This study is the first to evaluate a short screener for CI. Our analysis indicates that the BREESI possesses excellent positive and negative predictive validity with the QEESI and may be ideal for quickly determining potential CI in a range of health care settings and for epidemiological studies. While these findings appear robust, further replication of the BREESI’s performance is needed in other population samples to further establish validly.
Notwithstanding, we highly recommend that anyone endorsing any one of the three items on the BREESI should take the full QEESI to specifically identify intolerances and confirm CI. From Table 2, it appears that endorsing the intolerance to chemical item is by far the most salient.
The BREESI is not a substitute for the QEESI but rather a time-saving tool to identify individuals with CI in medical clinics or epidemiological studies. Identifying those who are, or are not, likely to have CI with a highly sensitive screening tool greatly reduces clinical assessment time. In this regard, the BREESI may be particularly useful for researchers, clinicians, and workplace or community investigations.
In the past, there has not been a widely agreed-upon case definition for the diverse symptoms and conditions related to CI. For decades, this lack of consensus has thwarted research on CI, just as the lack of consensus regarding a case definition for “Gulf War Illness” has impeded research.17 Clinicians today have difficulty diagnosing TILT-related conditions because there has not been training regarding this disease mechanism in medical schools. Physicians who could benefit from using the BREESI include most primary care clinicians, allergists, occupational medicine doctors, psychologists, and psychiatrists. These clinicians commonly see patients with multi-system health complaints, cognitive confusion, fatigue, and depression. They could use the BREESI and QEESI to help them and their patients identify CI and avoid or minimize many illness triggers.
Exposures that may initiate TILT in susceptible individuals include oil spills, chemical releases, fracking, burn pits, as well as exposure events such as the EPA’s sick building episode and the World Trade Center disaster. In addition to these major events, everyday exposures to pesticides, fragrances personal care or other fragranced products can initiate or trigger TILT. Clinicians and epidemiologists who work with exposed individuals or communities need to be conversant with the two-stage TILT disease mechanism if they hope to make sense of the seemingly unrelated health problems these individuals report. It is all too easy to dismiss TILT’s physiological effects as being the result of stress or psychosomatic effects. “Too many symptoms in too many organ systems” frustrates clinicians and patients alike. Of course, TILT and stress can and do occur simultaneously. Stress can accompany any illness. However, it is important to recognize that usual medications prescribed for stress, such as antidepressants or anxiolytics, may exacerbate symptoms of TILT. When patients report myriad symptoms in multiple organ systems and complain of ineffective or adverse treatment outcomes, clinicians, patients, and families understandably may become frustrated and give up on one another.
How can clinicians differentiate TILT from “stress”? It is the new-onset (or marked worsening) of chemical, food and drug intolerances that are the hallmark symptoms of TILT— much as fever is a hallmark of infection whose presence always requires a careful work-up, including exposure histories and laboratory testing to rule out alternative explanations. Currently, there are no validated diagnostic tests for CI— except removing individuals from suspected exposures and a judicious reintroduction of triggers, optimally to occur within the confines of an Environmental Medical Unit (EMU).18 Indeed, most medical conditions recognized today initially suffered this same historical diagnostic dilemma, e.g., lupus, diabetes, HIV, stroke, and depression.
Although TILT and stress can occur simultaneously, the 3-item BREESI screener enables physicians and researchers to screen for chemical, food, and drug intolerances. Coupled with a detailed exposure history, the QEESI can assist in diagnosing TILT. Individuals answering “yes” to any one of the three BREESI screening questions, should undergo further evaluation using the 50-item QEESI. The QEESI’s four scales and masking index, provide a reasonably comprehensive overview of each person’s symptoms, intolerances, and the life impact of their illness (www.TILTresearch.org).
An especially useful feature of the QEESI is the “Symptom Star,” which is readily generated by graphing the 0–10 symptom severities from the QEESI on a 10-point ‘target’ diagram (see Fig. 2)18. When filled out in the patient’s presence, the Symptom Star enhances doctor-patient communication and helps assure patients that their concerns have been heard. The Symptom Star is similarly helpful for depicting changes in symptoms following an exposure event, as well as responses to interventions or treatments in individual patients, or in groups for research purposes19
The QEESI Symptom Star is shown in Fig. 2. This illustrates symptom severity in an individual before and after an exposure event (e.g., pesticide application, indoor air contaminants, chemical spills). Terms: HEAD = head-related symptoms; COG = cognitive symptoms; AFF = affective symptoms; NM = neuromuscular symptoms; MS = musculoskeletal symptoms; SKIN = skin-related symptoms; GU = genitourinary symptoms; GI = gastrointestinal symptoms; COR = heart/chest-related symptoms; AIR/MM = airway or mucous membrane symptoms; (•) before exposure event; (○) after exposure event. Two good examples of how the Symptom Star has been used in patient care are demonstrated in case reports by Yun et al., 20 Imai and Imai21
Three potential uses for the QEESI include: (1) Research – to characterize and compare study populations, and to select subjects and controls; (2) Clinical Evaluations – to obtain a profile of patients’ self-reported symptoms and intolerances. The QEESI can be used at intervals to follow symptoms over time or to document responses to treatments or exposure avoidance; (3) Workplace, Community, or Epidemiological Investigations – to identify and assist those who may be more chemically susceptible or who report new intolerances. Affected individuals should have the option of discussing results with investigators or their personal physicians.
The BREESI can be administered in less than 1 minute and the QEESI can be completed in 10–15 minutes. Previously, tallying symptoms and symptom severities, as well as taking detailed exposure histories, could take hours—deterring some clinicians from seeing patients with CI.
Our assessment tools can help identify susceptible individuals, even without knowing the specific disease mechanism and in the absence of any biomarker. TILT is observed worldwide following a broad spectrum of synthetic/petrochemical exposures since WWII (past 75 years). The increased recognition of TILT demands more research on the CI disease process and the taking down of silos between scientific domains and eliminating interdisciplinary barriers.
TILT is a viable disease mechanism initiated and triggered by environmental exposures (chemicals, foods, and drugs) involving prominent neurological symptoms, which are not necessarily psychogenic in nature. TILT provides a unifying explanation for the myriad symptoms clinicians see today.4, 6, 7, 22, 23
Historically, new theories of disease arose when physicians observed patterns of illness that did not fit accepted explanations for disease at that time, for example, the germ or immune theory of disease. Similarly, CI does not conform to current accepted explanations for disease or toxicity because there is not yet a known physiological mechanism to explain chemical intolerance; no biomarker has been identified; and avoidance of chemical, food, and drug triggers is difficult and often impractical.