Building-related intolerance

Chronic indoor air-related symptomatology fulfills the WHO’s criteria for IEI (IPCS/WHO 1996). Previous findings concerning individuals with indoor air-related non-specific symptoms attributed to indoor molds have recognized similarities with IEI (Al-Ahmad et al. 2010; Khalili et al. 2005). Disability, as IEI, can be encountered among individuals with indoor air-related ill health.

Our findings further revealed indoor air-related disability as a phenomenon with persistent and recurrent non-specific symptoms in several organ systems attributed to indoor air factors (e.g. indoor molds), leading to avoidance and restrictions to several daily life functions. In addition, the disability shows various signs of distress and comorbid diseases with no medical or exposure-related explanations. Our study findings add to the understanding of this phenomenon (Figure 8) (Norbäck 2009; Redlich et al. 1997; WHO 1983, 2009). These findings strengthen the hypothesis that indoor air-related disability with an increasing severity gradient shares features with EI and FSS, and that BRI and other EIs seem to represent the same phenomenon (Dantoft et al. 2015; Das-Munshi et al. 2007; Rief et al. 2017; Van den Bergh et al.

2017a; Watanabe et al. 2003a). Lacour et al. (2005) have previously summarized the overlap between EI and FSS, and these shared common mechanisms have been suggested as maintaining EI and FSS, i.e., sustained stress and arousal due to central sensitization (Yunus 2015).

Figure 8 Manifestation of indoor air-related disability with typical characteristics.

6.1.8 MANAGEMENT OF INDOOR AIR-RELATED DISABILITY

So far, EI has been considered a chronic, stable condition, resistant to therapy (Bailer et al. 2008b; Black et al. 2001; Dantoft et al. 2015; Das-Munshi et al.

2007; Eek et al. 2010; Lacour et al. 2005). There is a lack of research on the course of EI and controlled interventions aiming to reduce reactivity to the environment. In a prospective study of the one year stability of somatic symptoms and IEI, the strongest predictor of IEI was somatic attributions, followed by prominent cognitions of environmental threats and a tendency to focus on unpleasant bodily sensations and consider them as pathological (Bailer et al. 2007). In addition, a five-year follow-up study in a general population sample showed that anxiety (negative affect) associated with the development and persistence of symptoms and life impact attributed to common airborne chemicals (Skovbjerg et al. 2015). Recent data on the natural course of EI have shown that EI is reversible (Palmquist 2017). In a longitudinal population-based study over a six-year period, one fifth of the individuals with self-reported EI attributed it to chemicals, certain buildings, EMFs or everyday sounds recovered, especially those with less affective and behavioral changes (Palmquist 2017). Furthermore, increasing evidence of central mechanisms in chronic responsiveness, as an active inferential process that is highly dependent on prior experiences, expectations and contextual cues, provides a compelling explanation for EI (Van den Bergh et al. 2017a),

which enables treatment strategies for prevention and recovery to be targeted, even in severe EI.

Various biopsychosocial factors have shown to influence building residents’

reports of symptoms. Previous clinical experiences of patients with indoor air-related ill health have revealed long-lasting, disproportionate amounts of functional restrictions in everyday life and sustained symptoms over follow-ups. This shows a need for a biopsychosocial approach in management (Al-Ahmad et al. 2010; Edvardsson et al. 2008; Karvala et al. 2013, 2014) Effective, practical means of support and treatment for these individuals are lacking.

The first RCT setting (Study I) aimed to decrease excess concerns, symptoms and disability through counseling and psychoeducation of patients with indoor air-related symptoms and work disability. Over the six-month follow-up, however, the limited counseling did not improve the patients’

symptom management skills or work ability. There may be several reasons for the ineffectiveness of the intervention. A plausible explanation would be the long-lasting symptom history related to disability, which requires more intensive intervention. Characterization revealed numerous persistent, ongoing indoor air-related non-specific symptoms and disability among patients, and the features of IEI and FSS. Counseling that provides knowledge regarding mechanisms does not necessarily affect patients’ interpretations of the causes of the symptoms. In a previous study of individuals with IEI-EMFs, accurate feedback after a placebo-controlled provocation study was insufficient to change their attributions to mobile phone signals or reduce symptoms over six-month follow-up (Nieto-Hernandez et al. 2008). In another previous study of patients with chronic health conditions, health promotion counseling provided by a physician seemed to improve health-related QOL, although this was not apparent in those with anxiety or depression (Al Sayah et al. 2014). The counseling techniques used in Study I for management of symptoms may not have taken into account all the emotional and cognitive features of IEI and FSS, although they aimed to minimize the perceived harmfulness of indoor air-related factors.

Although Study I found no intervention effect, it showed that this type of approach can be carried out, and that for features of IEI and FSS, the chosen framework may be helpful and suitable for health care. Therefore, the next RCT (Study III) was designed to target patients with a shorter symptom duration and aimed toward early detection of disability in OHS units. Taking into account previous findings regarding the features of IEI and FSS, inclusion was designed on the basis of IEI criteria and focused on indoor exposures. The intervention programs were developed on the basis of the evidence of effects in similar conditions. Thus, in the biopsychosocial approach, similar management strategies were applied as those for FSS (Henningsen et al. 2018;

Van Dessel et al. 2014), despite a lack of evidence-based treatments for IEI.

For FSS, CBT has shown positive effects; for example, reduction of somatic symptoms (Van Dessel et al. 2014). Therefore, CBT was the natural choice for

an intervention arm, as well as better counseling than that in Study I. Both arms in the RCT design (Study III) have focused on reducing stress and improving health behavior (e.g. mechanisms of physiological arousal and emotion-behavior-symptom cognitions) rather than on cognitive distortions.

The unexpectedly slow recruitment processes in Study III may indicate the cultural, societal and general attitudes towards biopsychosocial approaches in the management of indoor air-related disability. In general, although precise data are lacking, the availability of psychosocial treatments (e.g. CBT) are probably inadequate in the Finnish healthcare system. Nevertheless, in many health problems, the functional nature is recognized and the care guidelines highlight psychosocial treatment options, such as in the case of different pains (e.g. Pain: Current Care Guidelines Abstract 2017) and insomnia (Insomnia:

Current Care Guidelines Abstract 2017).

In the management of indoor air-related disability, individuals’ social surroundings and responses (such as the environmental factors included in the ICF concept) can either support or hinder the well-being, health and work ability of individuals. This input may iatrogenically harm and maintain illness behaviors (Dantoft et al. 2015; Kirmayer and Taillefer 1997; Rief and Broadbent 2007; Watanabe et al. 2003a). For example, when interpretations of symptoms/physical sensations as a sign of illness lead individuals to seek medical advice, this in itself can lead to the individuals maintaining a sick role and to repeated tests and medicalization. In this model of a vicious circle in doctor-patient contact, the patient’s physician can initiate further investigations even if there is no organic basis for the symptoms (Henningsen et al. 2007).

Disability from indoor air-related ill health can be identified and should be treated effectively. The findings of Study II showed that environmental control and avoiding factors perceived as harmful was a typical coping response among the patients. In IEI, the pathway toward disability is associated with avoidance due to perceived symptom triggers (Dantoft et al. 2015; Skovbjerg et al. 2009a, 2012b; Watanabe et al. 2003a). It is clear that when there is, for example, significant moisture and mold damage in buildings, avoidance before repairs may be reasonable; but needless avoidance should not be supported.

Management to reduce fear response and adverse avoidance strategies requires that the patient feels in control of the exposure situation. This requires trust in health care providers’ explanations for symptom mechanisms and that no health hazard exits in the indoor environment.

As regards indoor air-related ill health, recognition of features similar to IEI and FSS reduces the continuous search for medical and environmental explanations. Effective treatments for disability prevention are seriously needed. In the future, the course of interventions should be directed towards centrally mediated and threat-response mechanisms activated by environmental triggers. In addition, the stepped care FSS model, i.e. the more severe or complex the symptoms and limitations, the more intense and multifaceted is the treatment needed for patient recovery (Figure 7) (Fink and

Rosendal 2015; Henningsen et al. 2007, 2018; olde Hartman et al. 2017), could be utilized in the treatment strategy of BRI and other EIs.