perceiving symptoms and are more likely to seek help for
symptoms than men. Much of this is due to gender role expectations and
social learning wherein women are allowed to complain about symptoms and
seek help.
Psychopathologies, such as depression and anxiety, contribute to vigi-
lance regarding symptoms. Nonetheless, many studies have found that close
to half of individuals with MUIs have no significant psychiatric pathology.
However, other psychosocial factors, such as premorbid perfectionism,
overactivity, emotional rigidity, neuroticism, and poor coping mechanisms,
have been shown to increase risk for MUIs. An example of an important
psychosocial stressor that appears to make women more vulnerable to MUIs
is susceptibility to abuse. Although boys and men suffer sexual and physical
abuse as well, it appears to be more common in girls and women. Because it is
such a difficult area to study, relying on notoriously subjective self-report,
the true prevalence of such abuse may never be understood. There is no ques-
tion that a trauma history accompanied by a lack of protective factors, whether
these be personality factors, psychological resilience, social support, or physi-
ology (genetic fitness), contribute to a greater risk of MUI.
What is the best approach for psychologists confronting people with
MUIs? Early diagnosis and management can help reduce disability. Sharpe
and Carson (2001) proposed a paradigm shift in which unexplained symp-
toms become "remedicalized" around the notion of a functional disturbance
of the nervous system. They proposed that integrating psychological treat-
ment into general medical care would improve the care of individuals with
MUIs. Certainly, the treatment evidence in this volume indicates that psy-
chological approaches are generally more efficacious than drug therapies.
Others (Heath, 1999; Wilhelmsen, 2005) have argued that normalizing rather
than pathologizing unexplained symptoms with an emphasis on acceptance
is the best approach. Is medicalization of MUIs helpful to patients in that it
legitimizes their complaints, or is it more helpful to encourage coping with
symptoms and reducing reliance on fruitless medical visits? This is where
health psychologists must step up to the plate and advocate for a biopsy-

186 MEDICALLY UNEXPLAINED ILLNESS

chosocial approach to patients with MUIs, rather than treatments guided by
"either-or" explanations.
Future research ought to avoid reductionism and biological primacy
and examine the contributions of interdependent mechanisms. MUIs may
defy efforts to be simplified, just as individuals with MUIs cannot be lumped
into a single category. Malterud (2000) warned against this "universalist lump'
ing trap" and the tendency to stereotype women with MUIs as a homogenous
group. The complexity of MUIs calls for more dynamic models to better ap-
portion variance among multiple factors (Hamilton & Gallant, 1993). Em-
phasizing the role of stress in MUIs, Van Houdenhove, Egle, and Luyten
(2005) exhorted researchers to use "multiwave data to investigate recursive
interactions" between past and current stressors and personality variables
and how these interactions initiate or perpetuate MUIs (p. 367). This vol-
ume has laid out the evidence for multiple factors and for the complex and
dynamic interaction of biopsychosocial factors. It is the task of future re-
searchers to illuminate gender factors more fully in searching for explana-
tions of MUIs.

CONCLUSION 187
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REFERENCES 245
 AUTHOR INDEX

Aaron, L. A., 30, 61,62,93 Backstrom, T., 101

Aarsse, H. R., 110 Badcock, C. A., 146, 152
Abrahamsson, J., 75 Bader.J.O., 118
Abu-Shakra, M., 100 Bailer, J., 142, 143
Aceves-Avila, F. J., 38 Baker, G. A., 85
Adams, N., 165, 167 Bakheit, A. M. O., 121
Afari,N., 119 Balaam, B., 156
Afzal, A., 159 BaldiJ.C., 178
Ahles, T. A., 108-109 Baldwin, C. M., 136
Ahlmen, M., 166 Ball, R. W., 56
Akman, D.,31,75, 77, 78, 154 Ballenger, J. C., 81
Alagiri, M., 72 Ballweg, M. L., 56
Alberts, M., 118 Bane, C., 55
Albuquerque, R. J., 58 Barlas, P., 56
Aldag.J.C., 61, 99-100, 108 Barnett, R. C., 46
Alexander, R. W., 107 Barreiro, M. A., 84
Alhoashle, A., 100 Barren, J. T., 73
All, A., 31,77, 78 Barsky, A., 22, 24, 62
Ali, U., 73 Barsky, A. J., 3, 4, 19, 21-24, 27, 30, 35, 53,
Allen, L. A., 24 57, 72, 145
Aloisi, A. M., 58 Bascom, R., 139
Alonso, C., 101 Baxter, G. D., 57
Altemus, M., 120 Bayerl, C., 142
Altiparmak, E., 68 Bazelmans, E., 147, 175
Ambrose, K., 95 Beard, G., 14, 15
Amend, D., 138 Becker, D., 14, 15, 47
American Psychiatric Association, 10, 16, Behan, P. O., 121, 123
24, 82, 135-136 Bell, D. A., 166
Anagnostis, C., 45 Bell, I. R., 136, 138, 139, 141
Anderberg, U. M., 101 Bengstsson, C., 33
Anderson, A. H., 58 Benhamou, Y., 150
Anderson, ]., 92, 109 Benjamin, S., 90, 104
Anderson, J. S., 119 Bennett, E. J., 75, 146, 152
Anderson, T., 42 Bennett, R. M., 95, 163, 164
Anthony, M. M., 142 Benson, M. J., 70, 151
Appleby, L., 119 Bentall, R. P., 174
Arias, I., 41 Benyami, Y., 40
Arnold, L. M., 95, 164 Berglund, L., 101
Arnow, B., 42 Bergmann, S., 4, 115
Asbring, P., 37 Bergstrom, G., 168
Ashford, N. A., 133 Berman, B. M., 165, 167
Assefi, N., 165 Berman, S., 75, 76
Assefi, N. P., 37 Bernardy, N. C., 54
Auchenbah, M. B., 95 Bernklev, T., 150
Auer, C., 50 Bernstein, D., 42, 63, 109
Austad, C., 127 Bhagwagar, Z., 54

247
Bierl.C., 118 Brohimer, S. O., 144
Bildt, C., 29 Brosschot, ]. F., 110
Binder, L. M., 39 Brostoff, ]., 122
Binkley, K. E., 140, 142 Buchwald, D. S., 30,37,61,62,93,106,118,
Bishop, S. R., 44 119, 123,124,126,136,165
Bissell, M., 139 Buchwald, D. P. R., 122
Bjelle, A., Ill, 163,166 Buckley, L, 36, 128
Bjorkman, D., 74 Bullington, ]., Ill
Bjornsson, E. S., 75 Buntin, M. S., 102
Black, D.W., 135, 136,141,142 Burckhardt, C. S., Ill, 163, 164, 165, 166
Blackwell, B., 32 Burke, H. M., 54
Blakely, A. A., 127, 174 Burnam, M. A., 24
Blanchard, A., 47, 137 Burnett, C. K., 159
Blanchard, E. B., 43, , 78, 79, 84, 87, 153, Busch, A., 166
154, 155, 159 Busichio, K., 118
Blazer, D., 15, 24, 42 Buskila, D., 50, 95, 100
Bleeker, M. L., 143 Butler, M. P., 131
Bleijenberg, G., 115, 118, 147, 175, 178 Butler, S., 176
Blinkhorn, A., 101
Blondel-Hill, E., 173 Caccappolo-van Vliet, E., 141
Blumenthal, E., 28 Caceres, J., 28
Blunt, K. L., 167 Cairns, R., 117
Bodin, L., 168 Camilleri, M., 75, 150, 151
Boissevain, M. D., 91-92 Campbell, K. A., 39
Bella-Wilson, K., 143 Campbell, R., 28
Bombardier, C. H., 117-118, 166 Campbell, R. S., 168
Bond, F. W., 148 Campbell, S. M., 105
Boneva, R., 120 Cannon, J. G., 56
Bonkovsky, H. L., 139 Caress, S. M./134, 136
Bonner, D., 176 Carlson, C. R., 58
Bor, H. H., 62 Carrico, A. W., 119
Borglin, G., 33, 34 Carrion, V., 54
Bornschein, S., 23, 142 Carson, A., 186
Borus, J. F., 3, 19, 21-24, 30, 72, 145 Carson, J. W., 148
Bose, M., 67 Carson, K., 42
Bosmajian, L., 71, 146, 152 Carter, A. C., 99
Bosmans, E., 50 Caseras, X., 119
Botha, J. L., 36 Cately, D., 103
Bouchery, E., 119 Cathebras, P. J., 115,124,126
Boughton, C., 116 Celentano, D. D., 36
Boyce, P.M., 71,84, 85, 155, 156 Celiker, R., 100
Bradley, L. A., 85 Cevik, R., 104
Brahler, E., 29 Chalder, T., 73, 118, 128, 129, 176, 177
Brandt, L.J., 150-152 Chandler, H. K., 107
Brassloff, L, 122 Chang, L, 4, 36, 57, 67, 75-77, 79, 82, 96,
Brecklin, L., 42 154
Breeding, P. D., 99 Chase, T. N., 99
Bremner, J. D., 53, 54 Chauduri, A., 123
Breslin, P. A., 35, 56, 137 Chen, M., 123, 124
Breuer, J., 14 Cheney, P. I., 122
Brewin, C., 54 Cheskin, L. J., 76
Broderick, J. E., 168 Chesterton, L. S., 56, 58

248 AUTHOR INDEX

Chircop, A., 182 DaCosta, ]. M., 18
Chottiner, S., 72 Dahl, A. A., 27, 33
Chrisler, J. C., 39 Dalton, P., 35, 56, 137
Christodoulou, Q, 36, 119 Daly Iverson, M., 166
Chrousos, G. P., 30 D'Amato, M., 80
Ciccone, D. S., 64, 107-108, 118, 127 Dancey, C. P., 78, 83
Cimarolli, V., 28 Daniell, W., 138
Clark, J.N., 125 Dao, M. D., 146
Clark, M. R., 118 Darbisire, L., 179
Clauw, D. J., 30, 49, 61, 63, 79, 90, 95, 97, Daun, J. M., 56
99-100, 103, 168 David, A., 174
Claypoole, K., 138 Davidoff, A. L., 86
Clayton, P. J., 16, 17,24 Davies, R. M., 101
Cleare, A.]., 54, 103, 120, 121, 174 Davis, A., 122
Cleary, S. D., 56 Davis, C., 35
Cloninger, C. R., 16, 17, 24, 36 Davis, M. C., 37, 43, 46, 54, 111, 112, 113
Clouse, R. E, 150 Dawson, D., 149, 160
Cluydts, R., 119, 121 Deale,A., 176, 177
Coe, C, 101 Deary, I. J., 30, 66
Cohen,]. M., 122 De Bellis, M., 54
Colpan, L., 104 de Chateau, P., 51
Comer, R. ]., 51 DeHueck, A., 167
Cook, D. B., 122 De Laat, A., 56, 58
Cooper, M., 126 De Leeuw, R., 58
Cope, R, 115,119,122,124,174 DeLuca, J., 19, 22, 29, 36, 65,117,119,122,
Corazziari, E., 69 123, 126, 127, 141, 174
Corradi, K., 116 De Meirleir, K., 121
Corydon Hammond, D., 151 Demitrack, M. A., 120
Costa, D. C, 122, 123 Demoulin, C., 95
Costa, P. T., 35, 71, 128, 146, 152, 166 Dendy, C., 126
Cottier, L., 81 DeSouza, C., 17
Cowen, P. J., 54 de Souza Coehlo, L., 55, 120, 122
Cox, D.J., 182 Dessein, P. H., 98-99
Cox, D. L, 119 Devine, P. G., 45
Coy, T. V., 37 Devins, G. M., 78
Coyle, C., 127 deVree, B., 118
Crane, C., 33, 38, 40, 83, 84 Dinan, T. G., 121
Craske, M., 82 Dinser, R., 64
Creamer, P., 165 Dirnberger, G. M., 69
Creed, F., 22, 24, 42, 62, 86, 147, 149, 150, Diseth, T, H., 53
160, 161 Dolan, R., 174
Creilaard, M., 95 Donnay, A., 139
Creswell, C., 128, 129 Doolittle, N., 35, 56, 137
Crofford, L. )., 49, 99-100, 121, 164, 165, Doscher, F., 127
169 Douglass, R., 124
Croisier, J., 95 Drossman, D. A., 54, 67, 69-71, 75, 81, 82,
Crombez, G., 44 84-86, 88, 150, 153, 154, 156, 157
Cronan, T. A., 112 Dumit, J., 38
Crowell, M. D., 86 Dunne, C. A., 108
Csuka, M. E., 107 Dunne, F. J., 108
Cullen, M. R., 133, 141 Dwyer, ]., 116
Curie, C. J., 118 Dzurec, L. C., 127, 174

AUTHOR INDEX 249

Ebel, H., 131 Finestone, H., 42, 107
Eccleston, C., 28, 44, 148 Fink, P., 21, 23, 24
Edberg, A. K., 33 Finkelhor, D., 43
Edwards, H. T., 175 Fisher, R. S., 67, 70
Efskind, P. S., 150 Fitzgerald, O., 93
Egle, U. T., 7,105, 146, 147, 187 Floch, M. H., 152
Egyed, M, 50 Flor, H., 112, 169
Ehlert, U., 54 Floyd, H. H., 131-133
Ekdahl, C, 166 Ford, C. V., 16, 19
Ekeberg, O., 124 Forsman, L., 51
Ekselius, L, 101 Forsman, M., 51
Elliot, D. K., 107 Forstl, H., 23, 142
Ellis, S. P., 119 Forsythe, A., 24
Else-Quest, N. M, 35, 57 Fossey, M. D., 81
El-Serag, H. B., 74 Fostel, J., 120
Em, S., 104 Foster, N. E., 57
Emmanuel, A. V., 83 Frank, R., 29
England, R., 105 Frankenhaeuser, M., 51, 52
Engret, V., 121 Freeman, T. R., 25
Ennis, M., 53 Freidberg, F., 176
Epstein, R. M., 25, 37, 146 Freud, S., 14
Epstein, S. A., 110 Frey, B. M., 56
Eriksen, H. R., 47, 57, 95 Frey, F. J., 56
Escobar, ]. I., 24 Friedberg, L. B., 127
Eslick, G. D., 68 Friedman, M. J., 54, 138
Evans, D. L, 29 Friel,]., 131
Evcik, D., 167 Fries, E., 53
Evengard, B., 4, 118, 124, 129 Fritch, A., 59
Evers, S. M., 167 Fuhrer, R., 115
Ezzo, ]. M., 165, 167 Fukuda, K., 116, 117, 124
Fulcher, K. Y., 178
Fang, H., 120 Fullerton, S., 64
Farthing, M. J. G., 67 Furunes, B., 33
Farup, P. G., 72, 152
Fasman, R., 112 Gaab,J., 121
Pass, R., 64 Gabrielli, W., 17
Fedoravicius, A. S., 32 Gallager, A. M., 94
Feinstein, A. R., 18, 19 Gallant, S., 7, 187
Felldin, R., 110 Gallhofer, B., 109
Ferrans, C. E., 119 Galovski, T. E., 78, 153, 159
Ferrari, R., 38 Gamgerale, F., 45
Fichter, M. M., 24, 50 Gange, S. J., 56
Fiddler, M., 42 Gara, M., 24
Fiedelak, ]. I., 118, 123 Garada, B. M., 122
Fiedler, N., 4, 132-134, 136, 139-141, 174 Gardner, C. O., 27
Field, A. D., 74 Gardner, G., 42, 63, 107, 109
Fielding, J.F., 93 Garfinkel, P. E., 147, 158
Fields, H., 127 Garralda, E., 127
Fields, J., 174 Garrison, R. L., 99
Fillingam, R. B., 58 Garrity, D., 30, 61, 136
Findley, D. A., 39 Gasbarro, I. D., 147, 158
Findley, L.J., 119 Gastanaga, V. M., 61

250 AUTHOR INDEX

Gaston-Johansson, F., 110, 167 Groessl, E., 112
Gatchel, R. ]., 45 Groleau, D., 146
Gaynes, B. N., 70 Grove, R., 178
Geddes.J. R., 118 Gruber, A. J., 62
Geisser, M. E., 59, 96-97 Gudleski, G. D., 43, 87
Gelfand, A., 41 Guerriero, R. C., 167
Gelfand, A. N., 72 Guglielmi, R. S., 182
George,]. P. K., 131 Guilfoyle, A. M., 178
George, L, 15, 24 Gunderson, J., 59
Gershon, M. D., 80 Guo, W., 120
Gibson, P. R., 144 Gupta, K., 142
Gijsbers van Wijk, C. M., 25, 33, 36, 39 Gupta, O. P., 75
Gilchrist, ]., 155 Gur, A., 104
Gill,]., 167 Gurbaxani, B., 120
Gillespie, N. A., 50 Gureje, O., 20
Gil-Rivas, V., 127, 174 Gurrala, J., 151
Glaser, R., 54, 55, 120 Gustafsson, M., 110
Gleason, O. C., 23, 25 Guthrie, E., 147, 149, 160, 161
Glithero, E., 19 Guze, S. B., 16, 17,24
Goertzel, B. N., 55, 120, 122 Gwee, K. A., 69
Gokcen, E., 167
Goldberg, D. L., 108 Hackman, A., 128, 174
Goldberg, R. T., 107 Hadhazy, V., 165, 167
Goldenberg, D. L., 62, 92-93, 95, 108, 116, Hadler, N. M., 37, 46, 92, 111
164, 165 Hadzi-Pavlovic, D., 18
Goldie, L, 45 Hafizi, S., 54
Golding, J. M., 24 Hahn, B. A., 74
Goldstein, R., 107 Hahn, M., 139
Gomez, R. L., 181 Hakala, M., 50
Gonsalkorale, W. M., 155, 159, 160 Hallberg, I. R., 33
Goodman, C., 178 Haller, E., 182
Goodnick, P. J., 90, 108 Halliday, P. D., 166
Goosens, M. E., 167 Halligan, S., 42
Gowans, S. E., 166, 167 Hallman, ]., 101
Cowers, W. R., 18 Hallman, W., 136
Gracely, R. H., 95, 98 Halpert, A., 81, 154
Graham, N. M., 56 Hamilton, ]. A., 7, 38, 39, 187
Graham, T., 92, 103 Hamilton, W. T., 94
Gralnek, I. M., 74 Hammer, J., 68
Gran, J. T., 4, 89, 99 Hanewald, G. J. F. P., 24, 39
Granges, G., 93 Hanno, P. M., 72
Grant, K. R., 32 Hansen, M., 24
Graveling, R. A., 131, 133, 138 Hapidou, E., 100
Gray, C. E., 121 Harris, L, 21
Gray, D. P., 40 Harris, R. E., 97
Gray, G. C., 61 Hart, R. P., 59
Grayson, C., 28 Harth, M., 92
Greco, A., 122 Hartz, A. J., 63, 118
Green, C., 72 Haug, T. T., 27, 33, 34
Greenberg, D. B., 116 Hausteiner, C., 23, 142
Greene, B., 154, 155 Hawley, D. ]., 108-109
Greenspan, J. D., 58 Hawton, K., 128, 174

AUTHOR INDEX 251

Hayes, S. C., 148 Houghton, L. A., 76, 77, 159
Haynes, S.N., 90, 110, 167 Howell, S. C., 68, 82
Hays, R. D., 74 Hu, Y. J. B., 54, 84, 85
Hayton, B. C, 115 Hudson, J. L, 30, 62, 95, 108-109
Hazlett.R. L, 90, 110, 167 Hudson, M. S., 108
Hazlett-Stevens, H., 82 Huenefeld, M., 92, 103
Heath, A. C., 50 Huster, D., 121
Heath, I., 186 Hutton-Young, S. A., 78
Heaton, K. W., 70, 71
Hedenberg, L, 166 Ichise, M., 122
Heft, M. W., 59 lezzi, T., 59
Heim, C., 54 Ihle, D., 30, 50
Heist, V., 121 Ihlebaek, C., 72
Heitkemper, M. M., 36, 72, 76, 77 Imperiale, T., 150
Helgeson, V. S., 45 Inanici, F., 61, 99
Hellesnes, B., 47 Isaksen, L. W., 37
Hellhammer, D. H., 53, 54
Hellhammer, J., 53 Jacks, A., 4, 118, 124
Hellstrom, O., Ill Jackson, J., 42
Helmteich, R. L., 77 Jackson, N. A., 76, 77
Hetnami, S., 64 Jackson, T., 59
Henderson, M., 127 Jacobson, D. L., 56
Henneberger, P. K., 136 Jaffee,J., 124
Henningsen, P., 26, 127 Jahn, S. C., 46
Henrich, G., 83 JailwalaJ., 150, 152
Herbert, L., 109 Jain, A. P., 75
Herdenfeldt, M., 59 Jajoo, U. N., 75
Hersbach, P., 83 Jakobsson, U., 33
Hesse, ]., 53 Jason, L. A., 4, 14, 15, 18, 39, 46, 64, 115,
Heymann-Monnikes, I., 155 116, 118, 119, 124, 125,179
Hibbard, J. H., 34 Jeejeebhoy, K. N., 147, 158
Hickie, I. B., 18, 50, 65 Jemelka, R. P., 84
Hidding, A., 167 Jensen, I., 45, 167, 168
Hill, A. B., 140 Jensen, M. P., 168
Hiller, W., 24 Jensen, R., 58
Hill Goldsmith, H., 35 Jerjes, W. K., 54, 121
Hirsch, S., 119 Joffe, B. I., 98
Hoffman, A., 64 Johns, K. R., 58, 100
Hohmann, A. A., 29 Johnson, D., 4, 64
Holbert, C., 39 Johnson, D. A., 159
Holdcraft, L. C., 165 Johnson, L. M., 37, 43, 112
Holland, J., 29 Johnson, S. K., 19, 22, 29, 36, 39, 47, 65,
Holloway, R. L., 163 116, 119, 126-128, 137, 141, 174
Holman, A., 24 Jones, A., 59
Holmes, G. P., 116, 117 Jones, K. R., 4, 30, 63, 72
Holtkotter, B., 79 Jones, M., 71, 85
Hommes, O. R., 147 Jones, R. H., 73, 75
Hoover, P. M., 127, 174 Jordan, K. M., 115, 124
Hornberg, C, 131 Junghaenel, D. U., 168
Home, R., 142
Horwitz, B. ]., 67, 70 Kaasa, S., 124
Hotopf, M., 25,117 Kael, A., 103

252 AUTHOR INDEX

Kahn, A. S., 46 Kith, P., 61, 124
Kaiser, K. S., 61 Kivimaki, M., 108
Kajumoto, Y, 123 Kizilay, B., 167
Kamm, M. A., 83 Kjellberg, A., 29
Kandrick, M. A., 32 Klaiberg, A., 29
Kaneez, H., 177 Kleinman, A,, 46
Kang, H., 136 Klonoff, E. A., 28
Kaptein, A. A., 137 Kolk, A. M. M., 24, 25, 33, 36, 39, 40
Kapur, N., 42 Koloski, N. A., 84, 156
Kapusta, M. A., 109 Komaroff, A. ]., 119
Karjalainen, K., 167 Komaroff, A. L, 93, 119, 122
Karlsson, G., Ill Komiyama, O., 56, 58
Karlsson, H., 50 Konrad, F., 23, 142
Karno, M., 24 Korn, L. R., 119
Karst, M., 98 Koyama, E., 147, 158
Kashikar-Zuck, S., 92, 103 Krantz.G., 51,54
Kato, K., 129 Kreutzer, R., 134
Katon, W. ]., 20, 24, 26, 42, 63, 72, 84, 107, Kroenke, K., 3, 21-23, 25-27, 33, 34, 64,
118, 126, 131, 142 115, 118,124, 145, 150
Kavanagh, G., 93 Kroll-Smith, S., 131-133
Keating, S., 81 Krueger, G. R, 64
Keck, P. E., 62, 95, 108, 164 Krupp, L. B., 127, 176
Keddy, B., 182 Kuhn, E. M., 63
Keefe, F. J., 42, 148 Kumar, D., 70,151
Keefer, L, 78, 153 Kurastune, H., 123
Keegan, D., 42, 63, 107, 109 Kuslys, T., 56
Keith, D., 107 Kwan, O., 131
Kele-Snijders, A., 167
Kellow, ]. E., 146, 152 Labum, R. V., 80
Kelly, B., 174 Lackner, J. M., 43, 75,87
Kelly, K. S., 53 Lacour, M., 133
Kelly-McNeil, K., 141 Laliberte, L., 177n
Keltner, D., 45 LaManca, ]. ]., 120
Kendall, B., 122 Lambert, P. L., 53
Kendler, K. S., 27 Landerman, R., 15, 24
Kennedy, C. L., 4, 64 Landis, C. A., 106
Kennedy, S. H., 35 Landrine, H., 28
Kennedy, T. M., 73, 75, 157 Lane,]., 144
Keogh, E., 28, 59 Lane,T.J., 115
Kessler, D., 40 Lange, G., 42, 87, 119, 120, 122, 123, 174
Keville, S., 73 Lange, L. A., 119
Khan, A. A., 27 Lapidus, L., 33
Khan, S. A., 109 Larson, ]., 28
Khine, A., 95 Lashuay, N., 134
KiecoltGlaserJ.K., 54, 55 Lasley, E. N., 54
King, C., 116 Lasry,]. C, 118, 128
Kipen, H. M., 4, 133, 134, 136, 139-141 Lautenbacher, S., 97
Kirk.J, 124 Lawrie, S. M., 118, 126, 174
Kirk, K., 50 Lax, M. B., 136
Kirmayer, L. ]., 22, 23, 25, 38, 39, 57, 64, Lea, R., 76
109,115,118, 128,145,146 Lee, H.]., 122
Kirschbaum, C., 104 Lee, O. Y., 4, 57, 76

AUTHOR INDEX 253

Lembo, T., 71 Maes, B., 50
Lentz, M. J., 106 Magill, M. K., 138
Leserman, J., 54, 84, 85 Mahurin, R., 123
Leventhal, E. A., 40 Mai, F. M., 166
Leventhal, H., 40 Maier, W., 27
Levine, P. H., 18, 63 Malleson, A., 92
Levy, R.L., 32, 71,74 Maloney, E. M., 55, 122
Lewis, D. H., 122, 123 Malterud, K., 37, 125, 148, 187
Lewis, G., 40, 127 Manders, D. N., 118
Leznoff, A., 140 Mangelsdorff, A. D., 21,115
Li, Z., 54, 84, 85 Mangold,]. C., 61,99
Lillis, ]., 148 Mann, A., 174
Lindal, E., 4, 115, 124 Mannerkorpi, K., 166
Linder, R., 64 Manu, P., 4, 30, 63, 72, 82, 115, 145
Lindqvist, P., Ill Maquet, D., 95
Linet, M. S., 36 Marks, I., 176
Linton, S. J., 43 Marteinsdottir, I., 101
Lipowski, Z. ]., 23 Martelli, M. F., 59
Lipson, J. G., 132, 137, 140, 144 Martin, A., 29
Liskow, B., 17 Martin, M., 33, 38, 40, 83, 84
Littlejohn, G. O., 58, 93, 100 Martin, N. G., 50
Ljungquist, T., 168 Martin, R., 73
Lloyd, A. R., 116, 120, 176 Martin, R. L, 16, 17,24
Lloyd, K., 40 Marucha, P. T., 55
Loevinger, B., 101 Masi, A. T., 9, 108-109,113,172
Loge.J. H., 124 Mason, N. J., 83
Longhurst, J. G., 28 Masuda, A., 148
Longstreth, G. F., 68, 70, 73 Matsushima, R., 123
Looper, K. J., 38, 146 Matthews, D. A., 115
Lopez, A., 124 Matthews, K. A., 46
Lous, I., 58 Mattsson, B., Ill
Lovelace, A. C. E., 144 Mavreas, V., 127
Lovitz, A. J., 70 Mawle, A. C., 63, 124
Lucassen, P. L. B. ]., 62 Mayer, E, A., 4, 36, 57, 64, 67, 74-76, 79-
Lui, Z., 101 81, 82, 154, 185
Lumley, M., 42 Mayer, T. G., 45
Lundberg, U., 46, 51,52, 54 Mayou, R., 25
Mayskiy, M., 164
Luoma, J. B., 148
Mazure, C. M., 28
Lustman, P. J., 150
McBeth,]., 90, 104
Luyten, P., 7, 187
McCabe.M, 119
Lydiard, R. B., 81
McCain, G. A., 91-92, 166
Lynch, A., 28 McCracken, L. M., 28, 148
Lynch, T., 42 McCrae, R. R., 35, 128
Lysens, R., 128 McDonagh, A. F., 139
McDonald-Hale, J., 85
MacCallum, R. C., 55 McEwen, B., 54
Maccia, C., 134 McGeary, D. D., 45
Mace, C. J., 19 McGlashan, T., 54
Macfarlane, G. J., 90, 104, 101 McGuire, L., 54
Macfarlane, T. V., 101 McKee, D. C., 70, 71
Machale, S. M, 122, 123 McKee, D. P., 67, 69
Macmillan, M. B., 14 McKenzie, R., 174

254 AUTHOR INDEX

McLean, S. A., 61 Nathan, H. P., 71
McTamney, ]., 132 Nayak, S., 108
McWhinney, I. R., 25 Nazeer, A., 54
Mechanic, D., 32 Neeck, G., 90, 103
Meeus, M., 113 Neerinckx, E., 128
Meggs, W. ]., 139 Neff, D., 153
Meier, N.J., 115 Neitzert, C. S., 35
Meijer, S., 21 Nelson, E., 124
Meisler,J.G.,91 Nelson, S., 41, 42
Mellner, C., 54 Nettleton, S., 32, 37, 39
Melton, L. ]., 67, 70 Neuman, L., 50, 95, 100
Meltzer, H., 127 Neutra, R. R., 134
Melville, D. L, 24 Niazi, N., 79
Mem, H.R., 79-81, 151 Nielson W. R., 92, 168
Meyer-Lindenberg, A., 109 Nieman, L. K., 56
Micale, M., 13-16 Niemi, P. M., 50
Michiels, V.,119 Nijs,]., 113
Millea, P. ]., 163 Nimnuan, C., 4, 26, 62
Miller, A. R., 82 Nisenbaum, R., 63, 124
Miller, C. S., 133, 135, 138, 139 Nishizawa, S., 55
Miller, G. E., 55 Nolen-Hoeksema, S., 28, 44
Miller, L. ]., 39 Noor, W., 69
Miller, V., 159 Nyberg, B., 166
Millon, C., 127 Nyberg, F., 101
Mischel, M. H., 36 Nye, F.J., 175
Mitchell, C. M., 70, 75 Nyenhuis, D. L., 29
Mohr, D. C., 54 Nygren, A. L., 45, 168
Moldofsky, H., 105 Nykvist, K., 29, 40
Monnikes, H., 146, 152
Monsbakken, K. W., 152 O'Hea, E. L., 39
Monson, R. A., 24
O'Keane, V., 121
Mooser, S. B., 131,137
Okifuji, A., 108-110,112, 169
Mor, V., 177n
Okifuji, L, 108
Morris, J. N., 77, 177n
Morris, S., 90, 104 Okiishi, C., 135
Morton, A. R., 178 olde Hartman, T. C., 62
Mossey, C. J., 164 Olden, K. W., 68, 74, 84
Moss-Morris, R., 65, 126, 178 Oleson, ]., 58
Moye, S., 78 Oliver, K., 112
Muller, D., 101 Olmsted, M. E., 37
Muller-Lissner, S., 151 O'Malley, P. G., 164
Munakata,]., 4, 67, 79, 154 Oppenheim, J., 14, 15
Myers, C. D., 58, 59 Orenstein, H., 17
Mykletun, A., 27, 33 Ostbve, M., 92
Ostensen, M., 102
Nagasaka, T., 59 Othmer, E., 17
Naliboff, B. D., 4,36, 57, 67, 72, 74, 75, 76, Otte, C., 54
77, 79, 82, 96,154 Ottenweller, J., 120
Narayan, R., 152 Oxhoj, M., 24
Narvanen, A. L., 37
Natelson, B. H., 19, 22, 29, 36, 61, 64, 65, Pachas, W. N., 107
118-120, 122, 125-127, 136, 141, Page, G. G., 55
174 Page, J. G., 69

AUTHOR INDEX 255

Palsson, O. S., 4, 23, 30, 63, 67, 72, 86,153, Prins,J. B., 115, 147, 175,177
159 Pritchard, W., 14
Paris, J., 22, 57, 145 Proctor, T. J., 45
Parisi, G., 152 Puri, B. K., 123
Parker, A. J. R., 103 Putnam, F. W., 54
Paul, C., 142
Pawlikowska, T., 115, 124, 126 Quigley, E. M., 67, 69
Payne, A., 155 Quisel, A., 167
Pearlman, T., 61, 124, 126
Pedersen, N. L, 4, 118, 124, 129 Racciatti, D., 120
Pederson, B., 58 Raine, R., 157
Peisen, R., 121 Rajwani, M. H., 167
Pelosi, A.J., 118. 174 Ramos'Remus, C., 38
Peloso, P. M., 166 Rangel, L., 127
Penick, E. C., 17 Rao, S. G., 164
Pennachin, C., 55, 120, 122 Raphael, K. G., 42, 87, 108
Pennebaker, J. W., 23, 35, 43, 168 Rasmussen, B. K., 58
Pepper, C. M., 127 Ratner, V., 72
Perdue, L, 28 Rau, L. M., 56
Peres, M. F. P., 30 Ray, D. C., 24
Perkins, S. J., 73 Reed, R.J., 61
Pernet, A., 122 Reeves, W. C., 63, 116, 117, 119, 124
Peters, M. L., 44, 96-97 Regimbeau, C., 150
Peterson, J. M., 138, 141 Reich, J.W., 37, 111
Petrie, K.J.,47, 126, 137,143 Reid, S., 135
Petzke, F., 95-97 Reilly, J., 85
Pfeiffer, A., 163 Repetti, R. L, 46
Phillips, S., 140 Reyes, M., 63, 124
Piccinelli, M., 27, 28 Reynolds, C. R., 53
Piesse, C., 146, 152 Reynolds, K. J., 119
Pilcher, J. J., 9, 113 Rhodes, J., 85, 87
Pilger, R, 30, 50 Ricci, C., 18
Pilkington, A., 131 Richardson, D. C., 31
Pilowski, L, 32 Richardson, P., 29
Pivik, J., 44 RichmanJ. A., 46, 179
Placek, E., 144 Richter, J. E., 85
Plant, E. A., 42, 45 Rief, W., 17, 29, 30, 50, 51,53, 57
Pliner, L. F., 108 Riley, R. L., 58
Plumb, M., 29 Ringel, Y., 86
Poonai, N., 141, 142, 182 Risdale, L, 179
Pope, C. R., 34, 36 Rist, F., 142
Pope, H. G., 30, 62, 95, 108 Rizzi, M., 105-106
Poulton, R., 82 Robbins, J. M., 22,39,57,64,109,115,118,
Powell,]. B., 115 124, 128, 145
Powell, L. H., 175 Roberts, M. H, 127
Powell, P., 175 Robertson, D. L., 174
Powell, R., 174 Robins, L. N, 24, 81
Powers, S., 92, 103 Robinson, F. P., 102
Poynard, T., 150 Robinson, M. E., 58, 59, 97
Prescott, C. A., 27 Robles, T. F., 54
Price, D. D., 58, 59, 89, 97, 113 Rollman, G. B., 97, 100
Price, R., 34 Rollnik, ]. D., 44

256 AUTHOR INDEX

Ron, M., 176 Schwarzwald, ]., 58
Rose, D., 155 Schweitzer, R., 174
Rose, N. R., 56 Seed, P. T., 179
Rosendal, M., 21 Segal, Z. V., 148, 157, 158
Rosenstock, L., 138 Segall, A., 32
Ross, K., 92, 109 Segerstrom, S. C., 55
Rossy, L. A., 164, 165 Berber, E. R., 112
Roy-Byrne, P., 50, 84 Seremetis, S., 42
Rugelsjoen, A., 102 Sewell, M., 127
Russell, I. J., 89, 92, 99, 109 Shafran, S. D., 173
Russo,]., 84, 118 Shahabi, L, 175
Russo, M. W., 70 Shapiro, C., 107
Sharon, C., 178
Sachs-Ericsson, N., 42 Sharpe, M., 4, 17, 25, 26, 62, 116, 118, 119,
Sackett, C. R, 148 126, 128, 174,175, 177,186
Sagami, Y., 81, 152 Shaver,]. L.F., 102, 106, 113
Saisto, S. A., 120 Shaw, G., 153
Salmon, P., 85, 87 Shaw, R., 50
Samuel, D. B., 10 Sherman,].]., 108-110
Sandier, R. S., 70, 71 Shibley Hyde,]., 35,45
Sandoval, R., 90, 108 Shipton, E. A., 98
Sanne, H., 110 Short, K., 119
Santor, D., 44 Shorter, E., 14-19
Sarac, A.]., 104 Shoulson, I., 99
Sarlani, E., 58 Showalter, E., 13-15, 19
Sattel, H., 26, 127 Sidhwa, H. K., 75
Scarinci, I. C., 85, 86 Siessmeier, T, 123
Scarisbrick, P., 105 Sigmon, S. T., 44
Schacter, C. L., 166 Silman, A. ]., 90, 104
Schad, T., 121 Silver, R. C., 24
Schagen, C. M. T., 39 Silverman, D. H. S., 80
Schagen, S., 24 Silverstein, B., 27, 28
Scheldt, C., 133 Silverthorn, D. U, 51,55
Schlesinger, L., 62, 108 Sim,]., 165,167
Schlosser, S., 135 Simon, C., 25
Schluederberg, A., 116 Simon, G. E., 131, 138, 140, 142
Schmaling, K. B., 61, 118, 119, 123, 124, Simren, M., 75
126, 127, 174 Sinaii, N., 56
Schmidt, U, 73 Sinclair,]. D., 112, 169
Schmidtke, K., 133 Skaife, K., 87
Schmulson, M., 57, 76 Skapinakas, P., 127
Schnurr, P. P., 54 Slade, D., 72
Schoenfeld, P., 151 Slater, E., 19
Schoeny, M. E., 64 Smith, B. W., 113
Schottenfeld, R. S., 143 Smith, G. R., 24
Schuster, M. M., 71, 86, 146, 152 Smith, L. K., 36
Schvaneveldt, R. W., 181 Smith, R. C., 26, 68
Schwartz, G. E., 136, 138, 141 Smith, T. C., 61
Schwartz, J. E., 168 Smith, W. R., 37
Schwartz, P. Y., 16 Smith-Rosenberg, C., 13, 15
Schwartz, R. B., 122 Smyth, C., 71
Schwarz, S. P., 153 Smyth, G. T., 71

AUTHOR INDEX 257

Smythe, H., 18, 105 Talley, N. J., 67-71, 73, 80-82, 84, 85, 150,
Snaith, R. P., 65 151, 155, 156
Snyder, C. R., 44 Tan, G., 151, 160
Snyder, H., 41 Tanaka, H., 123
Soderlund, A., 125 Tannahill, S. N., 131
Song, S., 4, 15, 64 Tannock, C., 122, 127
Southwick, E., 54 Tarlo, S. M., 142
Sparks, P. J., 131, 142 Taylor, A. E., 78
Spatz Widom, C., 42, 87 Taylor, M. L., 107
Speechley, M, 92 Taylor, R. R., 4, 15, 19, 39, 46, 64,116,118,
Speigel, D. A., 109 125
Spence, J. T., 77 Taylor, S. E., 52
Spence, M., 65 Teasdale, J. D., 148
Sperber, A. D., 71 Tennant, C. C., 146, 152
Spertus, I., 42 Tepper, I., 58
Spiller, R., 68 Terracciano, A., 35
Spitzer, R. L., 22, 27, 33, 34 Thieme, K., 112, 169
Spyker, D. A., 182 Thomas, ]. M., 94
St. Pierre, B. A., 56 Thompson, W. G., 68-71
Staff, P., 47 Thoresen, C. E., 175
Staib, L., 54 Tibblin, G., 33, 46
Stanton, A. L, 44 Tiersky, L. A., 118, 119, 127, 174
Stanwix, A. E., 98 Tikiz, C., 102
Stapp, J. C., 77 Tirelli, U, 122, 123
Starz, T. W., 112, 169 Tobin, R., 178
Staud, R., 89, 97, 113 Toft, T., 21
Staudenmayer, H., 140, 181, 182 Tomenson, B., 149, 160
Steele, L.,15, 118 Toner, B. B., 4,31, 73, 75, 77, 78,147,148,
Stefansson, ]. G., 4, 115 154, 155, 157, 158, 160
Steinemann, A. C., 134, 136 Tonori, H., 141
Stewart, W. F., 36 Tooley, G., 119
Stockbridge, H., 138 Toomey, T. C., 84
Stone, A., 104 Torpy, D. J., 103
Stone, J., 19, 37, 38 Torres-Harding, S. R., 14, 18, 39, 116, 119
Strassels, S., 74 Trickett, N. K., 54
Stratton, P., 56 Trimble, M. R., 13, 19
Strayer, D. R., 173 Tripp, D. A., 44
Stricklin, A., 127 Trotter, D. R., 107
Stuckless, N., 160 Truman, G., 156
Sullivan, J.L., 93 Tseng, C. L, 61, 125
Sullivan, M. J. L., 20, 26, 42, 44, 63, 107, Tsuji,]., 106
109 Turk, D.C., 108-110, 112, 167, 169
Sullivan, P. F., 4, 118, 124, 129 Turner, M. J., 159
Surada, A., 138 Turner, S. M., 78
Surawy,C., 128, 174, 175 Twamley, E. W., 46
Svedlund,]., 75 Twohig, M. P., 148
Swartz, M., 15, 24
Swinson, R. P., 142 Ullman, S., 42
Swyers, J. P., 167 Umali,]., 126
Unruh, A. M., 47, 58
Taamai, H., 123 Unutzer, ]., 42
Taillefer, S. S., 118, 128 Ursin, H., 47, 57, 95

258 AUTHOR INDEX

Uslan, D., 37 Wearden, A.]., 119, 178
WeAreFMily,91
Vahlberg, T., 50 Weber, D. A., 53
Vaith, P., 133 Webster, R., 19
Van Damme, S. V., 44 Weiman, M., 177n
van der Meer, J. W. M, 115, 118, 175 Weir, P. T., 92
VanderWerf, S. P., 118 Weisenberg, M., 58
van Drunen, C., 44, 96 Weiss, E. L., 28, 54
Vandvik, P. O., 72, 152 Wells, A., 42
Van Hoof, E., 121 Werner, A., 37
Van Houdenhove, B., 7,105,128,146,147, Wessely, S., 4, 9, 14-16, 18, 19, 25, 26, 30,
187 62, 103, 115, 118, 119, 128, 174,
Van Houdenhove, L, 128 176, 177
Van Hulle, C., 35 Westerholm, P., 45
Vanner, S. ]., 68 Wetzel, R. D., 17
van Puymbroeck, C. M., 37 White, C., 128
Van Santen, M., 166 White, K. P., 9, 92, 113
van Weel, C., 62 White, P. D., 94, 178
Vassallo.C. M., 121 Whitehead, W. E., 4, 23, 30, 32, 63, 65, 69,
Vatn, M. H., 150 71, 72, 74-76, 79, 82, 83, 86, 88,
Veale, D., 93 146, 149, 152, 159
Verbrugge, L., 4, 33, 36, 46 Whiting,]., 174
VercoulenJ.H., 147,174 Whorwell, P. J., 76, 77, 80, 155, 159, 160
Vercoulen, J. W., 119, 127 Widiger, T. A., 10
Verhaak, P. F. M., 21 Wiesmuller, G. A., 131,132
Vermetten, E., 54 Wigers, S. H., 102
Vernon, S. D., 119 Wilbur, J., 102
Vertommen, H., 128 Wilhelmsen, I., 57, 72, 185, 186
Vickroy, M., 118 Wilkinson, G., 27, 28
Vierck, C., 97 Williams, A., 29
Viramontes, B. E., 150 Williams, D. A., 97, 146, 147
Vishwanath, B. S., 56 Williams, J. M. G., 148
Visser, A. P., 21 Wilson, A., 118
Vlaeyen, J. W. S., 44, 96, 167 Wilson, R. ]., 143
Von Korff, M. R., 74 Winberg,]., 51
von Rad, M., 83 Winget, C., 32
Vythilingam, M., 54 Winters, W., 143
Wise, E. A., 58, 59
Witter, E. A., 119
WadeJ.B., 59
Witthoft, M., 142
Wadsworth, M., 25 Wolde-Tsadik, G., 70
Wagner, M., 64 Wolfe, F., 89, 92-94, 96, 99, 108-109
Waitzkin, H., 24 Wolters, G., 21
Wakefield, D., 116 Wong, C., 42
Walen, H. R., 112 Wood, D. R., 115
Walker, E. A., 20, 26, 41, 42, 63, 72, 73, 81, Woodman, C. L., 81
84, 107, 109 Woodruff, R. A., 16
Wallace, P., 119 Wool, C. A., 4, 23, 27, 35, 57
Wallman, K. E., 178 Wooley, S., 32
Walsh, S. ]., 56 World Health Organization, 16, 24, 26
Walters, G., 167 Worthington, H. V., 101
Wang, E., 102 Wright, C. C., 57
Ware, N. C., 46 Wright, D., 119

AUTHOR INDEX 259

Wyshak, G., 22, 23 Zautra, A. ]., 37, 43, 111, 112, 113
Zavestoski, S., 20, 37, 132
Yan, S., 74 Zhu, G., 50
Yao, J. F., 73 Ziem, G., 132, 139
Yates, W., 23, 25 Zigmond, A. S., 65
Yehuda, R, 42 Zilker, T., 23, 142
Yoder, J. D., 46 Zilko, P., 93
Yunus, M. B., 4, 61, 62, 95, 99-100, 108- Zimmerman, T., 26, 127
109 Zinsmeister, A. R., 67, 70
Zonderman, A. B., 71, 146, 152
Zachariae, R., 59 Zunder, T., 133
Zacker, C., 73 Zurowski, M., 107
Zar, S., 70, 151

260 AUTHOR INDEX

 SUBJECT INDEX

Abdominal pain or discomfort, 71 and IBS, 79-80

Abnormal illness behavior, 32 and pain, 59
Abridged somatization, 24-26 Antidepressants, 63
Absenteeism, 46, 74 for CFS, 174
Abuse, 186. See also Childhood maltreat- for FMS, 164, 165
ment; Sexual abuse; Substance abuse for IBS, 149-151,157
and CFS, 125-126 Antispasmodic medications, 150
emotional, 42, 78 Anxiety
and IBS, 84-87, 161 as CFS risk factor, 65
ACC. See Anterior cingulate cortex and childhood sexual abuse, 42
Acceptance and FMS, 108,110
of CFS condition, 176 and IBS, 78-79, 81-83
of FMS relapses, 171 and MCS, 140-142
Acceptance and commitment therapy, 148 and pain, 59
Acquired neurasthenia, 65 and somatization, 23, 25-26
ACR. See American College of Rheumatol- and symptom perception, 35
ogy Anxiety disorders, 26-30
ACTH. See Adrenocorticotropic hormone and gender, 27-28
(ACTH) and medical illness, 29-30
Adaptive copers, 112 and pain, 28-29
Adrenocorticotropic hormone (ACTH) Artificial neuron networks, 64
and CFS, 120, 121 Associative learning, 143-144
and FMS, 103 Asthenic personality, 17
and SD, 51, 52 Asthma, 141
Aerobic exercise, 63, 165 Attachment relationships, 43
Affect, 112-113 Autoimmune disorders, 39, 56
Age, 33-34, 137
Agoraphobia, 142, 182 Beard, George, 14
Alarm factors (for gastrointestinal disease), Behavior modification
68,69 for FMS, 168
Algometer, 90, 91 for IBS, 153-156
Allergy(-ies), 139 Belief systems. See Disease conviction beliefs
food, 18, 137, 151 Biological primacy, 38
universal, 131 Biology of MUIs, 49-60
Allodynia, 89 genetic factors, 49-50
Allostatic load physiology of somatization, 50-56
and CFS, 122 sensitization, 56—59
and MCS, 137 Biopsychosocial model of MUIs, x
and MUIs, 54-55 contextual perspective in, 185-187
Alosetron, 150, 151 factors influencing, 10, 11
American College of Rheumatology (ACR), and IBS, 20
89-90 sociosomatic explanations in, 146
Ampligen, 173-174 understanding of mechanisms with, 5,
Anesthetics, 164 6
Anterior cingulate cortex (ACC) Blood oxygen level dependent fMRI, 123
and emotion, 54 Bosnian conflict, 135

261
Bowel disease/disorders Cholecystectomy, 73
cognitive scale for functional, 155 Cholecystokinin antagonists, 80
inflammatory, 72 Chronic fatigue, 37
Brain Chronic fatigue immune deficiency syn-
and emotion, 54 drome, 116
and IBS, 76-77, 79-81 Chronic fatigue syndrome (CFS), 3, 5, 115-
and MCS, 138 129
and pain, 59 abuse associated with, 125-126
Brain fog, ix artificial-neuron-network model of, 64
Brain-gut axis, 80-81 case definitions of, 116, 117
Briquet's syndrome, 16-17 and depression, 27
diagnosis, 115-117
Cacosmia, 139, 141 and disease conviction beliefs, 37-39
Campylobacter gastroenteritis, 65 etiology, 119-129
CAM (complementary and alternative medi- female gender as risk factor for, 65
cine) treatments, 165 and FMS, 94
Cancer patients, 36 FMS overlap with, 93
Cardiovascular fitness training, 166, 167 gender disparity in, 4, 123-125
Catastrophizing, 43-47 and health care seeking, 37
andFMS, 98, 111, 167 history of, 15, 18
gender differences in, 43-44 and IBS, 72
and gender role expectations, 45—46 and legitimization of symptoms, 38
and hypervigilance, 44-45 and MCS, 136
and IBS, 158 and neuroimaging, 122-123
and stress, 46-47 neuropsychological performance, 119
Central nervous system and pathophysiology, 120-122
and FMS, 98 and personality factors, 127-129
and MCS, 133, 138 prevalence, 118-119
Central pain modulatory system, 97 prognosis, 117-118
Cerebrasthenia, 15 and psychiatric disorders, 126-127,141
CFS. See Chronic fatigue syndrome and sensitization, 57
CFS treatment, 173-179 and somatization disorder, 22
cognitive-behavioral therapy, 175-177 subgroups of, 65
drugs, 173-175 and suggestibility, 23
physical exercise, 177-179 and symptom perception, 36
Chemical AIDS, 131 treatments. See CFS treatment
Chemical hypersensitivity syndrome, 131 Chronic mononucleosis, 116
Chemical sensitivity, 18, 131. See also Mul- Chronic pelvic pain, 3
tiple chemical sensitivities and FMS, 93
Childhood, illness behavior learned in, 32- and IBS, 72
33 Chronic widespread pain, 89
Childhood maltreatment Circadian cycle, 120
and disease conviction beliefs, 41-43 Claudius (fictional character), 63
and FMS, 107-108 Clinical ecologists, 133
Childhood sexual abuse, 28 Cognitive-behavioral therapy, 147
and CFS, 125-126 case study, 169-172
and disease conviction beliefs, 41—43 for CFS, 175-177
and IBS, 84-87 for FMS, 167-169
and MUIs, 54 for IBS, 154-156
Childhood trauma Cognitive complaints, 119
and FMS, 107-108 Cognitive-psychobiological model of soma-
and MUIs, 54 tization, 51

262 SUBJECT INDEX

Cognitive therapy, 154-155 Desensitization training, 182
Colpermin, 153 Desipramine, 150, 157
Communication, 44 Dexamethosone, 121
Comorbidity, 61-63 DHEAS (dehydroepiandrosterone sulphate),
Complementary and alternative medicine 99
(CAM) treatments, 165 Diagnosis, psychiatric vs. medical, 38
Contact thermal heat, 96-97 Diagnostic and Statistical Manual of Mental
Conversion disorder, 16 Disorders (DSM), 10, 16, 17, 24, 25
Coping/coping styles Diary keeping, 171
andCFS, 174 Diet, 151-152
andFMS, 111-113 Diffuse noxious inhibitory control (DNIC)
and gender, 43-44 system, 97
and pain, 59 Disability, 37, 74-75
Coproporhyrin levels, 139 Disclosure writing, 168-169
Corticosteroids Disease conviction beliefs, 37-43
for FMS, 164 and CFS, 174-175
and SD, 51 and childhood maltreatment, 41-43
Corticotropin-releasing hormone (CRH) and disability, 37
and CFS, 120, 121 and FMS, 167-168
and IBS, 81 and IBS, 154, 156-157
and SD, 51,52 and legitimization of symptoms, 37-39
and stress, 55 and MCS, 181-182
Cortisol and somatic attribution, 39—41
and CFS, 120, 121, 174 Dissociation, 38, 87
and FMS, 103-105 DNIC (diffuse noxious inhibitory control)
and MUIs, 53-55 system, 97
and SD, 51,53 Doctor shopping, 6
CRH. See Corticotropin-releasing hormone and legitimization of symptoms, 38
CRH antagonist, 81 and MCS, 133
CRH injections, 103 Dolorimetry, 90, 91
Cross-sensitization, 138 DSM. See Diagnostic and Statistical Manual of
Cultural context, 18-19, 125 Mental Disorders
Culture-driven disorders, 38 Dual etiology hypothesis, 65
Dualism, 25
Deep sleep, 105 Dysfunctional copers, 112
Deep vein thrombosis, 38 Dyspareria, 72
Defensiveness, 128-129
Dehydroepiandrosterone sulphate Eating disorders, 73
(DHEAS), 99 Ecologic illness, 131
Dependent personality disorder, 17 Economic impact
Depression of CFS, 119
and CFS, 65, 126-127, 178 of IBS, 73-74
and childhood sexual abuse, 42 of MCS, 132
and FMS, 102, 108-109 Education
and gender, 46 about IBS, 163
and health care seeking, 36 about MCS, 147
and IBS, 78, 81, 83, 161 Education level, 34
and MCS, 140-142 Effort syndrome, 18
as overlapping symptom, 64 Emotion
and physical exercise, 166 andFMS, 98, 110
and somatization, 25-26 and IBS, 154
and symptom perception, 35 Emotional abuse

SUBJECT INDEX 263

 and health care utilization, 42 and legitimization of symptoms, 38
and IBS, 78 and MCS, 136
Emotional flexibility, 148 and modern social strains, 46
Employment, 37 and neuroendocrine system, 98-99
Empowerment, 148 nonrheumatic symptoms, 90
Endometriosis, 56 overlap with other MUIs, 92-93
Engel, George, x and pain hypersensitivity/central sensi-
Enteric nervous system, 80 tivity, 95-97
Environmental cues, 35 prevalence, 91-92
Environmental illness, 131 prognosis, 93-94
Environmental medicine physicians, 133 and psychiatric disorders, 108-111
Epinephrine and psychosocial issues, 107-113
and SD, 51,52 and sensitization, 57
and stress, 55 and sleep disturbance, 105-106
Epstein-Barr virus, 18, 116, 120 and stress, 103-105
Estrogen and suggestibility, 23
and FMS, 99 treatments. See FMS treatments
and MCS, 137 Fibrositis, 18, 89
and pain perception, 58 Filter model, 57
Exercise, physical. See Physical exercise 5-HT3 receptors, 150
Expressiveness, 45, 46 5-HT4 receptors, 151
Florence Nightingale disease, 39
Fact-based medicine, ix Fluoxetine, 178
Familial aggregation, 94-95 fMRI (functional MRI), 123
Family social climate, 87 FMS. See Fibromyalgia syndrome
Fatigue. See also Chronic fatigue syndrome FMS treatments, 163-172
as common symptom of MUls, 17-18 case study, 169-172
as comorbid symptom, 63 cognitive-behavioral therapy, 167-169
and neurasthenia, 14 drugs, 164
Fearfulness, 35 physical exercise, 166-167
Female body, medicalization of, 39 studies of, 164-165
Feminine gender role, 77—78 Food allergies, 18, 137, 151
Fiber, 151-152, 156 Food hypersensitivity, 70
Fibromyalgia syndrome (FMS), 3, 5, 89-113 Freud, Sigmund, 14
ACR criteria, 90 Functional dyspepsia, 71-72
and anxiety, 27 Functional MRI (MRI), 123
and childhood sexual abuse, 41
and childhood trauma, 107-108 Gastroenteritis, 65, 69-70
comorbid conditions, 92 Gender. See a/so Women
and coping, 111-113 and autoimmune disease, 56
diagnosis, 89-91 and catastrophizing, 43-45
and disease conviction beliefs, 37, 38 and CFS, 123-125
and emotional flexibility, 148 and depression/anxiety, 25-26
and emotion/pain, 98 and FMS, 99-103
etiology, 94-113 and health care seeking, 36-37
gender disparity in, 4, 99-103 and IBS, 75-77
genetic contributions to, 94-95 and MCS, 136-137, 140
and health care seeking, 37 and mood/anxiety disorders, 27-28
history of, 18 and MUIs, 4-5, 65, 186
and IBS, 72 and pain, 28-29
and immunological changes, 106-107 and sensitivity, 56-59
juvenile primary, 92 and somatic attribution, 39—41

264 SUBJECT INDEX

 and somatization, 23-25 and symptom perception, 35
and stress, 46-47, 51-53 Heat, 96-97
and symptom perception, 34-36 Helplessness, 44
and symptom report, 22, 33-34 Heme, 139
Gender-related medically unexplained Histrionic personality disorder, 16, 127
illness(es), 13-17 Hormones
Briquet's syndrome as, 16-17 and FMS, 100-102
chronic fatigue syndrome as, 15 and IBS, 76-77
and DSM, 16 and MCS, 137
hysteria as, 13-14 and stress, 51-53
neurasthenia, 14-15 HPA. See Hypothalamic-pituitary-adrenal
Gender-related social roles, 47 axis
Gender role Hydrocortisone, 174
catastrophizing and expectations of, 45- Hyperalgesia, 63, 89
46 Hyperventilation syndrome, 4
and IBS, 77-79 Hypervigilance
and pain, 59 and catastrophizing, 44-45
and symptom perception, 35 and IBS, 85
and treatment, 147-148 and pain, 59
Gender Role Expectations of Pain (GREP), Hypnotherapy, 159-160
59 Hypochondriasis, 25
Genetic factors Hypocortisolism, 174
ofCFS, 120-122 Hypothalamic-pituitary-adrenal (HPA) axis
of FMS, 94-95 and CFS, 120-122
of MUIs, 49-50 and FMS, 93, 103-104
Glucose, 51 and MUIs, 53-55
Gonadal function, 103 and SD, 51-52
Graded exercise, 177-179 Hysterectomy, 73
GREP (Gender Role Expectations of Pain), Hysteria, 13-18
59 Hysterical personality, 16
Group therapy
forCFS, 177 IBS. See Irritable bowel syndrome
for IBS, 157-158 IBS treatments, 149-161
Guar gum, 152 and diet, 151-152
Gulf War illness/syndrome, 3, 136 drugs, 150-151
Gulf War veterans hypnotherapy, 159-160
with CFS, 174 psychological, 153-159
and MCS, 135, 140 psychotherapy, 160-161
Gut motility, 69 stress reduction, 152-153
Gut transit times, 75 Idiopathic environmental intolerance (IEI),
131, 142, 143
Hamkt (William Shakespeare), 63 Illness behavior, 32—37
Harm avoidance, 36 abnormal, 32
Hazards, 47 characteristics of, 32
Headaches and health care seeking, 36-37
FMS overlap with, 93 and IBS, 82-84
tension, 4, 44 learned, 32-33
Health beliefs, 36 and symptom perception, 34-36
Health care utilization and symptom reporting, 33-34
and childhood sexual abuse, 41-42 Illness uncertainty, 36-37
and illness behavior, 36-37 Immune system
and somatic attributions, 40 and autoimmune disease, 56

SUBJECT INDEX 265

 and FMS, 106-107 Limit setting, 171
and MCS, 138 Local anesthetics, 164
and SD, 51-52 Loperamide, 150
and stress, 55-56 Luteinizing hormone, 77
Inflammatory bowel disease, 72
Injections, 164 Magnetic resonance imaging (MRI), 122
Insula, 76 Major depressive disorder (MDD), 108
Interleukin-1-receptor-II, 56 Manning criteria, 68
International Classification of Diseases (WHO), MCS. See Multiple chemical sensitivities
16,24 MCS treatments, 181-183
Interpersonally distressed copers, 112 MDD (major depressive disorder), 108
Interstitital cystitis, 72, 93 Mebeverine, 157
Irritable bowel syndrome (IBS), 3, 5, 67-88 Media coverage
and biopsychosocial model, 20 and disease conviction beliefs, 37, 38
and childhood sexual abuse, 41, 84-87 and MCS, 132
diagnosis, 68-69 Medical diagnosis
and disability/quality of life, 74-75 and mood/anxiety disorders, 29-30
and disease conviction beliefs, 38 psychiatric vs., 38
dual etiology hypothesis of, 65 Medicalization of female body, 39
economic impact, 73-74 Medically unexplained illnesses (MUIs), 3-
etiology, 69-70 7,9-11
female gender as risk factor for, 65 biopsychosocial factors influencing, 10,
FMS overlap with, 93 11
and gender, 4, 75-77 biopsychosocial model for understand-
and gender role, 77—79 ing, 5
and illness behavior, 83-84 common factors among, 4
and learned illness behavior, 32-33 comorbidity among, 61—63
overlap with other MUIs, 71-73 cultural context of, 19-20
and pain hypersensitivity, 96 defined, 3
pathophysiology, 79-81 difficulties presented with, 6-7
prevalence, 70-71 as distinct disorders, 63-66
and psychiatric disorders, 81-83 and DSM, 10
and sensitization, 57 fatigue as, 17-18
and somatic attributions, 40-41 gender disparity in, 4-5
subgroups of, 67 illnesses classified as, 3-4
subtypes of, 68 MCS as, 18
treatments. See IBS treatments misdiagnosis of, 18-19
and sensitization, 56-59
journal of the American Medical Association, shared factors of, 38
131-132 treatments, 6, 145-148
Juvenile primary fibromyalgia syndrome, 92 women with, 6
Medically unexplained symptoms (MUS),
Karnofsky Performance Status Scale, 177 21,26
Medical utilization. See Health care utiliza-
Lactose malabsorption, 71 tion
Learned illness behavior, 32-33 Menstrual cycle
Learning, associative, 143-144 and FMS, 99, 100-102
Legitimization of symptoms and pain perception, 58
and disease conviction beliefs, 37-39 Methyl tertiary butyl ether (MTBE), 139
of MCS, 182 Mind-body interactions, 148
Lifelong victimization, 126 Mind-body therapies, 165
Limbic system, 81 Mindfulness-based cognitive therapy, 148

266 SUBJECT INDEX

Modern social strains, 45-46 Noncardiac chest pain, 4
Mononucleosis, 65 Norepinephrine
Mood disorders, 26-30 and FMS, 99, 103
and gender, 27-28 andSD, 51
and medical illness, 29-30 Normalizing attributions, 39, 40
and pain, 28-29
Morbidity, 4, 29 Obsessive-compulsive personality disorder,
Mortality, 40 127
MRI (magnetic resonance imaging), 122 Olfactory sensitivity, 137
MTBE (methyl tertiary butyl ether), 139
MUIs. See Medically unexplained illnesses Paced Auditory Serial Addition Test (PASAT),
Multiple chemical sensitivities (MCS), 3, 5, 123
9, 131-144 Pain
and associative learning, 143-144 catastrophizing of, 98
defining, 132-134 and gender, 57-59
etiology, 138-144 and mood/anxiety disorders, 28-29
FMS overlap with, 93 perception of, 58-59
and gender, 136-137 sensitivity to, 57-58, 95-97
gender disparity in, 4 Pain Catastrophizing Scale, 44
history of, 18 Panic attacks/disorder, 30
and legitimization of symptoms, 38 and IBS, 161
overlap with other MUIs, 136 and MCS, 141-142
prevalence, 134-135 Parasympathetic response
prognosis, 135-136 and IBS, 80
and psychological factors, 140-143 and SD, 53
and sensitization, 56 Parenting style, 87
treatments. See MCS treatments Paroxetine, 150
Multiple sclerosis, 36 Partially hydrolyzed guar gum, 152
Muscular pain, fibromyalgia as. See PASAT (Paced Auditory Serial Addition
Fibromyalgia syndrome Test), 123
MUS. See Medically unexplained symptoms Patient activism, 37
Myalgic encephalitis, 94 Patient education
Myalgic encephalomyelitis, 39, 116 about FMS, 163
Myelasthenia, 15 about MCS, 147
Pelvic pain. See Chronic pelvic pain
Negative affect Pelvic symptoms, FMS and, 102
and somatic attributions, 40 Perfectionism
and symptom perception, 35 and CFS, 128
Negative-thought restructuring, 171 and FMS, 111
Neurasthenia, 14-17, 65 and IBS, 73, 158
Neurasthenic neurosis, 17 Peripheral-visceral mechanism, 79
Neuroendocrine system, 98-99, 103 Personality factors
Neurogenic mechanism, 138-139 and CFS, 127-129
Neuroimaging, 122-123 and symptom perception, 35
Neuropeptide Y, 101 Pesticides, 134, 137
Neuropsychological performance, 119 Pharmacotherapy
Neuroticism for CFS, 173-175
and CFS, 128 for FMS, 164
and symptom perception, 35 for IBS,150-151
New England Journal of Medicine, 132 Phospholipase A2, 56
Nociceptin, 101 Physical abuse
Nociceptive processing, 58 and IBS, 87

SUBJECT INDEX 267

 and pain reports, 43 and FMS, 108
and unexplained pain, 107 and IBS, 86, 161
Physical exercise, 63 and PTSD, 54
forCFS, 177-179 Relaxation training
and deep sleep, 105 for CFS, 176-177
forFMS, 94, 165-167 for FMS, 171
Physiological cues, 35 for IBS, 153, 156, 158
Pleasurable activities, seeking out, 171 Religious involvement, 175
Porphyrias, 139 Rome I criteria, 68
Postinfectious neuromyasthenia, 116 Rome II criteria, 68, 69
Postpartum period, 102 Rome III criteria, 68
Posttraumatic stress disorder (PTSD) Rumination, 28, 44
and abuse, 108
and cortisol, 54 SD. See Somatization/somatoform disorder
andFMS, 110 Secondary gains
Postviral fatigue syndrome, 94, 116 and learned illness behavior, 32-33
Pregnancy, 102 and trauma history, 43
Premenstrual dysphoric disorder, 101 Selective serotonin reuptake inhibitors
Premenstrual syndrome, 3 (SSRIs)
Pressure algometer, 90, 91 for FMS, 164
Prioritizing, 171 for IBS, 150
Progesterone, 99 Self-assessed health, 40
Psychiatric diagnosis, medical vs., 38 Self-blame, 86
Psychiatric disorders, 21-30 Self-help groups, 174-175
and CFS, 126-127 Self-monitoring, 98
andFMS, 108-111 Sensitivity
and IBS, 81-83 and childhood sexual abuse, 41, 42
and MCS, 140-143 and FMS, 89, 95-97
mood/anxiety disorders, 26-30 and IBS, 79-80
MUIs comorbid with, 21-23 and MCS. See Multiple chemical sensi-
as overlapping symptom, 64 tivities
somatoform disorders/somatization, 23- to pain, 57-58, 95-97
26 and symptom perception, 35
Psychiatric morbidity, 29 Sensitization
Psychoeducational treatment, 154 as MCS stage, 133
Psychological attributions, 39, 40, 146 and MUIs, 56-59
Psychological treatment, 153-159 Serotonin
Psychosocial factor(s), 31—47 and CFS, 121
catastrophizing as, 43^7 and FMS, 99
disease conviction beliefs as, 37-43 and IBS, 80
illness behavior as, 32-37 and stress, 55-56
Psychosocial issues, 107-113 Sexual abuse. See also Rape
childhood trauma, 107-108 in childhood. See Childhood sexual
coping, 111-113 abuse
psychiatric disorders, 108-111 and health care utilization, 42
Psychotherapy, 160-161 and IBS, 84-85, 87
Psyllium husk, 156 Sexual dysfunction
PTSD. See Posttraumatic stress disorder and FMS, 102
and IBS, 72
Quality of life, 74-75 Sick building syndrome, 19, 133
Sick role
Rape concept, 32

268 SUBJECT INDEX

 and health care seeking, 36 and IBS, 82
and legitimization of symptoms, 38 and MCS, 137
and symptom perception, 35 Substance P, 98, 99
Single photon emission computed tomogra- Suggestibility, 23
phy (SPECT), 122-123 Support groups, 155
Situational cues, 35 Sympathetic nervous system
Sleep disturbance, 105-106 and IBS, 80
Sleep-spindle, 106 and SD, 51-53
Social involvement, 46 Symptom perception, 34-36
Sociocultural trends, 23 Symptom report
Soldiers, 18 cognitive traits related to, 23
Solvent exposure, 134 and gender, 22
Somatic attribution, 39-41 and illness behavior, 33-34
Somatization/somatoformdisorder (SD), 23- and somatization, 23
26
abridged, 24-26 TDS (time-dependent sensitization), 138
and CFS, 22 Tegaserod, 151
characteristic of, 22 Temperature, EMS and, 96-97
classification of, 16 Temporomandibular joint dysfunction
and depression/anxiety, 25-26 (TMD), 3
as DSM classification, 24, 25 EMS overlap with, 93
and dualism, 25 and IBS, 72
and gender, 23-25 Tend-and-befriend response, 52-53
hysteria as, 17 Tender points
and IBS, 82 and EMS, 89-91, 100
and MCS, 142 injections into, 164
and medical illness, 30 and overlap of MUIs, 93
physiology of, 50-56 Tension headaches, 4, 44
and treatment issues, 145-146 Testosterone, 77
Somatosensory cortex, 81 Thermal heat, 96-97
Specificity, fibromyalgia and, 89, 90 Time-dependent sensitization (TDS), 138
SPECT. See Single photon emission com- TMD. See Temporomandibular joint dys-
puted tomography function
Spinal disorders, 45 Total allergy syndrome, 131
SSRIs. See Selective serotonin reuptake in- Toxic agoraphobia, 142
hibitors Toxicant induced loss of tolerance, 139
Stigma Trauma
with MCS, 144, 182 childhood, 54, 107-108
with MUIs, 38-39 and EMS, 107
of psychiatric labels, 146 symptom reports and undisclosed, 43
Stress Treatment issues, 145-148
accumulation of, 28 Treatments. See specific treatment, e.g.: CFS
and EMS, 103-105 treatment
and gender, 46^7 Tricyclic antidepressants
and IBS, 83, 154 for EMS, 164, 165
and immune system, 55-56 IBS, 149
and MCS, 137 Triggering, 133, 139
and SD, 51-53 Triggers
and treatment issues, 146 of IBS, 151
workplace, 108 of MCS, 133, 139
Stress reduction, 149, 152-153 20th century disease, 131
Substance abuse

SUBJECT INDEX 269

Undisclosed trauma, 43 and sexual assault, 42
United States, CFS prevalence in, 119 Victimization, lifelong, 126
Universal allergy, 131
Universal reactor syndrome, 131 Women
Unpleasantness ratings, 97 medicalization of female body, 39
Upper airway dysfunction syndrome, 139 treatment for MUIs in, 6
Urinary coproporhyrin levels, 139 Workplace stress, 108

Veterans Yuppie flu, 116

of Gulf War, 135, 140, 174

270 SUBJECT INDEX

 ABOUT THE AUTHOR

Susan K. Johnson received her MA in general psychology from New York

University in 1986 and her PhD in behavioral neuroscience from Rutgers
University in 1991. She was a neuropsychology fellow and research scientist
at the University of Medicine and Dentistry of New Jersey from 1992 through
1996. She joined the faculty of the Department of Psychology at the Univer-
sity of North Carolina at Charlotte, in 1996, where she is currently an asso-
ciate professor. She has published extensively in the fields of neuropsychol-
ogy and health psychology. She lives with her husband and two daughters in
Davidson, North Carolina.

271