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Delusional Parasitosis

A new study looks into the disorder known as delusional parasitosis, which many dermatologists believe is the true diagnosis behind the controversial disorder called Morgellon’s disease. Morgellons is a controversial disorder because many patients with symptoms believe they are being infected by an unusual organism, causing excessive itching, but no offending organism has been found. Some patients claim they have strange fibers exuding from the sores in their skin.

The term “Morgellons” was coined in 2002 by Mary Leitao, who was trying to find a diagnosis for her son who was suffering from skin lesions. Since then it has become a grassroots diagnosis – used by some patients to describe themselves but not accepted by the medical community.

Most dermatologists, rather, feel that the disorder is actually a manifestation of delusional parasitosis – a mental disorder. This has set up an unnecessarily confrontational situation. And of course, some charlatans are exploiting the situation by taking the side of the patients and offering them their nostrums as a cure.

These situations are always helped, but rarely resolved, by better information. It is in this context that Hylwa et al performed a retrospective analysis of patients diagnosed with delusional parasitosis at the Mayo dermatology clinic. They analyzed records from 108 patients who had either a skin biopsy (80 patients) or presented their own sample (a patient-provided specimen – also 80 patient), or both (52 patients).

They found that in all 108 cases no evidence of infection or infestation was found.

They did find, however, that 48% of biopsies showed dermatitis – inflammation of the skin. This finding has two plausible interpretations. The first is that in some patients with delusional parasitosis, they may have an underlying skin condition that causes non-specific dermatitis (an allergy, for example) and the symptoms of this dermatitis triggers the psychological reaction that results in the belief that they are infested with something foreign. In this case they could be simply misinterpreted their skin sensations. Further the chronic symptoms can cause stress and lack of sleep and result in the anxiety and depression that often accompanies this disorder.

The other plausible interpretation is that the dermatitis is secondary to scratching and perhaps treating the skin with irritating substances intended to treat the problem. The current study is not capable of distinguishing between these two possibilities.

The authors acknowledge the limitations of this study – mainly that it was retrospective. It also needs to be considered that their search criteria was for patients diagnosed with delusional parasitosis – not all patients with unknown or mysterious skin lesions. In that respect the results are not surprising – the diagnosis may result from a negative biopsy or sample analysis, and so of course patients with that diagnosis will have had a negative biopsy.

The authors do not even address the controversy surrounding Morgellons. Rather they are asking if skin biopsy is useful in patients presenting clinically with delusional parasitosis. Again – given the retrospective nature of this study I don’t think it answers that question.

This study does, however, review a large series of cases demonstrating a lack of biopsy or sample analysis findings in patients who fit within the clinical syndrome that is labeled as either Morgellons or delusional parasitosis. It should further be noted that those who claim that Morgellons is a distinct disease caused by a skin infestation cannot point to any objective evidence of an actual infestation to support that claim.

What proponents do have are mysterious fibers sometimes found in the skin lesions of people with this syndrome. The fibers often cannot be specifically identified, or they are identified as foreign fibers consistent with clothing. They usually do not appear to be of organic origin. At best the fibers represent an anomaly, and are not specific evidence of any underlying cause.

What is especially disturbing about the Morgellons phenomenon is the tone of the discussion, the extent to which the controversy has been politicized. Often irrelevant issues are brought to the forefront, such as patient empowerment or medical authority. Not that these issues are not important – they are just not relevant to the real question of what, exactly, is the underlying cause of what is referred to as Morgellons.

Patients who suffer from this syndrome are best served by bringing objective scientific evidence to bear to discover exactly what the cause(s) and best treatments for their symptoms are. But this issue is often derailed by accusations that the medical community is dismissing them and their claims. By grabbing the reigns of diagnosis and treatment such patients are given a false sense of empowerment, but are likely just cutting short earnest attempts to understand and treat their condition.

And of course, good science has to follow the evidence wherever it leads, even if the answer is not what is hoped. The truth does not care what people need or want – it is what it is.

Conclusion

This latest study will likely not change the debate about Morgellons vs delusional parasitosis. Although it should be kept in mind that delusional parasitosis (DP) is a disorder in its own right, and pre-existed any notion of Morgellons. Morgellons is likely just a recent manifestation of DP – a cultural entity spreading mainly on the internet. It should also be noted that DP likely contains two or more subgroups that have distinct causes – such as the two causes of dermatitis I discussed above.

At present there is no compelling evidence that Morgellons exists as a discrete entity separate from DP. The CDC is currently studying the condition (which they are calling unexplained dermopathy) but has not yet made any report of their findings.

My review of the evidence is that it best supports the conclusion that Morgellons is a mostly a psychocultural condition (it may be triggered in cases by an underlying skin condition). It is a combination of a cultural phenomenon spreading mostly online, giving specific manifestation to an underlying psychological condition. I am willing to be convinced that there is a biological process going on, but so far no compelling evidence to support this hypothesis has been put forward.

I also think that specific harm can be done to individuals with this syndrome by the spread of false information. Sufferers can easily be made to settle prematurely on a false conclusion, and in fact can reinforce their delusions if that is ultimate cause of their symptoms. They can be lured away from practical interventions and the medical community to dubious treatments that are, if nothing else, a waste of their resources.

The situation represents a challenge to the medical community. Perhaps the only solution is to explain and promote the scientific approach to diagnosis and treatment.

Posted in: Neuroscience/Mental Health

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47 thoughts on “Delusional Parasitosis

  1. This condition reminds me of the type of sensation that patient who abuse cocaine experience. They often have a hallucination that there are creatures crawling underneath their skin. This may be a variant of the delusional parasitosis condition that you are describing. The term Morgellons has never been used in their cases, as it sounds to be a cultural specific example. It would be interesting to see if cocaine abusers also have an inflammatory response in the subcutaneous tissue as has been found in the patients described in this article.

    Dr Sam Girgis
    http://drsamgirgis.com

  2. nybgrus says:

    I honestly can’t quite fathom why this level of controversy and debate exists. From everything I have read on the topic, it seems that Morgellons is clearly a psychosomatic issue, not a biological or organic pathology. Of course, H. pylori was considered to be “impossible” to be the cause of peptic ulcer disease, so I must remain open minded to the possibility – but I can’t help but feel that in this case resources are better spent elsewhere in medical research.

  3. windriven says:

    While living in China I developed chronically itchy skin – really disturbingly itchy – all over my body. I visited a physician in the certainty that I had picked up some sort of parasite. It didn’t take the physician long to determine that too hot showers and the brand of soap I was using were the problem.

    I was skeptical and planned to see a dermatologist on my next visit to the US, but I turned down the shower temperature, changed soaps and used an OTC skin moisturizer. The pruritis vanished.

    I mention this because the sensation of having parasites was intense. It is easy for me to understand people unwilling to believe the simple explanation of dry skin.

    Occam’s Razor strikes again.

  4. daedalus2u says:

    Dr Sam, I think you are right and the itching of cocaine abuse and of the disorder some call Morgellons have the same physiological basis. I mention that in my blog post. I think calling it a hallucination rather than delusional is more appropriate. I think the itching is very similar to the itching of primary biliary cirrhosis and of end stage kidney failure and relates to low nitric oxide in the skin, which potentiates mast cell degranulation. If mast cell degranulation is potentiated enough, then it can occur spontaneously and propagate as the products of mast cell degranulation trigger adjacent mast cells to degranulate, setting up a traveling wave of mast cell degranulation. I have blogged about it.

    http://daedalus2u.blogspot.com/2008/02/morgellons-disease-hallucinatory.html

    I think that calling it DoP is problematic for many people who have it and makes it harder to treat successfully. I think that calling this condition Delusion of Parasitosis is analogous to calling phantom limb pain “delusional limb pain”. Technically phantom limb pain is a delusion because there is no limb present to exhibit pain and everyone knows that there is no limb present. Fortunately for people with phantom limb pain, there is sufficient understanding to know that even though the limb is gone, the nerves that carry signals of pain to the brain are still present and can trigger signals interpreted as pain in a limb that is no longer there.

    All signals in the nervous system are subject to automatic gain control. That is the only way that the nervous system can remain functional over many years, through growth, in disease and in health. If the “gain” got turned up too high in the itch tranducing nerves, the symptoms would be an itch with no apparent “cause”, which would provoke scratching and eventually sores and lesions exactly as are observed in Morgellons.

    If the problem is automatic gain control in the peripheral nervous system, calling it a delusion is not correct. A better term would be Hallucination of Parasitosis.

  5. TsuDhoNimh says:

    The other plausible interpretation is that the dermatitis is secondary to scratching and perhaps treating the skin with irritating substances intended to treat the problem. The current study is not capable of distinguishing between these two possibilities.

    Read the sites where the Morgellons sufferers discuss what they are doing … often it’s bathing several times a day, dousing themselves with bleach, scrubbing their skin with 3M’s green scrub pads, etc.

  6. Well, that’s two articles discussing what Morgellons is not. :)

    Yet, anyone who’s ever dealt with someone experiencing psychosis, obsessive thoughts or body dimorphic disorder will tell you that you often have very little luck telling them. “No, really the CIA isn’t watching you” or “you don’t have to check to see if you left the stove on” or “really, you are too skinny, not too fat.”

    Why? Because those thoughts are the symptoms of the disease. The question is how do you work with the patient to help alleviate the symptoms. Is there any evidence that telling the patients that Morgellons isn’t parasites is actually helpful to them?

    This review of delusional disorder in dermatology suggests perhaps not. “There are no randomized control studies to establish the recommended treatment of this disorder. Some experts discuss the importance of establishing patient rapport by referring to the delusions as Morgellons disease [23]. After ruling out an organic cause, emphasis should be placed on how disconcerting the symptoms must be for the patient.”

    and a bit more

    “Medication trials have been intermittently effective. Pimozide has been used in doses of 0.5-2.0 mg daily. Koblenzer believes that Pimozide, with the added anti-pruritic effect, is a preferred treatment [24]. The use of atypical antipsychotics such as risperdal, olanzapine and aripiprazole may also be of benefit [21, 23]. In our experience, the use of extra-thin hydrocolloid dressings over the ulcerations is generally very effective because it provides a mechanical barrier to manipulation and facilitates wound healing. The wounds frequently become secondarily infected, making the use of topical or systemic antibiotics an important adjunctive measure.”

    http://dermatology-s10.cdlib.org/146/review/delusions/robles.html#23

    How do deal with these folks when they walk into the office?

  7. tmac57 says:

    This issue really bugs me,and I think that you have only scratched the surface.I find myself really irritated by these flakes that are proponents of Morgellon’s,and they leave me itching for a fight!

  8. tmac57 says:

    I wonder how many millions of people have been infected with a ‘disease’ that they acquired from the internet.

  9. mdcatdad says:

    Yesterday’s Washington Post had an article about a long search for the cause of a woman’s itching:

    http://tinyurl.com/42xnufs

  10. The patient empowerment issue is interesting, though. It’s a concept that comes up again and again with proponents of CAM, childbirth woo, anti-vaccinators, etc. I’m always curious about the demographic that finds medical advice to be personally insulting. I tend to suspect that there is an underlying power/status component that motivates people to reject science-based medicine. It would be really interesting to try to find common cultural or demographic markers that would indicate increased chance of rejecting credible medical advice.

  11. Harriet Hall says:

    I tried to post a comment and the Internet ate it. I’ll try again.

    There is a simple test that might help clarify this issue. A dermatologist told me about a patient who was itching and scratching and had skin lesions with no clear diagnosis. He thought the patient had created the lesions by scratching; the patient denied it. He put a cast on one arm and when he removed it after a month, the skin on that arm was pristine. The patient could no longer deny his contribution to the pathogenesis, and they could then go on to deal with the real problems.

    Oh, never mind! If a Morgellons patient wants to believe he has parasites, he will just rationalize that casting has somehow killed the parasites on that arm. :-)

  12. S.C. former shruggie says:

    It all depends, Dr. Hall.

    As I’ve mentioned before, I had delusional parasitosis once. It resolved after my neighbour’s abusive husband was finally charged, after I moved out of the building, and around the time the nightmares stopped. I rationalised plenty while I was still in the environment responsible for the stress and sleep loss that probably caused my psychsomatic symptoms, but I calmed down as the ich away. And vice versa.

    So it’s possible that for some people, if they stopped scratching, they’d stop irritating their skin and stop itching (also if they can’t scratch they may pay less obsessive attention to normal minor irritants.) This might give some people a breather to calm down and re-assess their situation. So that dermatologist’s test is worth a shot.

  13. Happy Camper says:

    Twelve days ago Mark Crislip mentioned in his post Parasites.

    “Against this hypothesis are the case reports where Morgellons is cured with Pimozide, an antipsychotic. Delusions of parasitism is often treated with olanzapine, another antipsychotic, but others have suggested pimozide is superior. Most infections would be unlikely to respond to antipsychotics, but I have never been satisfied with response to treatment as a means for confirming a diagnosis, that is a path better not followed without good reason. In my world docs often think if patients are improving on antibiotics the response is considered evidence of infection. I know better. But given the lack of a demonstrable parasite, a response to psychiatric medications is certainly suggestive.”

    As a lay person, I think this speaks volumes. There are real cases of parasites but when the presence of parasites are ruled out perhaps cases of Morgellons are nothing but a mental disorder and the only parasites involved are members of the sCAM community who use this diagnosis to push nonsense.

    I’m just saying

  14. stanmrak says:

    Genetically-modified food. Go ahead – laugh.

  15. Chris says:

    Only if you explain the joke, Stan. Because you seem to be the only one who has mentioned it. Now read the article more closely: it is about people who get the itchies and assume it is some kind of bug.

    Do you get the itchies and assume it is some kind of plant? Perhaps willow or alder pollen? Do you assume that the itchies are only caused by willow trees that have been cross bred? Because I am allergic to all willow and alder trees, and alder trees are essentially weeds around here. There has been no interest in breeding anything in them, so they have not been genetically modified.

    By the way, all plants grown for food have been genetically modified in some way, starting over ten thousand years ago by propagating plants that had desirable characteristics. Then there is the genetic modification done by cross-breeding.

    There is nothing in this article that has to do with genetically engineering food plants.

  16. Robin says:

    Bleah, I didn’t have itching but serious creepy crawlies and burning in my legs. I diagnosed myself as stressed out and pyschosomatic and tried distraction and meditation. But the sensations continued to the point where I was losing sleep. I overcame my embarrassment and made a doctor’s appointment, where to my surprise the physician took blood rather than giving me a psych referral. I had iron deficiency anemia which was causing Restless Leg Syndrome. Gabapentin helped with the creepy crawlies, and over the course of several weeks they faded as supplements built up my store of iron.

    I really sympathize with the Morgollen’s people. My creepy crawlies definitely caused anxiety and agitation. I remember fantasizing about cutting my own skin open and ripping my leg muscles to shreds! I could see how easy it would be to go from sane person to fluff and lint picker. It’s certainly plausible that they have some underlying neurological or immunological blip which launches them into the psychosocial aspect of it.

  17. BillyJoe says:

    Everytime I’ve been working in the garden, I break out in an itchy rash.
    Yeah, I hate gardening.
    ….but I still think it’s the damn dirt.

  18. daedalus2u says:

    Happy camper, one of the major symptoms of primary biliary cirrhosis is itching. The mechanism of that itching is not well understood. It turns out that Sertraline, an SSRI antidepressant can be quite effective at resolving the symptoms of itch in PBC. Does that mean that the itching of PBC is “all in the head”?

    People trying to make facile arguments about things they don’t understand is due to the Dunning-Kruger effect. When the physiology behind itching is not understood, and the physiology behind how anti-psychotics work is not understood, why does an anti-psychotic “working” on itch of unknown causation demonstrate that the itch is due to a psychotic delusion?

  19. Scott says:

    d2u:

    Nobody’s saying that the itch is due to a psychotic delusion (at least not that I’ve seen; HC certainly didn’t). The part that’s labelled as delusional is the conviction that said itch is due to parasites.

    The itch is pretty clearly a real sensation, which may be psychosomatic, physiological, or a combination – it likely even has different causes in different sufferers.

  20. daedalus2u says:

    Scott, people are saying it. Not everyone is saying it, but enough are saying it to make it a meme that is adversely affecting people who have the condition. Happy camper was saying exactly that, but perhaps not quite so explicitly as if symptoms of itch get better while on anti-psychotics, the symptoms of itch came from psychosis.

  21. Scott says:

    WHO is saying it? I don’t see anything vaguely similar to that in a single post here. I think you’re completely failing to distinguish between whatever underlying actual symptoms people claiming Morgellons may (or may not) have vs. what conclusions are drawn to explain those symptoms and measures taken to deal with them.

  22. Jan Willem Nienhuys says:

    I am suddenly reminded of the fact that the invento of homeopathy, Samuel Hahnemann, divided illnerss into two kinds: acute one and chronic ones. According to him the chronic ones were caused by three kinds of primary influences: syphilis, gonorrhea (called sycosis) and ‘psora’. Psora was by far the most important cause of chronic diseases. And psora was what we call scabies: a prasitic disease caused by Sarcoptes scabiei . I don’t know whether that cause was known then, for all I know people believed in generation spontanea at that time.

    Read Organon section 80 on the diseases caused by “the itch” – according to Hahnemann.

  23. Scott, the quote from Mark Crislip via HappyCamper ““Against this hypothesis are the case reports where Morgellons is cured with Pimozide, an antipsychotic. Delusions of parasitism is often treated with olanzapine, another antipsychotic, but others have suggested pimozide is superior.”

    For a patient, continuing to have a creepy crawler sensation or itch, but no longer believing that the cause is parasites wouldn’t really be considered a “cure”.

    The word “cure” suggests all distressing symptoms cease.

  24. Scott says:

    It cures part of the problem. I don’t see that as inconsistent.

  25. daedalus2u says:

    Scott, antipsychotics make the symptoms of itch go away.

  26. Prometheus says:

    It seems to me that there are two “flavors” of delusional parasitosis involved in “Morgellons disease”:

    [1] People who have a persistent itch but misattribute the cause to “parasites” or “Morgellons”.

    [2] People who have a delusion of parasitosis (e.g. “Morgellons”) and therefore imagine that they itch.

    I can easily see how #2 could occur, having had that experience myself after discovering a spider in my sleeping bag – the rest of the night, I swore I felt the “pitter patter of little feet” (in multiple sets of eight) even though there was only the single spider in my bag.

    Likewise, someone with a persistent itch (dry skin, etc.) could become convinced (perhaps after “researching” in the Internet) that the cause of their itch is “Morgellons” or even some real parasite (e.g. scabies).

    In that case, people with problem #2 should experience a complete relief of their symptoms on anti-psychotic medications and people with problem #1 would not (unless the medication had, for example, anti-histamine properties, as a number of anti-psychotic medications do).

    Of course, after weeks, months and possibly years of scratching a psychosomatic itch, even the people in the second situation will have a “physiological” (i.e. not psychological) cause of their itch, blurring the boundaries between the two.

    I’m also struck by the description of the fibers found in “Morgellons disease” – red, blue and other colours are described. I can’t claim to be an expert on parasites, but I’ve yet to see one that is so brilliantly (and variably) coloured. On the other hand, fibers from fabric are often brightly coloured.

    And I’ll again make the observation that in the one electron microscope examination of the fibers from a “Morgellons disease” patient, they are described as tangles of fibers. In other words, not even the electron microscope can resolve any cellular structure.

    Parasites – on this planet – are cellular organisms (exception: viruses, which are not visible to the naked eye, unlike the fibers in “Morgellons disease”) and their cellular structure should be easily resolved by an electron microscope (even an SEM). This finding, more than any of the others, strongly suggests that these fibers are just that – fibers. Not “parasites” and not alien implants, just fibers from clothing, carpet or just floating in the air.

    Prometheus

  27. Happy Camper says:

    @daedalus2u

    Don’t put words in my mouth, it’s disingenuous and rude! I didn’t mention “itch” once in my reply. An itch can be caused by many things such as an allergic reaction or insect bites etc. What I referred to was someone claiming that the creepy crawling being caused parasites. If no physical cause can be found AND the condition goes away with anti psychotics I would think it’s a good bet that that the condition was caused by a psychosis. That is unless there is some evidence that there is a side effect of anti psychotics that nobody else has yet discovered that you are privy to.

    My point was that the sCAM community is taking advantage of the “diagnosis” of Morgollen’s on unsuspecting patients to push their useless nostrums. In addition, I think that the evidence so far(as others have pointed out) is that Morgollen’s is actually delusional parasitosis unless you can enlighten us with evidence to the contrary.

    HC

  28. Happy Camper said “That is unless there is some evidence that there is a side effect of anti psychotics that nobody else has yet discovered that you are privy to.”

    What? Like also working as an anti-histamine? Wouldn’t that be ridiculous.

  29. Scott, in his article Mark Crislip states “Against this hypothesis are the case reports where Morgellons is cured with Pimozide, an antipsychotic. Delusions of parasitism is often treated with olanzapine, another antipsychotic, but others have suggested pimozide is superior. Most infections would be unlikely to respond to antipsychotics, but I have never been satisfied with response to treatment as a means for confirming a diagnosis, that is a path better not followed without good reason. In my world docs often think if patients are improving on antibiotics the response is considered evidence of infection. I know better. But given the lack of a demonstrable parasite, a response to psychiatric medications is certainly suggestive.”

    I have never been satisfied with response to treatment as a means for confirmation of diagnosis…

    Also, did you notice he said “case reports”. Not RCTs of a large sample of people who self-reported as morgellons suffers,

    Why take very preliminary evidence and apply it to a group of people who are self-described as morgellons, but may in fact have very diverse symptoms?

    From reading dermatologists accounts, it does appear that there is a psychiatric component to some of these folks reporting Morgellons. But we actually do have tools for diagnosing mental disorders (of all types). I’m not sure why we would abandon them at this point.

    I think it’s premature to start diagnosing a broad swath of patients as having psychosis based entirely on case studies of one type of drug being effective with some patient with the same self-diagnoses.

    But hey, if that’s what we have to do to find a platform to complain about CAM or SCAM, then so be it, I guess. Because that’s the really important thing here, right? Not finding answers for miserable people.

  30. daedalus2u says:

    There are a lot of antipsychotics with antihistamine effects and a lot of antihistamines with antipsychotic effects.

    http://www.ncbi.nlm.nih.gov/pubmed/15334189

    Much of the weight gain of atypical antipsychotics is associated with binding to the H1 histamine receptor, the same histamine receptor that diphenylhydramaine blocks. Diphenylhydramine is also an SSRI.

  31. Chris says:

    BillyJoe:

    Yeah, I hate gardening.

    Heathen. Some of us need weed therapy and prune therapy. For Your Information: fear of bugs is not an asset.

    And some of us need good antihistamines in the spring time, and fortunately my most recent prescription works! I only use it during the day, at night I use the very reliable “knock you to sleep” Benadryl.

  32. Scott says:

    @ michele:

    I don’t see anybody “diagnosing a broad swath of patients as having psychosis.” All I’m saying is that d2u is incorrect to suggest that anybody here is arguing that the itch is a delusion; the parasitosis is the delusional part. I’m certainly not suggesting any general conclusion as to the causes of the itching.

  33. Scott,

    when Happy camper says “I think that the evidence so far(as others have pointed out) is that Morgollen’s is actually delusional parasitosis unless you can enlighten us with evidence to the contrary.”

    as well as HCs earlier statement. “As a lay person, I think this speaks volumes. There are real cases of parasites but when the presence of parasites are ruled out perhaps cases of Morgellons are nothing but a mental disorder.”

    It sounds to me like diagnosing a broad swath of people, or least assuming he/she has a diagnoses unless proven wrong. Perhaps you and I have different readings, though. Or perhaps that wasn’t what MC was trying to communicate.

    ———

    A story unrelated to the above point, just sharing my own itchy experience.

    This week I’ve been very itchy, creepy crawly feeling, primarily my scalp and face. I have two age children, so yes, the first thing I did was check for lice. Nope.

    But, it’s been a hectic few weeks between everybody in the house having strep, art fairs, field trips, etc. So I think, oh well my nerves are getting to me and ignore it.

    Then, doing a quite search on Delusional Parasitosis out of curiosity from this article, I find this neat little tidbit at http://delusion.ucdavis.edu/manifest.html *

    “Secondary Organic Delusional Parasitosis
    where there is an underlying physical illness is present, including:

    * drug abuse
    * hypothyroidism
    * cancer
    * cerebrovascular disease
    * tuberculosis
    * neurologic disorders
    * vitamin B12 deficiency
    * diabetes mellitus”

    Oh, I have autoimmune hypothyroidism and due to the hectic couple of weeks, found I had forgotten to take my medication for several days in the last week as well as thoughtlessly popping my antibiotics along with the synthroid I did take, which, I think, I’m not supposed to do. (stupid, I know).

    Funny thing, I’ve had these spells on a off for years now. I’ve been working on the assumption that everyone had them.

    I should stop saying to people “Don’t you hate it when you feel all itchy, like something is crawling through your skin or hair?”

    *Ugh, huge spider graphic at top of page. They get the award for best graphic to viscerally communicate the experience of a disease.

  34. daedalus2u says:

    Scott, I wasn’t specifically suggesting that people here were saying that the itching that people with DoP experience is delusional, but happy camper seemed to be coming very close. If misunderstood what he was meaning, I am sorry and I apologize.

    Many people do hear the diagnosis DoP and think “crazy person”. It is not DoP to feel an itch and think it might be a parasite. When Prometheus found a spider in his sleeping bag, what happens is that the gain of the itch sensors gets cranked way up. The sensations of itch he had were real, they were from the gain being so high that random noise triggers the sensation of itching. That is how automatic gain control works. The gain is turned up until the sensors start detecting “stuff”, then you back it down a little. If you turn up the gain in any amplifier, eventually it will saturate with noise. Physiology sets the “gain” to optimize the trade-off of false positives (noise from too much gain) from false negatives (no signal because not enough gain). In a high parasite environment, a false negative is worse than a false positive. The gain goes way up and there are lots of false positives (as Prometheus experienced). Other people have remarked that they start to feel itchy reading threads like this. That is their automatic gain control increasing the gain on their itch sensors.

    Low nitric oxide is what turns up the gain on the immune system. That is why when the respiratory burst is triggered, it results in a robust turn-on of the immune system. The respiratory burst generates superoxide and that superoxide lowers the NO level and increases the gain in the vicinity. That positive feedback results in a robust turn-on of the immune system. When the NO level is low for other reasons, the “gain” is also higher which results in a lower threshold for turning on the immune system. The automatic gain control of the immune system is set mostly through the basal NO level. If the level is low, the gain is high (but it is more complicated than that).

    There is a great deal of misinformation about the various somatiform disorders. I consider Morgellons to be one of them. For a very long time PTSD was thought to be malingering. Even now, CFS is considered by many to be psychological. At one time all neuropsychiatric disorders were thought to be due to evil spirits. Now some of us know that they are not. Many people still believe in evil spirits and the Catholic Church is still actively promoting that belief.

    http://www.uscatholic.org/church/2011/05/theyre-baaack-whats-behind-return-exorcist

    At SBM, our default is that everything that happens is a result of something physical, that all mental processes are due to physiological processes not manifestations of an immaterial mind or supernatural effects. In the case of DoP, there are subjective sensations of itching experienced by the patient, the patient scratches those itches and when the itches don’t go away attributes them to parasites. The patient goes to the doctor, and the doctors finds nothing. There may be nothing on the skin, but there is something that is triggering the nerves that make the connection between the skin and the patient’s mouth saying he feels itchy.

  35. Paratope says:

    I’ve been morbidly fascinated by Morgellan’s ever since I read that Joni Mitchell has it and is crusading about it. I find that an underlying problem in almost all discussions about it is that people–patients, physicians, writers–typically believe that when the cause of symptions is identified as psychological, it means that the symptoms and the suffering are not real, and that the patients’ experience is being denied. This is of course bound to the stigma associated with mental illness, and it is also pervasive in the culture. In this post, for example, Stephen Novello describes quacks as “taking the side of the patients,” implying that those who explain correctly that it is psychosomatic in origin are somehow against the patient–”delusionsal” is an insult. This bias against psychological explanations also characterizes discourses about CFS and fibromyalgia. Suffering that originates in the brain should be considered as deserving of care and treatment as that caused by pathogens.

    1. Harriet Hall says:

      @Paratope,
      “people–patients, physicians, writers–typically believe that when the cause of symptions is identified as psychological, it means that the symptoms and the suffering are not real, and that the patients’ experience is being denied.”

      I don’t know of anyone who thinks the symptoms and suffering are not real or who denies the patients
      experience. It is because we know they are real that we try to determine the true cause and treat it realistically.

  36. Harriet Hall “Oh, never mind! If a Morgellons patient wants to believe he has parasites, he will just rationalize that casting has somehow killed the parasites on that arm. ”

    and also said “I don’t know of anyone who thinks the symptoms and suffering are not real or who denies the patients
    experience. It is because we know they are real that we try to determine the true cause and treat it realistically.”

    One of the hurdles that folks with mental disorders of all kind face is that the general public often seems to believe that once the person knows that they have a delusion, anxiety, mood disorder, etc, they should just stop it. In the above quote, you say ” If the patient wants to believe…” Of course, you could have been talking about non-delusional patients or just using an common phrase, but that language is completely in sync with popular thinking that people with mental disorders should “just get ovetoot.”

    It’s been my experience that the general public has difficulty understanding that thinking is often not a voluntary process. Perhaps doctors are better at understanding this, but I have very little evidence either way to know if they are or not. With no evidence to the contrary, I don’t see why I shouldn’t believe that doctor’s attitudes are very similar to those of the general public.

    It seems every article on SBM that discusses psychosomatic disorders does very little to outline handling of patients or treatment of those disorders. Honestly, occasionally stating “We know their pain is real.” without any additional effort to explain the disease, treatment or outcomes, sounds more like lip service than anything else.

    This is probably a by-product of the focus of the blog, which is often more anti-quack than pro-SBM. I respect the bloggers decision to write on topics that interest them, but I won’t give the writers credit for understanding topics that they seldom or never discuss. If you want me to believe that you have an in-depth understanding and concern for psychosomatic illnesses, you need to demonstrate it.

    1. Harriet Hall says:

      @micheleinmichigan,
      “If you want me to believe that you have an in-depth understanding and concern for psychosomatic illnesses, you need to demonstrate it.”

      “Psychosomatic illnesses” is an imprecise term used loosely to mean somatiform disorders or to refer to the truism that psychological and social factors are important along with physical factors in all illness. I used to belong to the American Psychosomatic Society, read their journal, and attend their meetings. I learned a few things but I had to unlearn many of them later as I became a better critical thinker and as more evidence emerged. For instance, I had to recognize that H. pylori was more important than mental attitude in causing ulcers, and I had to recognize that visualization exercises were useless in prolonging the life of cancer patients. I don’t think anyone really has what you could call an in-depth understanding of why patients develop somatiform disorders or delusions of parasitosis, and I don’t think there are any simple treatments proven to improve outcome. We are all struggling in this field.

      What could I possibly do to convince you that I am concerned about these patients and care about them? I don’t feel any particular need to make you personally believe in my concern, but I’m wondering what you are thinking. If you think I should write a definitive science-based article explaining why they are suffering and how to stop their suffering, you are asking for the impossible. If you are expecting some kind of tearful emotional outpouring saying how my heart is bleeding for these poor people, that’s the kind of emotional appeal that is more appropriate to a popular magazine than to a science-based website. The best way to show real concern for these patients is to stress that science is the only way to determine what will really help them.

  37. sorry, italics code fail.

  38. Mark Crislip says:

    “If you want me to believe that you have an in-depth understanding and concern for psychosomatic illnesses, you need to demonstrate it.”

    I don’t. Nor cardiology nor OB nor Neurosurgery. Never said I did.

    I work with the primary to get the patient to those who do know what they are doing.

    Worst thing a patient can have is a subspecialist mucking about in a area where they have little if any training or experience.

    As Mr Calahan said, Mans got to know his limitations.

  39. @Mark Crislip

    Yes of course, one of the reasons I completely adore your articles is not just your humor but because you know your limits.

    But the problem is, within the context of this blog, there is no working with the primary physician to see that the patient gets the psychiatric care that he/she may need. There are only articles saying what Morgellon’s is not.

    It’s rather like watching an episode of “What Not To Wear” where Stacy and Clinton tell the poor woman how awful her wardrobe is, throw out all her clothes, she cries and that’s the end. No helpful wardrobe advice, no trip to New York to buy the right clothes, no make-up and hair consultation, no wonderful reveal.

  40. daedalus2u says:

    Michelle, but having a make-over quack come in and convince them to wear a clown suit, with clown shoes and wear a big red nose is not helping either.

  41. Harriet Hall says:

    @micheleinmichigan,
    “within the context of this blog, there is no working with the primary physician to see that the patient gets the psychiatric care that he/she may need. There are only articles saying what Morgellon’s is not.”

    1. Dr. Novella didn’t just say what Morgellons is not; he said what he thinks it is. If there is a psychiatric diagnosis, it goes without saying that psychiatric care is appropriate.
    2. He didn’t say how to cure Morgellons because no one knows how to do that.
    3. This blog is not intended to “work with primary physicians to see that patients get appropriate care.” It is intended to provide information on science-based medicine. Your expectations are unreasonable.

  42. @Harriet Hall (and partly still Mark Crislip or any of the blog editors)

    Sometimes I think words are not my friend, they so often undermine my point.

    I said “If you want me to believe that you have an in-depth understanding and concern for psychosomatic illnesses, you need to demonstrate it.”

    I did not mean to suggest that YOU* (Harriet Hall) don’t have knowledge or concern. I have often been impressed with your empathy when you speak about patients. I was talking about the blog as it’s own entity, somewhat how one might talk about The New York Times.

    So if the New York Times did not have a writer with an in depth understanding of economics issues, I might criticize it’s coverage of the issue of global warming if it only suggests “we know the impact of carbon controls on industry is real.”

    I’m sorry to be a jerk on this issue. But I still feel that, overall, the readers of Science Based Medicine’s are not receiving a knowledgeable, nuanced coverage of the current science* in treating somatiform disorders or other psychiatric illnesses. This is normally no problem, but in articles like the ones about Delusional Parasitosis*, it becomes more problematic.

    @David Gorski – You are a volunteer group. I know, I know. It’s not easy to get folks to spends lots of time to write articles for free. I’m a complete dweeb for complaining.

    I don’t want to fault the blog (and really not the individual writers) so much as try to point out how that hole in the writing staff, unfortunately, may give an impression of disinterest (where none exists) or lack of knowledge.

    Perhaps when someone posts assuming that this blog mirrors the attitudes that popular journalism and the ever day Joe often exhibit, (like Paratope did) one could take this unfortunate impression of disinterest into consideration and give the commentor the benefit of the doubt…?

    See, when I’m having trouble communicating something, I just throw more words at it and hope that the general impression of syllable arrangement will communicate the gesalt of my meaning. Sort of language based abstract expressionism. Sorry for that.

  43. Harriet Hall – I genuinely have no interest in hearing any pie in the sky stories about cures for psychiatric diseases. All I’d like is a knowledgeable physician to write on the topic from a science based perspective.

    It’s not even an expectation. I’m just attempting to say that I believe the topic would be well served by the additional observations of someone with some expertise in that area. That the lack of specialist in the area ends up leaving the picture incomplete.

    [sigh]
    perhaps an interpretative dance would better communicate my thoughts. I’ll post the link to youtube when I’ve finished.

  44. Du2 – Michelle, but having a make-over quack come in and convince them to wear a clown suit, with clown shoes and wear a big red nose is not helping either.

    Well (setting aside my opinion of whether Stacy or Clinton are actually make-over clowns or not.) I agree to that it’s just that I think it doesn’t end there.

    Must go pay attention to my life now.

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