Patients labeled with delusions of parasitosis composea heterogenous group: A retrospective study from a

referral center

Jason S. Reichenberg, MD,a Michelle Magid, MD,b Christine A. Jesser, ScD,c and Clifton S. Hall, MDa

Austin, Texas

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Background: There are few diagnostic tools available to the dermatologist to help in the diagnosis ofpatients with delusions of parasitosis (DOP).

Objective:We sought to find differences in presentation and clinical course between patients who receiveda final diagnosis of DOP and those who received a final diagnosis of a primary medical condition or otherpsychiatric disorder.

Methods: We performed a retrospective chart review of patients referred with a diagnosis of DOP. Eachpatient received a final consensus diagnosis.

Results: In all, 47 patients were included in the study. Patients reporting bugs were more likely to be givena final diagnosis of delusional disorder or found to have a medical diagnosis, whereas patients noting fiberswere more likely to have a somatoform disorder. A review of systems can be helpful in making a finaldiagnosis. Patients referred to the clinic for DOP were 300 times more likely to require a physician tocontact the hospital’s legal counsel compared with other patients in the practice.

Limitations: The retrospective nature of the study resulted in limited laboratory testing and psychiatricevaluation in some patients. Many of the patients may have been inappropriately referred to the DOP clinicbecause of other psychiatric comorbidities.

Conclusion: Patients referred to this practice as ‘‘delusional’’ had a heterogeneous final diagnosis. Thechief symptom of the patient was predictive of the patient’s final diagnosis. The use of writtenquestionnaires may be helpful. These patients have a greatly increased risk of requiring the physician toseek legal counsel. ( J Am Acad Dermatol 2013;68:41-6.)

Key words: delusions; legal action; Morgellons; obsessive-compulsive; parasitosis; picker; somatoform.

Abbreviations used:

CDC: Centers for Disease Control and PreventionDOP: delusions of parasitosisMMS: Modified Mini ScreenPTSD: posttraumatic stress disorderROS: review of systems

‘‘Delusions of parasitosis’’ (DOP) was firstcoined in 19461 to describe patients whohad a fixed, false report of skin infesta-

tion. Many subsequent studies have looked at thediagnosis and treatment of patients with DOP.2-4 Theterm ‘‘Morgellons disease’’ was introduced in 2003,referring to patients who believe they have fibers orspecks in their skin. The greater dermatology com-munity has not embraced the ‘‘Morgellons’’ nomen-clature, with some suggesting that ‘‘Morgellons’’ is

the Departments of Dermatologya and Psychiatry,b Univer-

ty of Texas Southwestern-Austin Program; and Seton Analyt-

s and Health Economics.c

ing sources: None.

licts of interest: None declared.

pted for publication August 6, 2012.

just a new name for DOP.5 A recent study by theCenters for Disease Control and Prevention (CDC)

Reprint requests: Jason S. Reichenberg, MD, Department of

Dermatology, University of Texas Southwestern-Austin Program,

601 E 15th St, Austin, TX 78701. E-mail: jreichenberg@seton.org.

Published online October 10, 2012.

0190-9622/$36.00

� 2012 by the American Academy of Dermatology, Inc.

http://dx.doi.org/10.1016/j.jaad.2012.08.006

41

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JANUARY 201342 Reichenberg et al

did not find a medical or infectious cause for thiscondition, pointing out that these patients are similarto patients with DOP.6

Based on our previous experience, we suspectedthat patients who report fibers may differ from thosewho report bugs, and that some patients have beengiven a misdiagnosis of DOP.

CAPSULE SUMMARY

d Patients with delusions of parasitosis willoften seek care from a dermatologistinstead of a psychiatrist.

d Patients reporting bugs/threads on theirskin make up a heterogeneousdiagnostic group with variablepresentation and treatment options.

d Focused patient questioning and self-administered questionnaires may help todistinguish between patients who aredelusional and those with somatoformdisorder, with a true medical diagnosis,or who pick at their skin.

This study focused on pa-tients with a referral diagnosisof DOP. It looked at patients’chief symptom, demograph-ics, clinical presentation, self-administered surveys, andlaboratory data. The goal wasto find differences among pa-tients who received a finaldiagnosis of delusional dis-order, somatoform disorder,other psychiatric disorder, ora previously undiagnosedmedical condition.

METHODSStudy population andclinical characteristics

This study was approvedby the hospital’s institutional

review board and conforms to the standards of theDeclaration of Helsinki.

This study was a retrospective review of patientsseen by a single provider (J. S. R.) in his dermatologyclinic at the University of Texas Southwestern-Austinbetween January 1, 2008, and December 31, 2011.Patients were eligible if they had been either: (A)referred by another physician with a label of ‘‘delu-sions of parasitosis’’; or (B) self-referred to the officewith the belief that they had a skin condition but hadbeen told that they were ‘‘delusional.’’

Data collection included patient chief symptom, age,marital status, occupation, duration of illness, and num-berof clinicvisits. Eachpatient’s chartwas reviewedby2dermatologists (J. S. R. and C. S. H.) and 1 psychiatrist(M. M.) and a consensus diagnosis was made.

The team reviewed self-administered patient ques-tionnaires, which included a 24-question review ofsystems (ROS) and a Modified Mini Screen (MMS) forpsychiatric disease. The MMS was chosen because ithad been validated in patientswith psychiatric disease(ie, depression) along with another diagnosis (ie,substance abuse).7-9 When evaluating for psychiatricdisease, the team used criteria from the Diagnosticand Statistical Manual of Mental Disorders, FourthEdition.10Medical causeswere ruled out before givinga final diagnosis of psychiatric disease.

The group also noted whether or not the hospi-tal’s legal counsel, referred to as ‘‘risk management,’’was involved with each patient’s case.

Data analysisDemographic and clinical characteristics were

examined by chief symptom and by final diagnosis

group.

Chief symptoms weregrouped as:d Infection: patient reportedthey had a bug, infection,or parasite.

d Fiber: patient reported thatthey saw fibers, threads, orspecks.

d Lesion: upon detailed ques-tioning, the patient did notreport infectionor fibers andhad other skin concerns.

Final diagnoses weregrouped as:d DOP: patient given thediagnosis of DOP orschizophrenia.

d Somatic: patient had mul-

tiple somatic symptoms ‘‘above and beyond whatcan be explained by physical exam and diagnos-tic testing,’’10 and was given a diagnosis ofsomatoform disorder.

d Other: picker, obsessive-compulsive disorder,medical diagnosis found, or no cause found.

Upon review, it became clear that many patientswere referred to the DOP clinic simply because theyhad psychiatric disease (ie, personality disorder,mania) in addition to their skin concerns or con-sumed a great deal of physician time. For example,one patient was referred to the clinic for DOP duringa manic episode. She picked her skin obsessively,but had no concerns about infections. She was putinto the chief symptom ‘‘lesion’’ group and receiveda final diagnosis of ‘‘other’’ (skin picking).

Mean ages were compared using analysis ofvariance; Kruskal-Wallis tests were used to com-pare duration of illness and number of clinic visits;and x2 tests (2 degrees of freedom) were used tocompare marital status, occupation, and need forrisk management by categories of chief symptomand by final diagnosis.

Logistic regression models were used to exam-ine the association between chief symptom andlikelihood of being in a particular final diagnosisgroup.

Table I. Demographic information for all patients referred for delusions of parasitosis from 2008 through 2011,separated by chief symptom

Chief symptom

P valuexInfection,* n = 15 Fiber,y n = 18 Lesion,z n = 14

Mean age at initial visit, y (6SD) 53.4 (11.1) 50.9 (14.7) 51.8 (18.5) .89Median duration of illness, mo (IQR) 24.0 (3.0-60.0) 6.0 (2.0-14.0) 12.0 (3.0-24.0) .53Median No. of clinic visits (IQR) 3.0 (2.0-6.0) 2.5 (1.0-3.0) 2.5 (2.0-7.0) .36Gender, n (%) .66Male 5 (33.3) 4 (22.2) 5 (35.7)Female 10 (66.7) 14 (77.8) 9 (64.3)

Marital status, n (%) .73Single 6 (46.2) 6 (37.5) 5 (35.7)Married 6 (46.2) 6 (37.5) 5 (35.7)Divorced 1 (7.7) 4 (25.0) 4 (28.6)

Occupation, n (%) .42Medical professional 3 (23.1) 4 (26.7) 3 (25.0)Other occupation 7 (58.9) 8 (53.3) 3 (25.0)Unemployed 3 (23.1) 3 (20.0) 6 (50.0)

IQR, Interquartile range.

*Patient reported bug or infection in their skin.yPatient reported fibers, threads, or other inanimate objects in their skin. If patients reported infection and fibers, they were categorized in

fiber group for this analysis.zPatient did not report infection or fibers.xFrom tests of association between chief symptom category and mean age at diagnosis (analysis of variance), median duration of illness and

clinic visits (Kruskal-Wallis), and gender, marital, and occupational categories (x2, 2 degrees of freedom).

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VOLUME 68, NUMBER 1Reichenberg et al 43

RESULTSA total of 49 patients’ charts were reviewed for the

study; 2 patients did not meet inclusion criteria. Thepatients’ age, marital status, occupation, duration ofillness, and number of clinic visits were not corre-lated with chief symptom (Table I) or predictive offinal diagnosis (Table II). A detailed summary of all47 patients’ data has been included as a supplemen-tal Table III, available online at http://www.jaad.org.

When separated by chief symptom, 21 patientsmet criteria for the chief symptom ‘‘Infection’’ groupand 18 patients met criteria for the chief symptom‘‘Fiber’’ group. Six patients reported both infectionand fibers, and were placed in both groups foranalysis. Fourteen patients denied a concern aboutinfections or fibers and were placed in the chiefsymptom ‘‘Lesion’’ group.

When the 47 patients were divided by final diag-nosis, 11 patients met criteria for DOP, and 3 metcriteria for schizophrenia. These 14 patients wereplaced in the final diagnosis ‘‘DOP’’ group. Nineteenpatients had multiple somatic symptoms out of pro-portion to their physical findings. No medical diag-nosis could be found to explain their symptoms,although most of these patients experienced depres-sion, posttraumatic stress disorder (PTSD), or anxietyand met criteria for somatoform disorder. Thesepatients were placed in the final diagnosis‘‘Somatic’’ group. Of the 14 patients placed in the

final diagnosis ‘‘Other’’ group, 8 were skin pickers,and 1 patient had each of the following: dementia,cocaine abuse, hereditary neuropathy, lichen planus,Demodex folliculitis, and trigeminal neuralgia.

Patient chief symptom was significantly associ-ated with likelihood of being in a particular finaldiagnosis group. When compared with patients inthe chief symptom ‘‘Lesion’’ group, patients in thechief symptom ‘‘Infection’’ groupwere 19 timesmorelikely (odds ratio 19, 95% confidence interval 2.0-190.9) to have a final diagnosis of ‘‘DOP.’’ Patients inthe chief symptom ‘‘Fiber’’ group were 5 times morelikely to receive the ‘‘Somatic’’ diagnosis (odds ratio5.0, 95% confidence interval 1.1-22.8). Those whodid not report fibers or infection as a chief symptom(‘‘Lesion’’ group) were 14 times more likely to beplaced in the final diagnosis ‘‘Other’’ group (oddsratio 14.4, 95% confidence interval 2.3-89.9).

A subset of patients had ROS (n = 18) and MMSpsychiatric data (n = 19) available for analysis.Patients in the final diagnosis ‘‘Somatic’’ group hada higher number of questions answered ‘‘yes’’ onROS questionnaire (median = 12) as compared withpatients in the final diagnosis DOP (median = 7) orother (median = 8) (Fig 1) groups.

Information from the MMS psychiatric screencould aid in predicting a final diagnosis. Patients inthe final diagnosis ‘‘Somatic’’ group reported ahigher number of anxiety symptoms (median = 3)

Table II. Demographic Information for all patients referred for delusions of parasitosis from 2008 through 2011,separated by final diagnosis

Final diagnosis

P valueyDOP/schizophrenia, n = 14 Somatoform, n = 19 Other,* n = 14

Mean age at initial visit, y (6SD) 53.5 (5.3) 48.7 (17.0) 54.9 (17.4) .44Median duration of illness, mo (IQR) 13.0 (2.0-36.0) 2.0 (6.0-12.0) 24.0 (10.0-111.0) .06Median No. of clinic visits (IQR) 2.5 (2.0-4.0) 3.0 (2.0-5.0) 3.0 (2.0-6.0) .90Gender, n (%) .40Male 6 (42.9) 4 (21.0) 4 (28.6)Female 8 (57.1) 15 (79.0) 10 (71.4)

Marital status, n (%) .86Single 4 (36.4) 8 (42.1) 5 (38.5)Married 5 (45.5) 8 (42.1) 4 (30.8)Divorced 2 (18.2) 3 (15.8) 4 (30.8)

Occupation, n (%) .33Medical professional 2 (16.7) 4 (23.5) 4 (36.4)Other occupation 7 (58.3) 9 (52.9) 2 (18.2)Unemployed 2 (16.7) 4 (23.5) 5 (45.5)

DOP, Delusions of parasitosis; IQR, interquartile range.

*Other diagnosis including picker/obsessive-compulsive disorder; medical diagnosis was found to explain; or no cause was found.yFrom tests of association between final diagnosis and mean age at diagnosis (analysis of variance), median duration of illness and clinic

visits (Kruskal-Wallis), and gender, marital, and occupational categories (x2, 2 degrees of freedom).

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as compared with patients in the final diagnosis‘‘DOP’’ (median = 0) or ‘‘Other’’ (median = 0.5)groups. Patients in the final diagnosis ‘‘DOP’’ grouphad fewer symptoms related to PTSD (median = 0)when compared with the final diagnosis ‘‘Somatic’’and ‘‘Other’’ groups (median = 1 for both).

Of the 47 patients in the study, 6 (12.77%)required intervention from risk management. Thisincluded 2 patients who had to be dismissed from thepractice because of inappropriate behavior, 2 whothe physician was concerned may be an immediatedanger to themselves (lighting themselves on fire,suicidal thoughts), and 2 who filed formal com-plaints about the physician. As of this writing, noneof the patients requiring risk management in thestudy were involved in formal lawsuits. In the sametime period of 2008 through 2011, the dermatologist(J. S. R.) saw 7574 other patients, and only 3 (0.04%)patients required risk management. The dermatolo-gist in this DOP clinic was 320 times more likely toseek legal counsel for these patients than for patientsseen in a standard outpatient clinic.

LimitationsThis was a retrospective study, which presents

several limitations. The inclusion criteria specifiedpatients referred (by themselves or others) to thepractice with a diagnosis of DOP. There was nofurther pre-screening of patients, so other psychiatricconditions may have been mislabeled as DOP. As anewly formed referral center, the study may have

seen a different patient population than that of amore well-established academic center. The refer-ring physicians were provided no formal training inpsychiatry. In addition, the practice is located inAustin, Tex, the site of an annual meeting forMorgellons disease, which may have skewed thepopulation further.

Because of the retrospective nature of the study,the laboratory testing performed on each patientvaried. Because most patients refused psychiatricreferral, psychiatric diagnoses were made throughchart review and screening questionnaires, which isnot the gold standard. The MMS screen has beenfound to have sensitivity between 54%8 and 82%9 indifferent patient populations. Some patients showedsigns of both delusional disorder and somatoformdisorder, making a final psychiatric diagnosisdifficult.

The ROS was adapted from a standardized rheu-matologic questionnaire, and was not originallyintended to identify somatoform disorders. Sincethe time of this study, the authors have replaced thisquestionnaire with the Patient Health Questionnaire15, which has proven reliable in diagnosing somaticsymptoms.11 Because of the small number of patientswho received ROS and MMS questionnaires, thedata, although helpful in illustrating trends, could notbe analyzed for statistical significance.

There were limited data available regarding thepatients’ response to treatment. The authors areplanning a future study to show outcome data.

0

5

10

15

20

25

30

DOP Somatic Other

Fig 1. Number of questions (among 24 total) answeredaffirmatively on review of systems for patients referred fordelusion of parasitosis between 2008 and 2011. Patientswere separated by final diagnosis. Median (arrow) andrange (lines) shown. Final diagnoses of: delusions ofparanoia or schizophrenia (‘‘DOP’’); multiple somaticsymptoms and no clear medical cause (‘‘Somatic’’);picker/obsessive-compulsive disorder or medical diagno-sis was found to explain symptoms (‘‘Other’’).

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DISCUSSIONKoblenzer12 has written about distinguishing be-

tween delusional disorders and conditions such asphobias or obsessions. This study confirms herfindings; many patients reporting something in theirskin meet criteria for a somatoform disorder. Othersend up being pickers or are discovered to have a(treatable) medical disease. Each of these groups hasa different presentation and show significant differ-ences in their scores on self-administered surveys.

Somatoform disorder is less commonly discussedin the dermatologic literature; these patients dem-onstrate ‘‘physical pain and distress above andbeyond what can be explained by physical examand diagnostic testing.’’10 Some theorists suggest thatsomatoform illness is a defense mechanism thatallows people to avoid the stigma of a psychiatricdiagnosis (eg, depression or anxiety), while stillgetting the care they desperately need. In this study,one of the patients with somatoform disorder calledherself the ‘‘princess and the pea,’’ referring to thefairy tale about a princess who is able to feel a tinypea under her mattresses.

There appears to be a difference between patientswho report an infection or ‘‘bugs on my skin’’ andthose who report fibers. Patients with concerns ofbugs are more likely to have either a true infection ora fixed delusion. Those whose concerns are ofinorganic substances such as fibers are less likely tofall into the delusional category, and often meetcriteria for a somatoform disorder.

Written questionnaires were helpful in predictingfinal diagnosis; patients with somatoform disorderanswered positively to at least to 7 ROS questions; a

low ROS number was predictive of DOP or a medicaldiagnosis.

The MMS for psychiatric disease is a quick tool toaid in distinguishing between patients with delu-sional and somatoform disorders. Patients who weredelusional often had a negative series of answers.Patients with somatoform disorder often admit toanxiety, PTSD, and depression on this screen. Thissurvey often served as a conduit to allow thedermatologist to openly discuss psychiatric diseasewithout the stigma of a ‘‘delusional’’ diagnosis.Because the questions on the MMS regarding psy-chosis were neither predictive nor rapport-building,the authors have dropped them from future surveys.

The distinction among these various psychiatricdiagnoses has a great impact on patient treatment.Patients with DOP may respond to antipsychoticmedications, and can be treated according to previ-ously published guidelines.13,14 In contrast, patientswith somatoform disorder will often admit to under-lying anxiety, depression, or PTSD and respond toantidepressants.15 They may be willing to go totherapy to better cope with their ‘‘princess and thepea’’ hypersensitivity, even if they do not believe thatthe underlying cause of their symptoms is psychiatricin nature. In the authors’ experience, these patients,if caught early in their disease process, can be wellmanaged with selective serotonin reuptake inhibi-tors and continual reassurance by the physician. Ifleft for many months or years, their functioning willspiral downward into disability and isolation.

Patients who are pickers will often respond tohigh doses of selective serotonin reuptake inhibitorsor cognitive behavioral therapy. The dermatologistshould make an effort to treat any underlying skinprocess that triggers the patient to pick, such as acneexcoriee.15

Many patients who presented with Morgellonsdisease met criteria for somatoform disorder and hadconcomitant depression or anxiety. A high rate ofpsychiatric disease has been cited both in the recentCDC report (63% on 1 global assessment)6 andprevious studies (28.7% depression by patient self-report).16 Fully exploring the cause of Morgellonssymptoms is beyond the scope of this article.Regardless, the authors have given antidepressantsto several patients presenting with ‘‘fibers’’ andwitnessed a dramatic improvement in their qualityof life. In this practice, citalopram has become first-line treatment for these patients once an easilytreatable medical cause is ruled out. Larger studiesshould be undertaken to determine if all patientswho believe they have fibers would equally benefitfrom antidepressant treatment, or if they, too, makeup a heterogeneous group.

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This study found many patients mislabeled withDOP. These results are in contrast to the experienceof other psychodermatology specialists (J. Koo, MD,oral communication, February 7, 2011). Many possi-ble reasons for this are discussed in the ‘‘Limitations’’section. Perhaps the referring providers in this studywere less concerned about distinguishing betweenDOP and other psychiatric disorders.

The authors were surprised at the greatly in-creased necessity of legal counsel when dealingwith patients referred for DOP. Interestingly, it wasnot just the patients with a final diagnosis of DOPwho required legal intervention. In another study of‘‘difficult patients’’ in the primary care setting, thesetime-intensive patients were much more likely tohave a mental disorder (67% vs 25%, P\.0001), withsomatoform disordered patients causing the greatestamount of ‘‘difficulty.’’17 A discussion with the riskmanagement team for this hospital network (includ-ing 500 physicians in 20 specialties) estimated that40% of all telephone calls involve patients withpsychiatric issues.

ConclusionPatients who were referred with a diagnosis of

DOP made up a heterogeneous group in this study.Many of the patients labeled by other providers asDOP did not warrant the ‘‘delusional’’ diagnosis.Some had a somatoform disorder. Others had atreatable dermatologic diagnosis, confounded by acomorbid psychiatric disease such as bipolar disor-der or personality disorder. The final medical orpsychiatric diagnosis can often be reached by usingfocused questioning and written questionnaires.There is a greater likelihood of requiring legalcounsel when working with this patient population.These patients are a challenge to dermatologists,both in their initial diagnosis and in their long-termtreatment.

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1. Wilson JW, Miller HE. Delusions of parasitosis (acarophobia).

Arch Dermatol Syph 1946;54:39-56.

2. Zomer SF, De Wit RF, Van Bronswijk JE, Nabarro G, Van Vloten

WA. Delusions of parasitosis: a psychiatric disorder to be

treated by dermatologists? An analysis of 33 patients. Br J

Dermatol 1998;138:1030-2.

3. Trabert W. 100 Years of delusional parasitosis: meta-analysis of

1,223 case reports. Psychopathology 1995;28:238-46.

4. Lepping P, Russell I, Freudenmann RW. Antipsychotic treat-

ment of primary delusional parasitosis: systematic review. Br J

Psychiatry 2007;191:198-205.

5. Murase JE, Wu JJ, Koo J. Morgellons disease: a rapport-

enhancing term for delusions of parasitosis. J Am Acad

Dermatol 2006;55:913-4.

6. Pearson ML, Selby JV, Katz KA, Cantrell V, Braden CR, Parise

ME, et al. Clinical, epidemiologic, histopathologic and molec-

ular features of an unexplained dermopathy. PLoS One 2012;7:

e29908.

7. Alexander MJ, Haugland G, Lin SP, Bertollo DN, McCorry FA.

Mental health screening in addiction, corrections and social

service settings: validating the MMS. Int J Ment Health Addict

2012;1:105-19.

8. Spotts JL. Utility of the Modified Mini Screen (MMS) for screen-

ing mental health disorders in a prison population [disserta-

tion]. Iowa City: University of Iowa; 2008. Available from: URL:

http://ir.uiowa.edu/etd/462. Accessed January 29, 2012.

9. New York State Office of Alcoholism and Substance Abuse

Services (OASAS). Clinical and administrative practice improve-

ment (CAPRI) series volume 1, number 1. Albany (NY): Perfor-

mance and Practice Improvement Unit. Available from: URL:

https://www.oasas.ny.gov/treatment/COD/documents/CAPrI.

pdf). Accessed June 3, 2012.

10. American Psychiatric Association. (2000). Diagnostic and statis-

ticalmanual of mental disorders. 4th ed. doi:10.1176/appi.

books.9780890423349. Available at: http://psycho.silverchair.

com/resourceTOC.aspx?resourceID=1. Accessed September 17,

2012.

11. Kroenke K, Spitzer RL, Williams JB. The PHQ-15: validity of a

new measure for evaluating the severity of somatic symp-

toms. Psychosom Med 2002;64:258-66.

12. Koblenzer CS. The challenge of Morgellons disease. J Am Acad

Dermatol 2006;55:920-2.

13. Koo J, Lee CS. Delusions of parasitosis: a dermatologist’s guide

to diagnosis and treatment. Am J Clin Dermatol 2001;2:

285-90.

14. Sandoz A, LoPiccolo M, Kusnir D, Tausk FA. A clinical paradigm

of delusions of parasitosis. J Am Acad Dermatol 2008;59:

698-704.

15. Magid M, Fridlington J, Reichenberg J. Management of

psychodermatologic disorders. US Dermatology 2008;3:64-8.

16. Savely VR, Stricker RB. Morgellons disease: analysis of a

population with clinically confirmed microscopic subcutane-

ous fibers of unknown etiology. Clin Cosmet Investig Derma-

tol 2010;3:67-78.

17. Hahn SR, Kroenke K, Spitzer RL, Brody D, Williams JB, Linzer M,

et al. The difficult patient: prevalence, psychopathology, and

functional impairment. J Gen Intern Med 1996;11:1-8.

Table III. Detailed information regarding 47 patients referred for delusions of parasitosis from 2008 through 2011

Patient No.

Chief symptom:

infection*

Chief symptom:

fiberyPositive ROS

except skin-yes of 30zDepression-yes

of 4xMania-yes

of 4xAnxiety-yes

of 5xOCD-yes

of 2xPTSD-yes

of 2xPsychosis-yes

of 7x Final diagnosis

Legal

problem{

1 Yes 7 1 0 0 0 0 0 DOP Yes2 Yes DOP3 Yes DOP4 Yes 3 3 0 0 0 0 0 DOP5 Yes 10 2 0 0 0 0 0 DOP6 Yes 7 0 1 0 0 0 0 DOP7 Yes DOP8 Yes 1 0 0 0 0 0 0 DOP9 Yes Other (MC)10 Yes Other (MC)11 Yes Other (picker) Yes12 Yes DOP (schizophrenia)13 Yes Somatoform14 Yes 23 4 1 3 0 1 0 Somatoform15 Yes Somatoform16 Yes Yes 18 4 1 2 2 2 4 DOP Yes17 Yes Yes DOP (schizophrenia) Yes18 Yes Yes Somatoform19 Yes Yes Somatoform20 Yes Yes Somatoform21 Yes Yes 11 2 0 3 1 1 0 Somatoform22 Yes Somatoform23 Yes DOP24 Yes 3 0 0 0 0 0 0 DOP Yes25 Yes 5 0 0 0 0 1 0 Other (nothing)//

26 Yes Other (picker)27 Yes 24 0 0 3 0 1 1 Somatoform28 Yes 7 0 0 0 0 0 0 Somatoform29 Yes 7 0 0 0 1 2 0 Somatoform30 Yes 0 0 0 0 Somatoform31 Yes 18 1 1 4 2 2 2 Somatoform32 Yes 12 1 0 2 0 2 0 Somatoform33 Yes Somatoform34 Other (MC)35 Other (MC)36 11 2 0 1 0 1 0 Other (MC)37 Other (picker)38 Other (picker)

Continued

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Table III. Cont’d

Patient No.

Chief symptom:

infection*

Chief symptom:

fiberyPositive ROS

except skin-yes of 30zDepression-yes

of 4xMania-yes

of 4xAnxiety-yes

of 5xOCD-yes

of 2xPTSD-yes

of 2xPsychosis-yes

of 7x Final diagnosis

Legal

problem{

39 Other (picker)40 Other (picker)41 Other (picker)42 Other (picker)43 DOP (schizophrenia)44 Somatoform45 12 3 1 4 1 0 0 Somatoform46 13 3 0 2 0 2 0 Somatoform Yes47 Somatoform Yes

DOP, Delusions of parasitosis; MC, medical condition; OCD, obsessive-compulsive disorder; PTSD, posttraumatic stress disorder; ROS, review of systems.

*Patient reported bug or infection in their skin.yPatient reported fibers, threads, or other inanimate objects in their skin.zFor patients who received ROS questionnaire, No. of questions (not related to skin) to which they answered affirmatively (of total No. noted in heading).xFor patients who received Modified Mini Screen for psychiatric disease, No. of questions to which they answered affirmatively (of total No. noted in heading).//Patient was not found to have a medical reason for her report of ‘‘threads,’’ and had a negative psychiatric evaluation.{Patient required assistance from risk management department to draft cease-and-desist letter, because of, eg, patient symptoms.

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