Morgellons Disease and Delusions of Parasitosis

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  • Morgellons Disease and Delusions of ParasitosisDavid T. Robles,1 Jonathan M. Olson,1 Heidi Combs,2 Sharon Romm2 and Phil Kirby1

    1 Department of Medicine, Division of Dermatology, University of Washington School of Medicine, Seattle, Washington, USA

    2 Department of Psychiatry, University of Washington School of Medicine, Seattle, Washington, USA

    Abstract Morgellons disease is a controversial and poorly defined symptom cluster of skin lesions and somaticsymptoms, most notably fibers in the skin. Because of widespread coverage in the media and on the

    Internet, there are an increasing number of patients presenting to dermatologists. We present three patients

    who believed that they had fibers in their skin. We offer a discussion of delusions of parasitosis to de-

    monstrate similarities between these conditions. It has been suggested by a limited number of healthcare

    providers that an unknown infectious agent underlies this symptom complex yet no available evidence

    supports this assertion. Laboratory values that would be reflective of an infectious process (e.g. elevated

    white blood cells, sedimentation rate, C reactive protein) are routinely normal and biopsies often reflect only

    nonspecific findings such as acute and chronic inflammation with erosion or ulceration.

    Patients with Morgellons disease generally lack insight into their disease and reject the need for psy-

    chiatric help. The goal is to build trust and refrain from minimizing what the patient experiences. Attentive

    examination of the patients skin and fragments they present is necessary to rule out a true underlying

    pathologic process and to establish a trusting relationship. A supportive, non-confrontational approach is

    ideal. The patient is best treated by a team of practitioners of several specialties, including dermatologists,

    psychiatrists, and counselors.

    Morgellons disease gained widespread attention following a

    report in a Pittsburg newspaper about biologist Mary Leitao,

    who described thin fibers emerging from awound on the face of

    her 2-year-old son.[1] Morgellons disease has rapidly received

    extensive attention as a result of news publications, television,

    and dissemination through the Internet. Currently, the term

    Morgellons retrieves about 188 000 hits on the Google

    search engine (Google, accessed 28 October 2010). In con-

    trast, a PubMed search accessed on 28 October 2010 using the

    keyword Morgellons returned only 22 documents.[2-23] Be-

    cause of the controversial nature of this condition and given the

    multiple and various symptoms, a scientific agency, the US

    Centers for Disease Control and Prevention, is in the process of

    undertaking a study to answer questions about this dermo-

    pathy. The goals are to identify patients and the factors that

    contribute to their illness. The study also includes assessment

    of skin biopsies and characterization of the foreign materials

    obtained.[24]

    We present three patients treated in our clinic and discuss

    the differential diagnoses and suggested treatment of this

    condition.

    1. Case Reports

    1.1 Case 1

    The patient was a 60-year-old man who had experienced

    severe, chronic, facial ulcerations for 25 years. He had a fixed

    belief that unusual fiber material was embedded in his skin,

    which he believed stemmed from nickel poisoning following

    a work-related chemical exposure to his face and torso 2 de-

    cades earlier. He reported having consulted approximately

    20 physicians for this condition. Enraged with the medical system,

    he spent 3 years writing a 3000-page unpublished book about

    his terrible experiences with doctors. He expressed frus-

    tration that no physicians had been able to determine the exact

    nature of his condition. He denied a history of illegal drug use

    and did not believe that he was infested with parasites. On

    examination, he had irregularly shaped ulcerations on his chin

    (figure 1a). He used tweezers to pull out what he described as

    hard hair bulbs, cartilage, and unusual fiber material.

    The lesions frequently became secondarily infected with

    Staphylococcus aureus from chronic manipulation. The patient

    CURRENT OPINION Am J Clin Dermatol 2011; 12 (1): 1-61175-0561/11/0001-0001/$49.95/0 2011 Adis Data Information BV. All rights reserved.

  • responded transiently to antibacterials but believed they be-

    came ineffective or intolerable due to adverse effects. A punch

    biopsy revealed nonspecific changes including ulcerations

    associated with acute inflammation.

    We treated the patient with desonide ointment for inflamma-

    tion and doxycycline 100mg twice daily for staphylococcal

    coverage and applied a hydrocolloid dressing (DuoDERM

    Extra Thin; ConvaTec, Skillman, NJ, USA) to cover the lesion.

    He reluctantly agreed to a consultation with a psychiatrist in

    our multidisciplinary team but he terminated the interview

    prematurely and refused further psychiatric follow-up. The

    patient was seen in the dermatology clinic at close intervals

    (every 24 weeks) and was called weekly by a dermatology

    resident to ensure that he was continuing to cover the lesions

    and to avoid further manipulation. Following 9 weeks of this

    regimen it was noted that his lesions had resolved and the pa-

    tient was no longer obsessed about fibers emanating from his

    skin (figure 1b).

    1.2 Case 2

    The patient was a 35-year-old woman with a long history of

    facial lesions and resultant scars. Her frequent facial ulcer-

    ations caused her to lose her job as a waitress. She reported that

    something was irritating her skin and described black fi-

    bers that she had extracted from facial skin. She stated that she

    could twist her neck until she heard a pop that relieved an ill-

    defined tension in her skin. She was adamant that parasites

    were not responsible for her skin problems and denied feeling

    any organism crawling in her skin. She had a contracted scar in

    the glabellar area from previous ulcerations (figure 2a). Both

    cheeks had areas of hypo- and hyperpigmentation from pre-

    vious excoriations and inflammation (figure 2b). On her chin

    she had an erythematous, eroded plaque with a thin, honey-

    colored, hemorrhagic crust. She was treated with the applica-

    tion of a hydrocolloid dressing and oral doxycycline 100mg

    twice daily for 2 months for S. aureus secondary infection. At

    the 2-month follow-up her erosions were almost completely

    healed. The patient was then referred to a psychiatrist in our

    multidisciplinary team for further evaluation regarding issues

    of depression and anxiety centered on her chronic skin problems.

    1.3 Case 3

    This was a 50-year-oldwomanwith a 30-year history of skin-

    picking behaviors. She had a fixed delusion that she had

    rocks and fibrous threads under her skin and ingrown

    hairs over her face extending to the submandibular region. She

    felt compelled to pick them out using needles and tweezers. She

    had caused significant facial scarring, which had worsened in

    the previous 3 years. Physical examination revealed numerous

    scattered, irregularly shaped, depressed scars in a semi-symmetric

    distribution. There was no evidence of an underlying derma-

    tologic condition or secondary infection. She consulted a psy-

    chiatrist from September 2003 through June of 2005 during

    which time she received medication treatment including esci-

    talopram, trazodone, risperidone, and nortriptyline. She also

    engaged in cognitive behavior therapy focused on reducing her

    a

    b

    Fig. 1. (a) A patient with irregularly shaped ulcerations on his chin frommanipulation with tweezers to get rid of fibers from his skin. (b) Follow-up after 9 weeks

    of conservative wound-care measures and antibacterial treatment to control secondary staphylococcal infection.

    2 Robles et al.

    2011 Adis Data Information BV. All rights reserved. Am J Clin Dermatol 2011; 12 (1)

  • skin-picking behavior. With treatment she reduced her skin-

    picking behavior from a peak of 10 hours per 24 hours to a

    minimum of 30 minutes per 24 hours. She was not able to

    completely cease this activity.

    2. Discussion

    Morgellons disease has been the recent focus of attention in

    the lay press and a source of controversy among the medical

    community. Physicians should be aware of the content on the

    Internet regarding this topic since many patients come in with

    copies of content from websites and self-diagnose their symp-

    toms. One website that we have seen patients refer to is the

    Morgellons Research Foundation (MRF) [http://www.

    morgellons.org/]. Mary Leitao, the founder of the MRF, used

    the term Morgellons to describe fibers emanating from her

    sons skin, after seeing Sir Thomas Brownes 1674 description

    of mysterious fibers and harsh hairs coming from the skin

    of children.[4] Most physicians, including the authors of this

    article, reject the notion that Morgellons disease represents an

    emerging infectious disease as labeled by the MRF.[25] Some

    authors suggest that it is simply delusional parasitosis by an-

    other name.[6] According to the MRF, patients with Morgel-

    lons disease have a constellation of signs and symptoms: skin

    lesions that are both spontaneous and patient generated, sen-

    sations of movement, filaments of varying colors and textures

    removed from the skin that may auto-fluoresce or glow when

    viewed under a microscope with UV light, muscle and joint

    pain, chronic fatigue, cognitive dysfunction, and emotional

    effects ranging from depression to mania.[25] Virginia Savely,

    family nurse practitioner and member of the medical advisory

    board of theMRF, believes that an unknown infectious agent is

    the underlying and unifying cause of this condition.[11] This

    claim has not been substantiated. The MRF disparage the

    notion that the cause is psychologically driven. Savely et al.[11]

    claim that, with the aid of a 60 hand-held digital microscope,a network of blue fibers under the skin was visualized, as well

    as blue and white fibers protruding from their lesions. We

    have carefully evaluated the skin and skin fragments of all our

    patients reporting symptoms consistent with Morgellons dis-

    ease using a hand-held 7 Bausch& Lomb magnifier (Bausch& Lomb, Rochester, NY, USA), a 10DermLite II PRO HR

    (3Gen, LLC, San Juan Capistrano, CA, USA) and a 100 and400 microscope but have been unable to identify fibers otherthan hair and fabric. Savely et al.[11] have hypothesized a

    possible tick-borne disease or plant etiology of Morgellons

    a b

    Fig. 2. (a) A patient with a disfiguring contracted scar in the glabellar area from previous manipulation to extract fibers from the skin. (b) Both cheeks have

    areas of hypo- and hyperpigmentation from previous excoriation and inflammation.

    Morgellons Disease and Delusions of Parasitosis 3

    2011 Adis Data Information BV. All rights reserved. Am J Clin Dermatol 2011; 12 (1)

  • disease but this has not been substantiated by available evi-

    dence or corroborated by physicians outside of the MRF.

    We propose that Morgellons disease is similar to delusions

    of parasitosis (DP). In DP the delusional focus is on being in-

    fested with parasites, whereas patients with Morgellons disease

    believe that unusual fibers or other material is in their skin

    (table I). Similar to patients with DP, patients self-mutilate by

    picking and digging at their skin to extract offending substances

    resulting in chronic wounds and scars. In our experience, since

    patients withMorgellons disease are concerned about fibers in

    their skin, they commonly use tweezers to pull the fibers from

    their skin, demonstrating the so-called tweezer sign.[22] How-

    ever, this finding is not entirely specific for Morgellons disease

    as patients with DP frequently use tweezers to extract bugs or

    eggs from their skin. A common explanation is that removing

    the fibers or unusual material provides a sense of relief,

    which is reminiscent of hair pulling in trichotillomania. Lesions

    may become secondarily infected and require topical and sys-

    temic antibacterial therapy.

    The fixed belief that fibers or other debris are buried within

    the skin is similar to DP. DP is a condition characterized by a

    fixed, false belief of cutaneous infestation with parasites not

    secondary to another psychiatric illness.[26] Similar to those

    with Morgellons disease, patients are convinced that they have

    a dermatologic, not a psychiatric problem.[27,28] For patients

    withDP, lack of insight and the unshakeable belief that they are

    infested despite evidence to the contrary is what distinguishes

    it from formication, in which patients experience symptoms

    of infestation such as a crawling or burrowing sensation in

    their skin but are able to accept the absence of infection when

    evidence demonstrates otherwise.[29] Although the disorder is

    uncommon, many dermatologists treat at least one patient

    with DP.

    Patients with DP may perform ritualistic purifications in-

    cluding medicated baths, and application of antibacterial

    cleansers and disinfectants. They frequently and vigorously

    clean or manipulate their skin. Patients with Morgellons dis-

    ease deny the existence of parasites. They focus on ridding

    themselves of distressing subcutaneous substances. Both

    groups may seek multiple medical consultations and present

    lint, fibers, dried blood, hair, and other skin fragments spuri-

    ously thought to represent the parasites (DP) or fibers

    (Morgellons disease). This classic finding is commonly referred

    to as the matchbox sign, named for the container in which

    patients bring material to physicians.[25] Clinical appearance

    may include excoriations, ulcerations, areas of lichenification,

    or prurigo nodules from self-manipulation following attempts

    to rid themselves of organisms and/or inorganic materials.[28]

    Laboratory values are normal and biopsies often show non-

    specific findings such as acute and chronic inflammation with

    erosion or ulceration.

    3. Treatment

    Similar to patients with DP,[26] patients with Morgellons

    disease lack insight into their disease and reject the need for

    psychiatric help. As a result, dermatologists may be more than

    the primary caregiver; they may be the only physician from

    whom patients will accept treatment. Only about one in seven

    dermatologists use a pharmacologic intervention, typically

    sedatives and anxiety-relieving drugs, for patients with DP.[27]

    For DP, pimozide has long been considered the antipsychotic

    medication of choice.[27-29] Pimozide is a dopamine D2 receptor

    blocker with a unique ability to antagonize the central opioid

    receptor system, which can help with pruritus and for-

    mication.[27] It may lead to a prolonged QT interval, like other

    antipsychotics. Adverse effects such as hypotension, ven-

    tricular arrhythmias, and sudden cardiac death have been re-

    ported, but are rare, and associated only with higher doses.[30]

    Some authorities recommend both pre- and post-treatment

    ECGs. Pimozide is usually started at 12mg/day with gradualincreases titrated to clinical response. Efficacy is foundwith low

    dosages ranging from 2 to 4mg/day; these dosages are unlikelyto cause cardiac or significant neurologic adverse effects.[29]

    Table I. Similarities and differences between Morgellons disease and de-

    lusions of parasitosis

    Morgellons disease Delusions of parasitosis

    Fixed false belief of fibers or

    unusual material in the skin

    Fixed false belief of infestation with

    parasites

    Convinced that they have a

    dermatologic problem, not a

    psychiatric disease

    Convinced that they have a

    dermatologic problem, not a

    psychiatric disease

    Typically reject psychiatric

    intervention

    Typically reject psychiatric

    intervention

    Typically see multiple physicians

    from multiple disciplines; physician

    hopping

    Typically see multiple physicians

    from multiple disciplines; physician

    hopping

    Often present lint, fibers, dried blood,

    hair, and other skin fragments

    spuriously thought to represent the

    fibers or unusual material

    (matchbox sign)

    Often present lint, fibers, dried blood,

    hair, and other skin fragments

    spuriously thought to represent the

    parasites (matchbox sign)

    Demonstrate the tweezer sign when

    they dig at their skin in an attempt to

    get rid of the fibers in their skin

    Frequently use disinfectants,

    elaborate cleansing rituals, and

    topical scabicides to rid themselves

    of parasites

    4 Robles et al.

    2011 Adis Data Information BV. All rights reserved. Am J Clin Dermatol 2011; 12 (1)

  • At higher dosages, pimozide has been associated with extra-

    pyramidal adverse effects, which may require treatment with

    antiparkinsonian medications.[31]

    Because of the adverse effect profile of pimozide, some

    experts recommend newer atypical antipsychotics, such as

    olanzapine and risperidone.[32] Dosages as low as olanzapine

    1mg/day and risperidone 1mg/day have been shown to be ef-fective for treating somatic delusions[33] but higher dosages

    (510mg/day for olanzapine and 24mg/day for risperidone)have also been reported for the treatment of DP.[28,34-37] In

    addition, Mercan et al.[38] reported benefit from intramuscular

    risperidone at a dosage of 37.5mg given every 2 weeks. These

    medications carry risks, including hyperlipidemia, diabetes

    mellitus, QT interval prolongation, and weight gain. Med-

    ication non-compliance is a significant obstacle, given the lack

    of insight patients demonstrate.

    4. Approach to the Patient

    4.1 Terminology

    Diagnosing patients with DP is difficult since, by definition,

    they have a fixed, false belief that they are infested with para-

    sites, thus telling them they have delusions of parasitosis is

    unacceptable. Some authors suggest the term pseudoparasitic

    dysesthesia instead of delusions of parasitosis.[39] Several

    editorials point out the advantage of the term Morgellons

    disease over themore pejorative term delusions of parasitosis,

    both as ameans of enhancing rapport[4-6] and as a starting point

    for a discussion with the patient. Koblenzer[7] takes this idea

    one step further, suggesting the symptom complex should be

    referred to as Morgellons syndrome, rather than disease,

    thereby side-stepping the issue of etiology and focusing on

    treatment. One may argue that using a term such as Morgel-

    lons when talking to a patient with a delusion of parasites or

    fibers in his/her skin may validate the content of websites suchas the MRF. It is certainly a slippery slope and we try to avoid

    using Morgellons as a diagnosis when talking to a patient. In

    our experience, offering this label or agreeing with a patients

    self-diagnosis is not necessary in building trust. However, it is

    important to be aware of these websites and their content.

    4.2 Building Trust

    The goal in approaching a patient for the first time is to build

    trust. It cannot be overstated that, regardless of etiology, the

    patients suffering is genuine and physician empathy is vital.

    Direct confrontation will irreparably damage the therapeutic

    alliance, especially if done early before a trusting relationship

    has been established. Careful examination of the skin and

    fragments that the patient brings in is an important part of

    building trust. We encourage patients to bring in their collections

    of skin or hair that they believe to contain fibers or parasites.

    We show the patient thatwe are providing a careful and thorough

    examination of their contents and in some cases we examine them

    microscopically together with the patient. Other diagnoses to

    consider include scabies, body or hair louse infestation, insect bite

    reactions, substance abuse, and folliculitis.

    Since many patients will have already consulted multiple

    physicians and will report that no-one has taken them seri-

    ously, we perform a skin biopsy in nearly all of our new

    patients with symptoms of DP or Morgellons disease. The skin

    biopsy serves multiple purposes: (i) other diagnostic possibil-

    ities can be eliminated; (ii) it shows the patient that, since they

    are coming to you for a dermatologic problem and not a

    psychological problem, you are truly trying to investigate their

    problem seriously; and (iii) for a subset of patients, when con-

    fronted with negative findings, it is a starting point for a dia-

    logue on the possibility that fibers or a parasitic infestation

    may not be present. Some patients, when confronted with

    findings that do not support their delusion will assume that the

    correct area of the lesion was not biopsied, thus we ask our

    patients before the biopsy to help us identify the area likely to be

    of highest yield. This involves them in the process and helps

    eliminate the chance of disregarding negative results on account

    of inaccurate sampling.

    Establishing a positive doctor-patient relationship may en-

    able the patient to accept medications. The physician should

    state that although the cause of their symptoms is unknown,

    there are other patients with similar complaints that have

    benefited frommedications that help with unusual experiences.

    Even with the paucity of data, antipsychotics appear to offer

    the best pharmacologic treatment.

    5. Conclusions

    Patients often present to dermatologists with reports of skin

    disorders consistent with psychiatric illness. The classic exam-

    ple is DP. In reviewing our clinical cases as well as the current

    literature, we find that patients withMorgellons disease andDP

    share a similar symptom complex. The fixed beliefs of the pa-

    tient and their presentation of proof in Morgellons disease

    parallel those in DP. Although there is a paucity of reliable

    literature, clinicians have found a supportive, non-confrontational

    approach with reassurance and medication helpful in working

    with this challenging patient group.

    Morgellons Disease and Delusions of Parasitosis 5

    2011 Adis Data Information BV. All rights reserved. Am J Clin Dermatol 2011; 12 (1)

  • Acknowledgments

    No sources of funding were used to prepare this article. The authors

    have no conflicts of interest that are directly relevant to the content of this

    article.

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    Correspondence: Dr David T. Robles, Division of Dermatology, University

    of Washington School of Medicine, 1959 NE Pacific St, Box 356524, Seattle,

    WA 98105-6524, USA.

    6 Robles et al.

    2011 Adis Data Information BV. All rights reserved. Am J Clin Dermatol 2011; 12 (1)

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