Patients labeled with delusions of parasitosis compose a heterogenous group: A retrospective study from a referral center

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<ul><li><p>Patients labeled with delusions of parasitosis composea heterogenous group: A retrospective study from a</p><p>l c</p><p>,b Ch</p><p>n, Texas</p><p>ilable to the dermatologist to help in the diagnosis of</p><p>tion and clinical course between patients who receivedfinal diagnosis of a primary medical condition or other</p><p>diagterm</p><p>DOP: delusions of parasitosisConflicts of interest: None declared.Accepted for publication August 6, 2012.</p><p>0190-9622/$36.00</p><p> 2012 by the American Academy of Dermatology, Inc.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</p><p>just a new name for DOP.5 A recent study by theCenters for Disease Control and Prevention (CDC)</p><p>From the Departments of Dermatologya and Psychiatry,b Univer-</p><p>sity of Texas Southwestern-Austin Program; and Seton Analyt-</p><p>ics and Health Economics.c</p><p>Funding sources: None.</p><p>Reprint requests: Jason S. Reichenberg, MD, Department of</p><p>Dermatology, University of Texas Southwestern-Austin Program,</p><p>601 E 15th St, Austin, TX 78701. E-mail: jreichenberg@seton.org.</p><p>Published online October 10, 2012.. Many subsequent studies have looked at thenosis and treatment of patients with DOP.2-4 TheMorgellons disease was introduced in 2003,</p><p>MMS: Modified Mini ScreenPTSD: posttraumatic stress disorderROS: review of systemsD had a fixed, false report of skin infesta-tionelusions of parasitosis (DOP) was firstcoined in 19461 to describe patients who</p><p>Abbreviations used:</p><p>CDC: Centers for Disease Control and PreventionKey words: delusions; legal action; Morgellons; obsessive-compulsive; parasitosis; picker; somatoform.because of other psychiatric comorbidities.</p><p>Conclusion: Patients referred to this practice as delusional had a heterogeneous final diagnosis. Thechief symptom of the patient was predictive of the patients 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.)contact the hospitals legal counsel compared with other patients in the practice.</p><p>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 clinicMethods: We performed a retrospective chart review of patients referred with a diagnosis of DOP. Eachpatient received a final consensus diagnosis.</p><p>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 topsychiatric disorder.referra</p><p>Jason S. Reichenberg, MD,a Michelle Magid, MD</p><p>Austi</p><p>Background: There are few diagnostic tools avapatients with delusions of parasitosis (DOP).</p><p>Objective:We sought to find differences in presentaa final diagnosis of DOP and those who received aenter</p><p>ristine A. Jesser, ScD,c and Clifton S. Hall, MDahttp://dx.doi.org/10.1016/j.jaad.2012.08.006</p><p>41</p></li><li><p>o the standards of the</p><p>tive review of patientsR.) in his dermatologys Southwestern-AustinDecember 31, 2011.had been either: (A)with a label of delu-f-referred to the officeskin condition but hadsional.ent chief symptom, age,ion of illness, and num-chartwas reviewedby2. H.) and 1 psychiatristsis was made.inistered patient ques-24-question review ofMini Screen (MMS) for</p><p>tiple somatic symptocan be explained bytic testing,10 andsomatoform disorde</p><p>d Other: picker, obsmedical diagnosis fo</p><p>Upon review, it becwere referred to the DOhad psychiatric diseamania) in addition tosumed a great deal ofone patient was referrea manic episode. Shebut had no concerns ainto the chief symptoma final diagnosis of ot</p><p>Mean ages were cvariance; Kruskal-Wall</p><p>RY</p><p>sionom aiatri</p><p>bugeterowithtrea</p><p>ueststionen poseue meir s</p><p>J AM ACAD DERMATOLJANUARY 2013</p><p>42 Reichenberg et alpsychiatric 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 givingThis study was approvedby the hospitals institutionalreview board and conforms tDeclaration of Helsinki.</p><p>This study was a retrospecseen by a single provider (J. S.clinic at the University of Texabetween January 1, 2008, andPatients were eligible if theyreferred by another physiciansions of parasitosis; or (B) selwith the belief that they had abeen told that they were delu</p><p>Data collection included patimarital status, occupation, duratberof clinicvisits. Eachpatientsdermatologists (J. S. R. and C. S(M. M.) and a consensus diagno</p><p>The team reviewed self-admtionnaires, which included asystems (ROS) and a Modifieddid not find a medical or infectious cause for thiscondition, pointing out that these patients are similarto patients with DOP.6</p><p>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.</p><p>This study focused on pa-tients with a referral diagnosisof DOP. It looked at patientschief 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.</p><p>METHODSStudy population andclinical characteristics</p><p>CAPSULE SUMMA</p><p>d Patients with deluoften seek care frinstead of a psych</p><p>d Patients reportingskin make up a hdiagnostic grouppresentation and</p><p>d Focused patient qadministered quedistinguish betwedelusional and thdisorder, with a tror who pick at tha final diagnosis of psychiatric disease.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.</p><p>Logistic regression models were used to exam-ine the association between chief symptom andlikelihood of being in a particular final diagnosis</p><p>group.Somatic: patient had mul-ms above and beyond whatphysical exam and diagnos-was given a diagnosis ofr.essive-compulsive disorder,und, or no cause found.</p><p>ame clear that many patientsP clinic simply because they</p><p>se (ie, personality disorder,their skin concerns or con-physician time. For example,d to the clinic for DOP duringpicked her skin obsessively,bout infections. She was putlesion group and received</p><p>her (skin picking).ompared using analysis ofis tests were used to com-The group also noted whether or not the hospi-tals legal counsel, referred to as risk management,was involved with each patients case.</p><p>Data analysisDemographic and clinical characteristics were</p><p>examined by chief symptom and by final diagnosisgroup.</p><p>Chief symptoms weregrouped as:d Infection: patient reportedthey had a bug, infection,or parasite.</p><p>d Fiber: patient reported thatthey saw fibers, threads, orspecks.</p><p>d Lesion: upon detailed ques-tioning, the patient did notreport infectionor fibers andhad other skin concerns.</p><p>Final diagnoses weregrouped as:d DOP: patient given thediagnosis of DOP orschizophrenia.</p><p>d</p><p>s of parasitosis willdermatologist</p><p>st.</p><p>s/threads on theirgeneousvariable</p><p>tment options.</p><p>ioning and self-naires may help toatients who arewith somatoformedical diagnosis,</p><p>kin.</p></li><li><p>rred</p><p>5</p><p>)</p><p>r skin</p><p>an ag</p><p>categ</p><p>J AM ACAD DERMATOLVOLUME 68, NUMBER 1</p><p>Reichenberg et al 43RESULTS</p><p>Table I. Demographic information for all patients refeseparated by chief symptom</p><p>Infection,* n = 1</p><p>Mean age at initial visit, y (6SD) 53.4 (11.1)Median duration of illness, mo (IQR) 24.0 (3.0-60.0Median No. of clinic visits (IQR) 3.0 (2.0-6.0)Gender, n (%)</p><p>Male 5 (33.3)Female 10 (66.7)</p><p>Marital status, n (%)Single 6 (46.2)Married 6 (46.2)Divorced 1 (7.7)</p><p>Occupation, n (%)Medical professional 3 (23.1)Other occupation 7 (58.9)Unemployed 3 (23.1)</p><p>IQR, Interquartile range.</p><p>*Patient reported bug or infection in their skin.yPatient reported fibers, threads, or other inanimate objects in theifiber group for this analysis.zPatient did not report infection or fibers.xFrom tests of association between chief symptom category and meclinic visits (Kruskal-Wallis), and gender, marital, and occupationalA total of 49 patients charts were reviewed for thestudy; 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.</p><p>When separated by chief symptom, 21 patientsmet criteria for the chief symptom Infection groupand 18 patients met criteria for the chief symptomFiber 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.</p><p>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 diagnosisSomatic group. Of the 14 patients placed in thefinal diagnosis Other group, 8 were skin pickers,</p><p>for delusions of parasitosis from 2008 through 2011,</p><p>Chief symptom</p><p>P valuexFiber,y n = 18 Lesion,z n = 14</p><p>50.9 (14.7) 51.8 (18.5) .896.0 (2.0-14.0) 12.0 (3.0-24.0) .532.5 (1.0-3.0) 2.5 (2.0-7.0) .36</p><p>.664 (22.2) 5 (35.7)</p><p>14 (77.8) 9 (64.3).73</p><p>6 (37.5) 5 (35.7)6 (37.5) 5 (35.7)4 (25.0) 4 (28.6)</p><p>.424 (26.7) 3 (25.0)8 (53.3) 3 (25.0)3 (20.0) 6 (50.0)</p><p>. If patients reported infection and fibers, they were categorized in</p><p>e at diagnosis (analysis of variance), median duration of illness and</p><p>ories (x2, 2 degrees of freedom).and 1 patient had each of the following: dementia,cocaine abuse, hereditary neuropathy, lichen planus,Demodex folliculitis, and trigeminal neuralgia.</p><p>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).</p><p>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.</p><p>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)</p></li><li><p>rred</p><p>n = 1</p><p>)</p><p>edic</p><p>at dia</p><p>ories (</p><p>J AM ACAD DERMATOLJANUARY 2013</p><p>44 Reichenberg et alas compared with patients in the final diagnosisDOP (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</p><p>Table II. Demographic Information for all patients refeseparated by final diagnosis</p><p>DOP/schizophrenia,</p><p>Mean age at initial visit, y (6SD) 53.5 (5.3)Median duration of illness, mo (IQR) 13.0 (2.0-36.0Median No. of clinic visits (IQR) 2.5 (2.0-4.0)Gender, n (%)</p><p>Male 6 (42.9)Female 8 (57.1)</p><p>Marital status, n (%)Single 4 (36.4)Married 5 (45.5)Divorced 2 (18.2)</p><p>Occupation, n (%)Medical professional 2 (16.7)Other occupation 7 (58.3)Unemployed 2 (16.7)</p><p>DOP, Delusions of parasitosis; IQR, interquartile range.</p><p>*Other diagnosis including picker/obsessive-compulsive disorder; myFrom tests of association between final diagnosis and mean agevisits (Kruskal-Wallis), and gender, marital, and occupational categand Other groups (median = 1 for both).Of the 47 patients in the study, 6 (12.77%)</p><p>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.</p><p>LimitationsThis was a retrospective study, which presents</p><p>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 haveseen 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 for</p><p>for delusions of parasitosis from 2008 through 2011,</p><p>Final diagnosis</p><p>P valuey4 Somatoform, n = 19 Other,* n = 14</p><p>48.7 (17.0) 54.9 (17.4) .442.0 (6.0-12.0) 24.0 (10.0-111.0) .063.0 (2.0-5.0) 3.0 (2.0-6.0) .90</p><p>.404 (21.0) 4 (28.6)</p><p>15 (79.0) 10 (71.4).86</p><p>8 (42.1) 5 (38.5)8 (42.1) 4 (30.8)3 (15.8) 4 (30.8)</p><p>.334 (23.5) 4 (36.4)9 (52.9) 2 (18.2)4 (23.5) 5 (45.5)</p><p>al diagnosis was found to explain; or no cause was found.</p><p>gnosis (analysis of variance), median duration of illness and clinic</p><p>x2, 2 degrees of freedom).Morgellons disease, which may have skewed thepopulation further.</p><p>Becau...</p></li></ul>

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