In recent years, results of several critical evaluations of patients claiming IEI have been published. Collectively these studies do not support a role for food and chemical sensitivities as a cause of the patient’s symptoms nor do they indicate immunologic dysfunction. Instead, they do provide evidence for a significant role for underlying psychiatric illness.
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Patients with IEI are predominantly female. Typically they had consulted numerous physicians for their symptoms before their diagnosis of IEI. In the absence of objective findings “case definition” is necessarily by self-report. Histories of the patients are extremely heterogeneous, with a majority reporting having multiple symptoms, although some are asymptomatic and a few have a clearly defined physical illness that had been undiagnosed and therefore not treated. There are no consistent physical findings or laboratory abnormalities. A series of 90 patients evaluated for work-related IEI showed that illness was attributed to an extremely heterogeneous group of environmental substances of different chemical compositions from an extremely diverse group of occupations. Their prior medical records revealed that two thirds of them had been treated for the same symptoms for many years before their occupational exposure, and three fourths had developed a new set of symptoms after provocation-neutralization testing. Furthermore, the most common alternative diagnoses made by nonclinical ecologists were somatoform illness, anxiety disorder, depression, hyperventilation, and iatrogenic disease.
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Several published series of psychiatric evaluations of IEI patients confirm the general impression that their perceived reactions to environmental chemicals and foods are best explained as a manifestation of underlying psychiatric disease. These reports are summarized in, which shows that many patients with environmental illness fit the DSM-IV criteria for several psychiatric illnesses. The predominance of women and the multisystemic polysomatic nature of the illness are suggestive of somatoform disorder, though not all patients meet the strict descriptive criteria. By including normal controls in their study, Black et al showed that the number of reported symptoms and the prevalence of mood disorder, anxiety disorder, and somatoform illness were all significantly higher in patients than in a normal population. Stewart et al pointed out that although somatoform illness is notoriously difficult to treat effectively the majority of patients in her study had psychotic, affective, or anxiety disorders all of which can be effectively treated with appropriate medications or psychotherapy or both. Unfortunately, most IEI patients are reluctant to accept a psychiatric diagnosis or treatment, opting instead for the extreme lifestyle changes that are recommended as treatment for that condition. Terr showed that clinical ecology treatment is almost always ineffective or counterproductive. Brodsky has studied the social consequences of extreme environmental chemical avoidance that leads to a lifestyle of social isolation centered around the illness.

The importance of preexisting psychiatric illness is made particularly clear by the study of Simon et al. They evaluated 37 aircraft workers who were exposed to phenol-formaldehyde and developed transient mucosal irritation that resolved on cessation of exposure. However, 13 of them reported chronic disabling symptoms provoked by common environmental agents diagnosed as IEI by a clinical ecologist. These patients had a significantly higher prevalence of preexisting psychiatric morbidity caused by anxiety, depression, somatization, and medically unexplained symptoms compared with the 24 with transient symptoms only.
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Patients who accept the concept of IEI as the explanation for their somatic symptoms are psychologically diverse, though limited or full-blown somatoform illness is the most common pattern. Other patients have been noted to display features of post-traumatic stress disorder, agoraphobia caused by conditioning, and panic disorder, and as an adult manifestation of childhood abuse. The phenomenon has also been called a “belief system” and “illness and disability as lifestyle.”