PSYCHIATRIC SKIN DISORDERS — Delusional Parasitosis and Friends.

“Neurodermatitis” is a medical euphemism for psychiatric skin disorders — skin disorders caused by mental illness. This group of disorders includes delusional parasitosis, Morgellons disease, neurotic excoriations, trichotillomania, and dermatitis artefacta. These conditions are different, yet similar in many respects. All of them are diagnoses of exclusion — diagnoses that are only made after intrinsic skin disorders have been ruled out by the physician. Most of these disorders can be spotted for what they are (by physicians) based on the unique pattern and distribution of the lesions. The skin lesions generally only occur in places that the patient can readily reach and the lesions tend to look highly unusual to the trained eye. The history of the patient is also an important piece of diagnostic evidence in most cases — e.g. a patient with other psychiatric diseases who has been to half-a-dozen dermatologists and no one can figure out what the heck is wrong with them. A skin biopsy can also be useful in equivocal cases. All of these disorders are potentially debilitating, and they all tend to be expensive and sometimes impossible to treat.

475px-An_introduction_to_dermatology_(1905)_scabies

An artist’s illustration of the “gross” (as opposed to “microscopic”) appearance of scabies, definitely not a psychiatric disease. Sometimes when you feel like you have bugs crawling under your skin you really do! As with all conditions, remember that just because someone has a mental illness doesn’t mean that they don’t also get physically ill from time to time like everyone else.

523px-Sarcoptes_scabei_2

An electronmicrograph of the scabies mite. Scabies is usually treated with a drug called permethrin. Outbreaks are common in nursing homes and also sometimes occur in hospitals and daycare centers.

Dermatitis artefacta is a form of factitious disorder, an intentionally caused medical problem that is self-inflicted to fulfill a subconscious need to assume the “sick role.” Patients with this disorder don’t feel normal unless everyone thinks that they are sick. When you are sick people tend to be nice to you and to give you lots of attention, and this is what persons afflicted with factitious disorders crave. Sometimes people with factitious disorder intentionally cause medical problems in their children. Instead of craving the “sick role” for themselves, these individuals crave the role of “caregiver for the sick.” This is called Munchausens Disorder by Proxy and it is a form of child abuse, probably the worst form of child abuse given the amount of psychological damage that is done to the child victim, which is immense.

Factitious_dermatitis

Self-inflicted skin lesions in a patient with dermatitis artefacta.

Delusional Parasitosis, as the name implies, is a delusional disorder. A delusion is a fixed belief that a person continues to believe even in the face of overwhelming evidence to the contrary. In the case of delusional parasitosis, patients are convinced that they have bugs crawling under their skin when they don’t. Obviously someone with scabies does not have delusional parasitosis — they really do have bugs crawling under their skin! A similar condition to delusional parasitosis is substance-induced formication. That’s “formication,” not “fornication” — the term is derived from the chemical “formic acid” that causes ant bites to sting. People intoxicated with stimulants, such as cocaine and methamphetamine, and persons under-the-influence of hallucinogens, such as LSD and PCP, sometimes feel like they have bugs crawling all over them. This is different than delusional parasitosis because the sensation resolves once the drug is out of their system.

640px-Crack_street_dosage

Crack cocaine. A common cause of substance-induced formication.

Morgellons Disease is now considered by most physicians to be a subtype of delusional parasitosis. Instead of delusions of insects crawling under the skin, people with Morgellons suffer from a belief that painful or itchy fibers are erupting from their bodies. Some people with this condition believe that they are contagious, whereas others suspect that they have been inoculated with nanofibers (or microfibers) by the government or by space aliens. The following ABC Nightline clip (courtesy of YouTube) is an interview of the original Morgellons patient, who also is the person who coined the term “Morgellons” in the contemporary context.

I was highly reluctant to put the link to this YouTube video here for reasons that will be obvious after you watch it. I felt significantly less equivocal about it after I learned that the “founder” of this disease is running a website that sells purported “natural cures” for Morgellons, and a lot of other conditions that are of questionable medical veracity. Still, I wish that the kids weren’t in the video… With that said, the video is highly educational on several levels, and even more so in 20/20 hindsight, both for healthcare providers and for laypeople, which is why I have reluctantly decided to share the link.

This video was produced before a pivotal 2008 CDC study failed to reveal a medical (other than psychiatric) etiology of the Morgellons syndrome. The results were published in 2012 — see Reference #4 below. The CDC researchers scoured the medical records of 2.8 million Kaiser Permanente patients, Kaiser being an HMO that is known for good record keeping and that commands a large percentage of the healthcare market in Northern California, an area with a high concentration of possible Morgellons sufferers. The researchers identified 115 patients who met the criteria for possible Morgellons. Of these patients, 41 chose to participate in the study, which was designed to help determine if Morgellons was a new disease or not.

In summary, after an exhaustive study the CDC did not find evidence of a new disease entity. The fiber samples taken from patients with purported Morgellons disease were found to be mostly cotton fibers of the type found in clothing, etc. Most of the patients in the study also had comorbid psychiatric conditions and/or substance abuse problems. This study is a really good example of how the CDC investigates a potential new disease and it is an excellent read if you are into reading that kind of thing (and probably remarkably boring to you if you aren’t into reading medical studies!). Please note that this study absolutely does not say that folks with “Morgellons” symptoms do not have a disease. It just suggests (indirectly) that the condition that they suffer from is a subtype of delusional parasitosis, which is a highly disabling disorder that is potentially treatable with psychotherapy and with medications, particular with a drug called pimozide that is both an antipsychotic drug and a potent antipruritic (anti-itch) medication.

Finally, Neurogenic Excoriation Disorder is a form of Obsessive-Compulsive Disorder (OCD). It usually starts with a person who suffers from both acne and from OCD. People afflicted with OCD have obsessions — disturbing and recurring thoughts — that can be temporarily alleviated by performing a compulsive act, such as excessive hand washing or, in the case of neurogenic excoriation disorder, skin picking. The bad news is that OCD can be highly disabling. The good news is that it is highly treatable with a combination of counseling and psychiatric medication. The medication of choice is generally a member of the SSRI class of antidepressants, which are among the most commonly prescribed medications in the United States and which have an excellent safety profile. Trichotillomania is a related condition in which sufferers feel compelled to pull their hair out (and they do — see image below).

1024px-Derma_me

An image of a person suffering from neurogenic excoriation disorder.

Trichotillomania_1

Trichotillomania.

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

***Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!***

The opinions voiced on this medical blog are solely the author’s own and they do not reflect the opinions or values of Dr. Noto’s employers, past or present. Dr. Noto’s medical blogs should never be used as supporting evidence for legal testimony — this is of course obvious to anyone who isn’t a complete moron, but some people are rather stupid.

REFERENCES

1. Morgellons disease: Managing a mysterious skin condition. http://www.mayoclinic.org/morgellons-disease/art-20044996?pg=1.

2. Gupta, AK. Psychocutaneous Disorders. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. Lippincott Williams & Wilkins, Philadelphia, PA. 2009.

3. CDC. Study of an Unexplained Dermopathy. http://www.cdc.gov/unexplaineddermopathy/

4. Michele Pearson, et al. Clinical, Epidemiologic, Histopathologic and Molecular Features of an Unexplained Dermopathy. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0029908.  Published: January 25, 2012. DOI: 10.1371/journal.pone.0029908

5. Scabies Image: Walker, Norman Purvis () An introduction to dermatology (3rd ed.), William Wood and company Retrieved on 26 September 2010.

6. Scabies Mite (Electronmicrograph): Author: Kalumet. Date: 06.11.2004. http://commons.wikimedia.org/wiki/File:Sarcoptes_scabei_2.jpg.

7. Neurodermatitis, Wikipedia Image: “Factitious dermatitis” by Neeraj Varyani, Sunny Garg, Garima Gupta, Shivendra Singh, and Kamlakar Tripathi. – This image in Case Reports in Psychiatry Volume 2012 (2012), Article ID 674136, 3 pages doi:10.1155/2012/674136 Case Report Trichotillomania and Dermatitis Artefacta: A Rare Coexistence. Licensed under CC BY-SA 1.0 via Wikimedia Commons – http://commons.wikimedia.org/wiki/File:Factitious_dermatitis.jpg#/media/File:Factitious_dermatitis.jpg.

8. Excoriation Disorder: http://en.wikipedia.org/wiki/Excoriation_disorder#/media/File:Derma_me.JPG

9. Crack Cocaine: Uploaded: March 6, 2005 by David.Monniaux. http://en.wikipedia.org/wiki/Crack_cocaine#/media/File:Crack_street_dosage.jpg.

10. Alien Fibers: Morgellons Disease – ABC’s Nightline. Uploaded August 25, 2011. https://www.youtube.com/watch?v=xsiJpuARHcE.

11. John Y.M. Koo. Dermatitis Artefacta. http://emedicine.medscape.com/article/1121933-overview.

12. Trichotillomania Image: http://commons.wikimedia.org/wiki/File:Trichotillomania_1.jpg.

 

Mental Illness 101: Part 3/3

Posttraumatic stress disorder (PTSD) is caused by exposure to traumatic situations in which your life was threatened. PTSD was first noticed in combat veterans and it has had many names throughout history–“shellshock” in WWI vets and “Vietnam Vet Syndrome” in veterans of that awful war. In order for a stress reaction to meet the diagnosis of PTSD the symptoms–hypervigilance (being on edge all of the time), avoidance of things that remind you of the traumatic event (like the war veteran who avoids places with helicopters), and reexperiencing (nightmares, intrusive memories, or both)–have to be present for more than 3 months. A civilian form of PTSD is common in victims of near death expericences, of sexual assault, and of severe child abuse The disease is usually highly treatable in most cases with a combination of counseling and medications. A famous person with PTSD was Audie Murphey–the most decorated American soldier of WWII.

Attention deficit/hyperactivity disorder (ADHD) is pretty self-explanatory–a severe deficit of attention span and hyperactivity, usually in a child. People with severe ADHD greatly benefit from stimulant medications (e.g. Adderal, which is amphetamine); however, this disorder is probably grossly over-diagnosed. If your kid can’t function because of their poor attention span and hyperactivity then it is reasonable to have them evaluated by a psychiatrist for ADHD. With that said, the overuse of powerful stimulants, which stunt growth and are addictive, is a major concern and this is not a diagnosis that should be given out lightly (as it often is).

Tourette’s Syndrome is a highly debilitating tic disorder in which sufferers have some sort of tic that they cannot suppress–at least not for long. The classic form of Tourette’s disorder is a patient who regularly yells profanities and is unable to stop–something that can make leading a normal life next to impossible. The treatment is with powerful antipsychotic medications and supportive counseling.

Factitious Disorder is a psychiatric disorder in which patients create medical problems in themselves so that they can fill an emotional void in their life by getting attention from healthcare providers. The classic example is a nurse who secretly injects herself with large doses of insulin and then presents to the emergency room with a dangerously low blood sugar (that “can’t be explained”). Factitious Disorder-by-Proxy (Munchausen’s Disorder-by-Proxy) is similar, but instead of making themselves ill the perpetrator makes their children ill. This disorder is one of the worst forms of child abuse and it has a very high mortality for the child. My brothers and I are survivors of Munchausen’s Disorder-by-Proxy.

Dr. Leonardo Noto

Physician and Author of Medical School 101, Intrusive Memory, The Life of a Colonial Fugitive, and The Cannabinoid Hypothesis.

Author Bio: Dr. Leonardo Noto is the nom de plume of a former airborne battalion surgeon who is now in civilian practice. Dr. Noto is the author of four books and he also writes for a medical education corporation that assists medical students, interns, and residents as they prepare for the medical board examinations. Dr. Noto is the proud father of an extremely spoiled 12-month-old American Bulldog who enjoys slobbering everywhere and tearing up things that he is not supposed to! Dr. Noto is an amateur practitioner of muay Thai and Brazilian jiu jitsu and he recently began learning to play the guitar (but he is currently a quite terrible musician, as his neighbors will readily attest).

Remember to discuss all health concerns with your personal physician (I don’t count!) before making any medical decisions. www.leonardonoto.com is intended to present general medical information for entertainment purposes and not as specific guide to any medical treatment. The author has made every effort to present accurate information; however, due to the ever-changing nature of medicine and the intrinsic caveats that are inherent in any particular case, no medical decisions should ever be made based on information gleaned from the internet (duh!). The internet and self-education are great, but they don’t replace your Doc!