Psychocutaneous Medicine

Treating Patients With of Parasitosis: A Blueprint for Clinicians

Ladan Mostaghimi, MD

Dermatologists often inquire how to approach It is common for dermatologists in a busy prac- a patient with delusions of parasitosis. Avoid- tice to have a negative countertransference toward ing negative countertransference and develop- these demanding distressed patients that will resist ing a therapeutic alliance with the patient are their recommendations and take too much of their key steps for dermatologists. Even though each time, which will in turn prevent a therapeutic alli- case is unique, this article serves as a blue- ance with the patient. Multiple publications and print for clinicians on how to approach and treat case reports on treatment of this difficult ailment these patients. emphasize the importance of a good therapeutic Cutis. 2010;86:65-68. alliance but do not address in any detail how to build this alliance.1-6 It is evident that derma- CUTIStologists need a better approach for these time- reating patients with delusions of parasitosis, consuming situations. or somatic type accord- Ting to the Diagnostic and Statistical Manual Preventing Negative Countertransference of Mental Disorders (Fourth Edition) classification, The existence of 2 different sets of beliefs causes can be difficult for dermatologists. Patients believe conflict between dermatologists and patients with that their skin is invaded and/or infested by exter- delusions of parasitosis. While the dermatologist nal Domaterials (ie, parasites, fibers),Not usually due to believes Copy that the problem is psychological, the abnormal sensations of the skin. They start to self- patient believes that the problem is a foreign material treat the invaders by using methods such as mul- that the physician is unable to find and treat; some tiple long baths each day, bleach, or other caustic patients are afraid that it will eventually kill them. detergents. They also attempt to dig out the invad- The definition of is a false fixed belief.7 ers by mechanical means, such as scissors, tweezers, Therefore, the dermatologist must first accept that or their nails, which leads to serious skin damage because of the fixed nature of the delusion, he/she as well as multiple infections and scarring. Derma- will not be able to reason with the patient or tologists try in vain to convince patients that there change the patient’s belief. In fact, many patients are no invasions/infestations. They also try to refer with monosymptomatic delusions, even those patients to a psychiatrist, a referral that usually treated with high doses of neuroleptic medications, makes patients angry and upset. The Internet, for will continue to believe that they are still infested the most part, has been an aggravating factor, with but the parasites are not as bothersome. multiple Web sites feeding into the delusions and A more appropriate approach for dermatolo- promoting use of different remedies to take care of gists is to empathize with their patients and not the nonexistent infestations. get upset when the patient returns insisting that “you are not a good doctor and nothing that you give me is working.” To be able to hear this com- ment and prevent the knee-jerk reaction of being From the Psychocutaneous Clinic, University of Wisconsin, Madison. The author reports no conflict of interest. hurt by the patient’s insulting approach is the first Correspondence: Ladan Mostaghimi, MD, Department of step in therapeutic alliance. Having a good thera- Dermatology, University of Wisconsin, 1 South Park, 7th Floor, peutic relationship with the patient and prevent- Madison, WI 53715 ([email protected]). ing serious self-injurious behavior ultimately is

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the best help a dermatologist can offer. Try to see patient scores highly for or anxiety, it the situation from the patient’s point of view and is easier to propose a referral to a psychiatrist. If accept that his/her beliefs are different from yours; there is any infection of the skin, ensure that it is as long as the patient is not an acute danger to treated promptly. himself/herself or others, he/she has the right to It is important not to feed into the delusion. have different beliefs. Tell patients, “We are going to look for and find the culprit if there is any, but in the meantime, Treating the Patient treatment of your depression and anxiety and/or After overcoming countertransference toward a sleep problems will help you have fewer bother- noncompliant patient, the dermatologist needs to some symptoms.” Refuse empiric treatment of start to be a healer. Delusions of parasitosis can parasites if they have not been found; treatment have multiple causes and/or differential diagno- will only convince patients that the delusions are ses; missing them could have catastrophic con- true and they will push for more treatments with sequences. There are 2 main types of delusional higher doses. It is important for dermatologists to disorders of the somatic type: primary (idiopathic) be familiar with a few antidepressant, antianxiety, and secondary. Secondary delusions of parasitosis and medications, as well as their are listed in the Table. side effect profiles, to be able to prescribe them if A systematic approach to treating patients the patient is willing.1-3,5,6,10 Dermatologists also with delusions of parasitosis follows. First, take should work with patients on skin care to avoid the patient’s concern seriously. Then take a com- wounding and scarring that will only aggravate the plete history and physical examination; review the abnormal sensations. patient’s medications and drugs of abuse. Some After the first session, ask patients to return for patients have delusions that are induced by a follow-up in 2 to 3 weeks to review the laboratory combination of , medications for pain, and results. At the second visit, if the patient has agreed stimulants such as a combination of dextroam- to take medications to help with depression, anxiety, phetamine and amphetamineCUTIS for attention-deficit/ or sleep problems, or neuroleptic agents for delu- hyperactivity disorder. Patients with abuse sions, he/she may already feel better and be more also have presented with delusional symptoms. receptive to other recommendations. If the labora- Baseline laboratory testing should include com- tory test results are abnormal, take time to go over plete blood cell count with differential; liver, kid- the results and recommend the appropriate treat- ney, and thyroid function tests; and vitamin B12 and ment. If the laboratory results are normal, use them folate levels. Iron studies and rapid plasma reagin to reassure the patient with phrases such as “In cases alsoDo should be performed. FurtherNot testing such of infestation,Copy we usually have hypereosinophilia, as urine drug screening, heavy metal screening, and the fact that your eosinophils are normal is a human immunodeficiency virus testing, and test- very good sign that there is no serious infestation,” ing for is determined based on history or “Normal laboratory results show that there is no or abnormal clinical or baseline laboratory find- dangerous infestation and what you feel may be the ings. Because temporal lobe epilepsy could cause result of your heightened sensitivity to normal stim- abnormal somatic hallucinations based on clinical uli on your skin, which happens with hyperexcit- presentation, a sleep-deprived electroencephalo- ability states of the brain due to chemical imbalance gram in some cases is useful. Take scrapings of or peripheral neuropathies. We have medications the skin and examine the material brought by the that would help you with these situations.” patient under the microscope; get a second opinion Many patients will show better compliance with from a dermatopathologist. Most patients appreci- treatment recommendations if they feel that their ate this approach and feel that their concerns are beliefs are respected and their concerns are not dis- not dismissed. On the other hand, dermatologists missed. Some patients will continue their delusions should avoid biopsies if there is no primary lesion; and self-injurious behavior. In these cases, always patients will generally report that the biopsy was remember that if a patient continues to follow up, not taken from the right location if the results are it means that he/she feels that the dermatologist negative. Also, screen the patient for depression is helping. and anxiety using reliable questionnaires such as the Beck Depression Inventory or Quick Inventory Refusing Psychotropic Medications or of Depressive Symptomatology (Self-report) for Referral to a Psychiatrist depression and the Beck Anxiety Inventory or If a patient continues to follow up but refuses psy- Penn State Worry Questionnaire for anxiety. If the chotropic medications or referrals to a psychiatrist,

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9

8 of Substances

Effects Effects of Medications

Amphetamines hydrochloride Methylphenidate bugs) (cocaine Cocaine Alcohol sulfate Phenelzine hydrochloride Pargyline Corticosteroids report) case (one Topiramate Bromide intoxication Bromide bleomycin (ie, medications Other clonidine ketoconazole, sulfate, mefloquine) captopril, hydrochloride,

Long-term Use and Side

ders CUTIS

Major depressive disorder depressive Major disorder Bipolar disorder psychotic Brief

Psychiatric Disor

Do Not Copy Conditions sclerosis Multiple disease Parkinson chorea Huntington infarction Cerebral tumors system nervous Central disorders Seizure epilepsy) lobe temporal (ie, loss Hearing

Neurologic

and and 12

Secondary Delusions of Parasitosis and Diagnoses Differential Medical Disorders diseases Infectious leukemia lymphocytic Chronic lymphoma Malignant CHF Arteriosclerosis mellitus B Vitamin deficiencies other Pellagra failure Renal disorder Thyroid disease Hepatic COPD stasis diseases: Dermatologic disease. pulmonary obstructive chronic COPD, failure; heart congestive CHF, virus; immunodeficiency human HIV, Abbreviations: dermatitis, vitiligo dermatitis, (ie, tuberculosis, , HIV) syphilis, tuberculosis, (ie,

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the dermatologist needs to continue with symptom- dictum derived from the Hippocratic Oath: First, atic treatment and avoid any harmful treatment. do no harm. Watchful waiting is key. Safety of the patient, his/her family, and the physician are important in REFERENCES this situation. Even though a therapeutic alliance  1. Koo J, Lee CS. Delusions of parasitosis. a dermatologist’s is important, dermatologists should not agree with guide to diagnosis and treatment. Am J Clin Dermatol. unreasonable demands of patients for further test- 2001;2:285-290. ing or more medications that are not helpful. If at  2. Fellner MJ, Majeed MH. Tales of bugs, delusions of any point patients have serious infections due to parasitosis, and what to do. Clin Dermatol. 2009;27: self-injurious behavior, such as caustic treatments 135-138. of skin or cutting and picking at the skin, dermatol-  3. Lepping P, Russell I, Freudenmann RW, et al. Anti- ogists could work with a family member and local psychotic treatment of primary delusional parasitosis. mental health centers to begin the process of invol- B J Psych. 2007;191:198-205. untary commitment. In these instances, if the court  4. Bak R, Tumu P, Hui C, et al. A review of delusions of para- finds the patient unable to consent to treatment, sitosis, part 1: presentation and diagnosis. Cutis. 2008;82: the patient would be committed to receive invol- 123-130. untary treatment. Keep in mind that this process is  5. Bak R, Tumu P, Hui C, et al. A review of delusions of para- traumatizing for patients and family members, and sitosis, part 2: treatment options. Cutis. 2008;82:257-264. as long as a patient is not an acute danger to  6. Sandoz A, LoPiccolo M, Kusnir D, et al. A clinical himself/herself and/or others, he/she could con- paradigm of delusions of parasitosis. J Am Acad Dermatol. tinue to refuse medications and the courts will not 2008;59:698-704. commit him/her to treatment. Finally, neuroleptic  7. Manschreck TC. Delusional disorder and shared psychotic medications do have serious side effects, and in disorder. In: Kaplan HI, Saddock BJ, eds. Kaplan and considering them, dermatologists should weigh Saddock’s Comprehensive Textbook of . 6th ed. Vol risks and benefits. Unless a patient is committed 1. Baltimore, MD: Williams & Wilkins; 1995:1031-1049. to receive involuntary treatment,CUTIS an informed  8. Fleury V, Wayte J, Kiley M. Topiramate-induced delu- consent from the patient is needed for treatment, sional parasitosis. J Clin Neurosci. 2008;5:597-599. which means that the patient must understand the  9. Huber M, Kirchler E, Karner M, et al. Delusional para- purpose for the medication as well as the risks and sitosis and the transporter. a new insight of benefits of using it. etiology? Med Hypotheses. 2007;68:1351-1358. In conclusion, working with patients with delu- 10. Lorenzo CR, Koo J. in dermatologic prac- sions of parasitosis requires patience and vigilance, tice: a comprehensive review. Am J Clin Dermatol. 2004;5: and Dophysicians need to remind Not themselves of this 339-349.Copy

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