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  • Dr. Smith's Web Snippets About Morgellons Disease

Dr. Smith's Web Snippets About Morgellons Disease

Below I have cut and pasted information from several sources. The primary purpose is to illustrate that the “experts” in the field of DOP recommended specific tests which should be done in the patient with symptoms which suggest DOP.

- Greg Smith

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From University of California at Davis web site: (http://delusion.ucdavis.edu/services.html )

Diagnosis and treatment of delusional parasitosis is challenging and requires great patience. Early on in the diagnosis, it is essential that a trained entomologist or parasitologist be consulted to rule out the presence of actual parasites.

1. Take careful and tactful case histories.

2. Run appropriate diagnostic tests to rule out other medical conditions. (In the case of secondary organic delusional parasitosis the delusion often disappears when the underlying organic illness is treated.)

3. Do a complete physical examination and laboratory evaluation, including:

o Skin scrapings and biopsies

o Complete blood count

o Chemistry profile

o Thyroid function tests

o Vitamin B12 levels

4. Rule out true infestations.

5. Rule out other organic causes such as allergies or contact dermatitis.

Determine whether there is a history of drug abuse




From Dermatology Times: 
http://www.dermatologytimes.com/dermatologytimes/article/articleDetail.jsp?id=361063
Report that CDC is investigating Morgello:
Aug 1, 2006
By: Bill Gillette
Dermatology Times


Atlanta — The federal government's Centers for Disease Control and Prevention has announced that it will begin investigating a mysterious disease for which no cause has been identified — and which most medical professionals, including dermatologists, believe isn't a disease at all, but a psychotic disorder.

It's called Morgellons disease. To date, no clinical studies have been done on Morgellons, and only one paper written on it. That paper, published earlier this year in the American Journal of Clinical Dermatology, describes Morgellons symptoms as "insect-like sensations (i.e., crawling, stinging and biting sensations) as well as skin lesions, which can be anything from minor to disfiguring in their appearance (and) fiber-like material (that) often can be removed from skin lesions as either single strands or what appear to be balls of wound fibrous materials."

Patients complain of disabling fatigue, inattentiveness, sleep disorders, joint pain, hair loss, vision problems, neurologic disorders and even occasional disintegration of previously healthy teeth. Patients say they frequently have to stop working, and report that even if they do continue to work they can function only minimally. 'Not taken seriously'

According to the paper, many of these patients "have sought help from between 10 and 40 physicians and report that their symptoms are not taken seriously" and that physicians "do not even conduct a thorough examination, but make an instant diagnosis of delusional parasitosis and attribute the obvious open sores on the patient's skin to attempts at self-mutilation."

Traditionally, write the authors, patients who present with these symptoms and complaints are given prescriptions for anti-psychotic drugs such as pimozide or risperidone.

The paper was authored by San Francisco physician Raphael B. Stricker, M.D.; Austin, Texas, nurse practitioner Virginia R. Savely, R.N., F.N.P.C.; and Morgellons Research Foundation Executive Director Mary M. Leitao, a South Carolina biologist who started the foundation four years ago after doing her own research into her three children's Morgellons-like symptoms that doctors could not explain.

The Morgellons Research Foundation has been instrumental in bringing attention to the mysterious affliction and in recruiting researchers and physicians around the country to learn more about the disease and back the foundation's claim that Morgellons is not the result of a delusional disorder. (Both Savely and Dr. Stricker are listed as members of the foundation's medical advisory board on the Morgellons Research Foundation's Web site, www.morgellons.org.)

CDC to weigh in

The CDC made its decision to investigate Morgellons after receiving numerous communications from "the lay public and clinical people" over recent years, says CDC spokesman Dan Rutz.

"These complaints have come in for a number of years," he says. "We're in the process of forming a multi-disciplinary working group to look into Morgellons and develop a scientific case definition. Until that's done, we're going after this with an open mind and not drawing any conclusions either way."

Some in the medical community say they think the CDC could merely be placating those who've communicated their concern about Morgellons not being taken seriously to the CDC — and, perhaps more significantly, to their congressional representatives.

William T. Harvey, M.D., is a retired U.S. Air Force physician and scientist who specialized in space science, space medicine and space medicine research, and later served as medical director for the Space Station Program for Lockheed Corp. and at the Johnson Space Center in Texas. He has come out of retirement to research Morgellons and treat patients, and is now a clinician at Rocky Mountain Chronic Disease Specialists in Colorado Springs, Colo. Dr. Harvey also serves on the Morgellons Research Foundation's medical advisory board.

"I know there's a lot of skepticism out there (about Morgellons), and that isn't necessarily a bad thing — there's a thin line between skepticism and gullibility," Dr. Harvey says. He has treated 850 patients over the past four years, and firmly believes that Morgellons is, indeed, a real disease — not a delusional disorder — caused by a bacteria known as Borrelia burgdorferi.

Dermatologists doubtful

Dermatologists, meanwhile, remain doubtful.

"I think there's no question that it's a delusional disorder," says Dan Eisen, M.D., assistant professor in the University of California, Davis, department of dermatology. "In my opinion, it can't be treated other than psychologically or psychiatrically."

"The bottom line is that, like any patient presenting with a skin problem, (patients presenting with Morgellons-like symptoms) need to be taken seriously and treated with the same care and attention one would give to a patient with a malignancy or other serious skin condition," says Christopher Zachary, M.D., professor and chairman of the department of dermatology, University of California, Irvine, School of Medicine.

"I believe that dermatologists are in a good position to diagnose and treat this condition, but one should realize that there are some who hold that this should be firmly in the territory of the psychiatrists, and that dermatologists should keep away," he says. "I disagree with this."

From American Family Physician (Vol 64, Number 11, Dec., 2001)

Authors: Koo and Lebwohl

Discusses the possible other psychiatric or physical illnesses which cause or can be associated with DOP

…….. DELUSIONS OF PARASITOSIS

Delusions of parasitosis belongs to a group of disorders called “monosymptomatic hypochondriacal psychosis.”Patients with the latter disorder present with isolated delusions regarding a skin complaint.6 Because the nature of the delusional disorder is truly isolated, these disorders are quite different from schizophrenia, which involves multiple functional deficits, including auditory hallucinations, lack of social skills and flat affect, in addition to delusional ideation.7 The most common form of monosympto- matic hypochondriacal psychosis encountered among patients with skin problems is called delusions of parasitosis.8 Patients with delusions of parasitosis firmly believe that their bodies are infested by some

type of organism. Frequently, they have elaborate ideas about how these “organisms” mate, reproduce, move around in the skin and, sometimes, exit the skin. These patients often present with the “matchbox” sign, in which small bits of excoriated skin, debris or unrelated insects or insect parts are brought in matchboxes or other containers as “proof” of infestation (Figure 2).

The psychiatric differential diagnosis includes schizophrenia, psychotic depression, psychosis in patients with florid mania or drug-induced psychosis, and formication without delusion, in which the patient experiences crawling, biting and stinging sensations without believing that they are caused by organisms.6 Other organic causes such as withdrawal from cocaine, amphetamines or alcohol, vitamin B12 deficiency, multiple sclerosis, cerebrovascular disease or syphilis should also be considered. If any of these underlying causes are diagnosed, a separate diagnosis of delusions of parasitosis should not be made.9

……………………………….

The challenge in managing patients with delusions of parasitosis is in introducing the use of an antipsychotic medication without offending the patient. This step requires a delicate balance between the patient’s right to informed consent and the goal of pursuing the most appropriate therapy. The authors

recommend a sensitive, empathic and diplomatic approach. The medication should be presented as a “therapeutic trial,” and any contentious argument regarding the pathogenesis of the disorder or the mechanism of action of pimozide should be purposely avoided. Encouragement suggesting that pimozide may “help one focus less on the skin and more on enjoying life” may help.

From E-Medicine: http://www.emedicine.com/derm/topic939.htm

Author: Noah S Scheinfeld, MD, JD, FAAD, Assistant Professor, Department of Dermatology, Columbia University; Head of Consultation Service, Department of Dermatology, St Luke's Roosevelt Hospital Center

Noah S Scheinfeld, MD, JD, FAAD, is a member of the following medical societies: American Academy of Dermatology

………. History: Patients must be queried about their symptoms, the duration of symptoms, and their belief about the etiology. Notably, Goddard has described a seasonality to DP.

The diagnosis and treatment of DP can be an involved clinical activity. Patients with DP can resist suggestions that their condition is psychiatric rather than physical and refuse referrals for psychiatric care. In fact, in 35% of patients, the belief of infestation is unshakable. In approximately 12% of patients, the delusion of infestation is shared by a significant other. This phenomenon is known as folie à deux (eg, craziness for 2) or folie partagé (ie, shared delusions). Variations in this are the conviction that a child, a spouse, or a pet is infested.

DP is a monosymptomatic psychosis, a type of psychopathology relatively distinct from the remainder of the personality. If the condition has a defined pathologic or external cause (eg, scabies) it is not truly DP. In investigating the history of a patient with such suspected delusions, other causes of itch must be investigated. To diagnose this condition, true infestations (eg, scabies), pediculosis, and primary systemic causes of pruritus must be excluded. Examples include hepatitis, HIV infection, dermatitis herpetiformis, thyroid disease, anemia, renal dysfunction, neurologic dysfunction, and lymphoma.

DP is distinct from formication. Formication involves the cutaneous sensation of crawling, biting, and stinging. Formication does not involve the fixed conception that skin sensations are induced by parasites. Patients with this condition can accept proof that they do not have an infestation. Many cases of formication remain idiopathic.

Mimics of DP

Other forms of psychiatric illness can mimic DP. Such psychiatric illnesses are accompanied by signs of mental illness. For example, patients with schizophrenia may think they are being attacked by insects as a manifestation of their paranoia.

A type of severe depression called psychotic depression may involve a belief that one is contaminated, or "dirty," because of an infestation by bugs. This patient has a depressed mood and a sense of helplessness, hopelessness, worthlessness, or excessive guilt; these signs should be evident in their clinical presentation (Koo, 2001).

Physical: Patients with DP create their skin rash. They can present with no findings, erosions or ulcers with or without crusts or prurigo nodularis. They may evidence a dermatitis related to attempted treatments, which may include irritating or corrosive cleansers or harsh abrasive devices

DIFFERENTIALS

Section 4 of 10 

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Dermatitis Herpetiformis
Scabies
Other Problems to be Considered:

Internal disease
Lymphoma
Cocaine abuse

WORKUP

Section 5 of 10 

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Lab Studies:

No laboratory test can help in diagnosing DP.

However, laboratory tests can help identify other diseases that can mimic DP.

To exclude infestation, a mineral oil preparation should be used to eliminate scabies, and a microscopic examination of skin and hair should be performed to exclude louse infestation.

Neurologic pathology due to toxins or vitamin deficiencies can be evaluated with the appropriate tests.

Tests to assess other causes of pruritus (eg, low iron level, liver or kidney disease) can be performed if clinically indicated. Examples include evaluation of the complete blood cell count; urinalysis; liver function tests; thyroid function tests; and determinations of levels of serum electrolytes and glucose, blood urea nitrogen, serum creatinine, serum vitamin B-12, folate, and iron.

Unless dermatitis herpetiformis needs to be excluded, skin biopsy is usually more useful to reassure patients of the lack of pathology than to diagnose DP.

Use of cocaine, methylphenidate, or amphetamines must be ascertained, and if occurring, it should be stopped.

It is useful to examine the "proof" that the patient brings in so that one may truthfully say that the material was examined and no parasites were found. One authority anecdotally relates how he found ants in the debris and, after explaining that these arthropods did not live on or in humans, was able to give practical advice to reduce the problem.

Imaging Studies:

In rare cases, neurologic impairment (eg, tumors, neuritis, multiple sclerosis) can mimic the symptoms of DP.

Causes of such impairment should be excluded with MRI or CT scanning if they are strongly suspected on the basis of the clinical findings.

Histologic Findings: DP has no specific histologic findings. All skin changes are secondary to rubbing, scratching, picking or other treatment attempts.

Dr. Koo actually states dermatologists are not trained or equipped to treat psychiatric ills

Dermatology Times, Oct. 1, 2006

http://www.dermatologytimes.com/dermatologytimes/article/articleDetail.jsp?id=375424

National report — Patients suffering from psychocutaneous illnesses are more likely to see dermatologists than any other physicians, yet dermatologists are perhaps the physicians least prepared to address these problems, says John Y. M. Koo, M.D., professor and vice chairman of dermatology at the University of California, San Francisco Medical Center and director of the department's psoriasis treatment center, phototherapy unit and clinical research unit……….

He adds that, unfortunately, "To this day, many dermatologists feel uncomfortable making psychiatric diagnoses or prescribing psychotropic medications. But the reality in America is that a huge proportion, if not more than half, of psychotropic medications prescribed are prescribed by nonpsychiatrists."

Forgotten derm

And while articles, education and advertisements regarding psychotropic drugs abound in primary care and family practice, Dr. Koo says, "Dermatology is the specialty that the psychopharmacology industry forgot."

As a result, he says dermatologists generally lack familiarity with psychopharmacology, and confidence in using such medications.

The only way to improve this situation is to make psychodermatology part of residency education, Dr. Koo says.

"We should try to teach ourselves the use of some selected psychopharmacologic agents, because with many of these patients, if we don't do anything for their psychopathology, oftentimes nothing gets done," he says.

This is from a very easy to understand article on DOP from the Department of Health - Government of Western Australia web site. 

http://www.mental.health.wa.gov.au/one/resource/34/Ekbom.pdf

How is it diagnosed?

Tests that eliminate the likelihood of other medical conditions, true infestations, and organic causes such as contact dermatitis and allergies should be performed. Diagnosis may also include taking a case history, performing a complete physical examination and laboratory evaluation including skin scrapings and biopsies, complete blood count, chemistry profile, thyroid function tests and Vitamin B12 levels. Cognitive function should be assessed and a history of drug use/abuse sought. Differential diagnosis includes Delusional Parasitosis: when there are persistent complaints of infestation, following repeated treatment for scabies, lice, etc and with an absence of evidence on examination.
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