The challenge of Morgellons disease: A patient with clinicopathologic correlation.

Morgellons disease is a rare condition characterized by patient-reported multicolored fibers and other nonorganic particles or organic particles embedded in and protruding from diffuse skin ulcerations. Although the scientific community is prone to believe that Morgellons disease is a psychiatric disorder, an infectious pathogenesis associated with Borrelia burgdorferi in the setting of Lyme disease has also been proposed. The histopathology is usually considered as nonspecific. To illustrate this condition, we present the case of an adult woman with significant ulcerative skin lesions and cicatricial changes on the face, trunk, and arms. After multiple biopsies and successful microscopic visualization of the fibers, she received a diagnosis of Morgellons disease in the setting of delusional infestation. No evidence of Borrelia infection was found. Treatment with antipsychotics was initiated, but the patient was lost to follow-up, as is often the case with patients with Morgellons disease.

Morgellons disease etiology and therapeutic approach: a systematic review.

Morgellons disease is characterized by patient reports of fibers embedded in and protruding from the skin. Etiologies from infection to delusion have been endorsed, and treatment guidelines are not well-defined. The objective of this manuscript is to evaluate the existing evidence regarding the etiology and treatment of Morgellons disease in an effort to better inform clinical management. A PubMed search including key words "Morgellons," "delusional parasitosis and fibers," "delusions of parasitosis and fibers," or "delusional infestation and fibers" was completed. Original publications directly assessing etiology or treatment methods of Morgellons disease published between January, 2010 and the time of manuscript preparation were reviewed and evaluated. Sixteen articles regarding etiology were reviewed. All studies were correlative in nature with various limitations. Support for a psychiatric etiology was more widespread than support for an infectious etiology. Eleven articles regarding treatment efficacy were reviewed. Antipsychotic regimens have the most evidence of efficacy. Existing data regarding Morgellons disease suggests a psychiatric etiology and supports treatment with a low-dose antipsychotic agent once non-psychiatric causes have been excluded.

How to improve the interface between dermatology and psychiatry: a review and expert suggestion regarding the management of delusional patients.

Psychodermatological problems are prevalent in dermatology practices. Among those, delusional infestation (DI) is the subject of one of the most challenging patient encounters practicing dermatologists may experience. This difficulty arises, at least partly, from the unavailability of psychiatric knowledge and skillset necessary to properly manage these patients, reflecting that most dermatology residency programs are unable to provide training in psychodermatology. This relates to the lack of faculty available with such expertise. This article reviews various suggestions made in the medical literature to try to improve this current unfortunate situation. However, the more common suggestion regarding organizing a multidisciplinary psychodermatologic clinic may be difficult to achieve as reflected by the scarcity of such clinics in the U.S. The authors offer alternative suggestions beyond the idea of organizing a multidisciplinary clinic.

Is Morgellons an organic disease? structural and functional abnormalities implicated in the pathophysiology of delusional infestation.

Little is known about the pathophysiology of delusional infestation (DI), a psychodermatologic condition in which patients have a fixed, false belief of being infested with parasites or inanimate material in their skin, despite lack of objective evidence. Because some delusional states, such as schizophrenia and psychotic state in bipolar disorder have been found to be associated with brain structural and functional abnormalities, a literature review was conducted to summarize available data on structural and functional abnormalities that are found to be associated with DI. A review of the literature found cases of brain imaging studies in patients with primary DI, as well as patients with secondary DI. Accumulating evidence from the studies reviewed suggests that dysfunction of the fronto-striato-thalamo-parietal network may explain how delusions manifest in DI and suggest that DI has an organic etiology. Abnormalities in the striato-thalamo-parietal network may cause false sensations of infestation through dysfunction in visuo-tactile regulation, whereas abnormalities in the frontal region may impair judgement. Delusional infestation patients also exhibit increased activation of brain structures implicated in itch processing. Furthermore, patients at high risk for cerebrovascular disease who present with secondary DI may benefit from brain imaging studies to rule out brain ischemic insult.

[Morgellons, a 'socially transmitted' disease]. / Morgellons, een 'sociaal overdraagbare' aandoening.

BACKGROUND: Morgellons disease is a controversial condition characterised by a great variety of skin-related symptoms such as wounds, itch and pain and whereby the patient strongly believes these are caused by threads or fibres penetrating the skin. The subject is often discussed in social media, which leads to increasing numbers of patients who think they have the condition. CASE DESCRIPTION: A 56-year-old woman had been suffering for three years of compulsive behaviour involving her hair and scratching her skin. She was convinced there were threads running under her skin. She had self-diagnosed 'Morgellons disease'. Psychodermatological treatment led to reduced symptoms. CONCLUSION: The majority of medical practitioners believe that Morgellons disease is a type of delusional infestation. Even though there are some medical and non-medical practitioners who take the position that there is an infectious cause, such a cause has never been found.

Delusional infestation versus Morgellons disease.

Delusional infestation is the conviction that one is infested with pathogens-either animate or inanimate-despite medical or microbiologic evidence to the contrary. Infestation with inanimate pathogens, specifically fibers or filaments, has been controversially termed Morgellons disease by the patients themselves, who believe that this is not a psychiatric disease but rather a new organic condition or a skin manifestation of an infection, such as Lyme disease. A large-scale study by the Centers of Disease Control and Prevention on patients presenting with Morgellons clinical manifestations did not find evidence of fibers in the skin nor an association with any infection, including Lyme disease. Once the diagnosis of delusional infestation is made, the cornerstone of treatment is antipsychotics, although this is often quite challenging, as patients are reluctant to take these medications.

Exploring the Psychological Profile of Patients with Delusional Infestation.

Delusional infestation (DI) is an uncommon psychiatric disorder in which patients present with the false and fixed belief (i.e. a delusion) that their skin and/or their environment is infested despite objective evidence to the contrary. Within psychodermatology specialist clinics there is a high rate of DI referrals. What is not known is the level of psychiatric and psychological co-morbidities associated with DI and whether psychiatric or psychological assessment would be warranted. One-hundred and thirty-eight adult patients with DI attending an outpatient psychodermatology clinic were given 3 standardised questionnaires. The results showed that 81% had a poor quality of life; 52% with anxiety, 41.6% with depression and 49% with appearance-related concerns. This study indicates high levels of psychiatric and psychological disorders in DI which require assessment and appropriate intervention.

Delusional Infestation: State of the Art.

Patients with a delusional infestation (DI) have an overwhelming conviction that they are being infested with (non) pathogens without any medical proof. The patients need a systematic psychiatric and dermatological evaluation to assess any possible underlying cause that could be treated. Because they avoid psychiatrists, a close collaboration of dermatologists and psychiatrists, who examine the patient together, seems to be a promising solution. It helps to start a trustful doctor-patient relationship and motivates the patient for psychiatric treatment. We here review diagnostic criteria, classification of symptoms, pathophysiology and treatment options of DI. Antipsychotic medication is the treatment of choice when any other underlying cause or disorder is excluded. Further research is needed to assess the pathophysiology, and other treatment options for patients with DI.

The first investigative science-based evidence of Morgellons psychogenesis.

Morgellons disease is an infrequent syndromic condition, that typically affects middle-aged white women, characterized by crawling sensations on and under the skin, associated with itchy rashes, stinging sores, fiber-like filaments emerging from the sores, severe fatigue, concentrating difficulty, and memory loss. The scientific community is prone to believe that Morgellons is the manifestation of various psychiatric syndromes (Munchausen, Munchausen by proxy, Ekbom, Wittmaack-Ekbom). Up until now, no investigative science-based evidence about its psychogenesis has ever been provided. In order to close this gap, we have analyzed the filaments extracted from the skin lesions of a 49-year-old Caucasian female patient, by using a Field Emission Gun-Environmental Electron Scanning Microscope equipped with an X-ray microprobe, for the chemico-elemental characterization of the filaments, comparing them with those collected during a detailed indoor investigation, with careful air monitoring, in her apartment. Our results prove the self-introduction under the epidermis of environmental filaments. For the first time in the literature, we have scientifically demonstrated the self-induced nature of Morgellons disease, thereby wiping out fanciful theories about its etiopathogenesis.

Information, consent and treatment of patients with Morgellons disease: an ethical perspective.

Morgellons is a medically contested diagnosis with foremost dermatological symptoms. Patients experience fibers emerging from the skin, together with a range of other somatic, psychiatric, and neurological complaints. Within the medical community, it is generally held to be a variation of delusional parasitosis/delusional infestation, which is usually treated with antipsychotics. Little attention has been paid in the literature to the ethical aspects of treating patients with Morgellons disease. The communicative strategies suggested in the literature display significant ethical issues, primarily the use of therapeutic privilege, i.e. withholding information from the patient. Since this limits patient autonomy, that approach is ethically problematic. Instead, the physician has an ethical obligation to respect the patient's autonomy, provide full information, and seek consent before initiating a psychiatric referral.

New findings in delusions of parasitosis.

Two new cases are presented with delusions of parasitosis. Both were women, one middle-aged and one elderly, and exhibited classic symptoms of parasites and "strings" in the skin indicative of Morgellons disease. Each had an additional psychiatric disorder: drug addiction to cocaine and senile dementia. They also illustrate the difficulty encountered by the dermatologist in providing adequate therapy because of resistance to psychiatric referral as well as to standard accepted medication. Newer psychotropics, such as risperdal and lexapro, show promise in helping these patients and add to the therapeutic armamentarium of pimozide.

Delusional infestation is typically comorbid with other psychiatric diagnoses: review of 54 patients receiving psychiatric evaluation at Mayo Clinic.

OBJECTIVE: Delusional infestation, which encompasses both delusions of parasitosis and delusions of infestation with inanimate objects (sometimes called Morgellons disease), has been said to represent a distinct and encapsulated delusion, that is, a stand-alone diagnosis. Anecdotally, we have observed that patients with delusional infestation often have one or more psychiatric comorbid conditions and that delusional infestation should not be regarded as a stand-alone diagnosis. The purpose of this study was to identify whether patients with delusional infestation have psychiatric comorbid conditions. We therefore identified patients who had been formally evaluated in the Department of Psychiatry during their visit to Mayo Clinic. METHOD: We retrospectively searched for and reviewed the cases of all patients with delusional infestation seen from 2001 through 2007 at Mayo Clinic, Rochester, Minnesota, and who underwent psychiatric evaluation. The diagnoses resulting from psychiatric evaluation were analyzed. RESULTS: During the 7-year study period, 109 patients seen for delusional infestation at Mayo Clinic were referred to the Department of Psychiatry, 54 (50%) of whom actually followed through with psychiatric consultation. Of these 54 patients, 40 (74%) received additional active psychiatric diagnoses; 14 patients (26%) had delusional infestation alone. Abnormal personality traits were rarely documented. CONCLUSIONS: Most patients with delusional infestation have multiple coexisting or underlying psychiatric disorders. Therefore, evaluation by a psychiatrist, when possible, is advised for all patients with delusional infestation.

Delusional infestation: clinical presentation in 147 patients seen at Mayo Clinic.

BACKGROUND: Delusional infestation is the conviction that one's skin is infested with foreign organisms or materials despite contradictory objective evidence. OBJECTIVE: To delineate clinical characteristics of patients presenting with delusional infestation. METHODS: We performed a retrospective study of patients meeting delusional infestation criteria who were seen for diagnosis and treatment in our tertiary care academic medical center (2001-2007). Medical records were reviewed to abstract demographic, historical, and physical findings and treatment. RESULTS: Over 7 years, 147 patients presented with delusional infestation; 87% (123/142) for another opinion. Mean age was 57 years; female-to-male ratio was 2.89 to 1; 82 (56%) were married. Mean duration of symptoms was 31 months. Employment data were available for 145 patients: 48 (33%) were self-described as disabled, 16 of whom cited delusions as their disability; 41 (28%) were retired; and 38 (26%) were employed. Reported infestations included multiple materials (45% [64/143]), not limited to insects (79% [113/143]), worms (27% [39/143]), and fibers (20% [29/143]). Most patients presented initially to dermatology or other specialties; only 3 presented to psychiatry. A high proportion (81%) had prior psychiatric conditions. Thirty-eight (26%) of the 147 patients had a shared psychotic disorder. LIMITATIONS: The retrospective nature of the study and the incompleteness of some data because not all the characteristics that were analyzed were documented for every patient. CONCLUSION: Patients were predominantly female, had a long history of symptoms, and had been seen previously at many medical centers. A large proportion were disabled or retired. Patients reported skin infestation with both animate and inanimate objects.

Delusional infestation with unusual pathogens: a report of three cases.

Delusional infestation (DI) is a psychiatric disorder characterized by a fixed, false belief that the patient is infested with extracorporeal agents. It is known by several names, including the more commonly used term 'delusional parasitosis'. The psychiatric disease is responsible for the cutaneous pathology. About 90% of patients with DI seek help from dermatologists, and most reject psychiatric referral. Thus, effective management requires incorporation of psychiatric principles. We report three cases of DI with inanimate materials, and examine 'Morgellons' disease. We believe that patients with unusual presentations of DI are likely to be seen more commonly in the future. These patients appear to be a subgroup of DI, and may be even more difficult to treat than other patients with DI.