And everything that creepeth upon the Earth

Courtesy Alex Wild Photography

Image courtesy of Alex Wild, click image for link

Not all hallucinations are disturbing, but most probably are.  They can be categorized by which sense is involved or by cause.  Schizophrenics often experience auditory hallucinations, hearing voices that are not actually present.  Many people can experience olfactory hallucinations, usually smelling foul odors that no one else can detect.  These are often caused by specific problems in the brain or nose.  A classic cause is seizure in the temporal lobe of the brain.

Visual hallucinations aren’t that common and usually aren’t associated directly with mental illness as auditory ones are.  Most of the time, visual hallucinations are caused by chemicals such as drugs, or by withdrawal from drugs.  Sometimes they are caused by specific brain disorders.  A classic cause of visual hallucination is delirium tremens, or acute alcohol withdrawal.  Victims often have disturbing visual hallucinations (one of my favorites being skeletons fighting with swords on the IV pole, although in that case, the patient wasn’t all that disturbed by it).

As if that weren’t enough, alcohol withdrawal is often accompanied by an additional type of hallucination called formication (from Latin formica ant). This is a tactile hallucination usually described as a feeling of bugs crawling on the skin.  It’s rarely pleasant.

Delusions differ from hallucinations.  Rather than being a sensory problem, they are a thought problem.  People with delusions believe something that is demonstrably false and cannot be convinced otherwise.

Which brings us to what is surely not the end of the story of “morgellons syndrome”.  Over the last few years, patient advocacy groups have militated for further investigation of this putative skin disease.  The disease is characterized by a variety of symptoms, most of which are cutaneous and include itching, sores, and foreign substances arising out of wounds.  Most physicians view this as a variant of delusional parasitosis, an illness where people believe they are infested but no proof of infestation can be found.

Patients typically have a pattern of skin lesions indistinguishable from damage done by scratching, and the fibers and other substances, when analyzed, have been found to be common substances such as clothing fibers.  Even a brief perusal of morgellons advocacy websites will demonstrate the hostility with which this analysis is viewed. Sufferers believe they are truly stricken—and they are. But the enemy is within rather than without. Their brains have convinced them that their skin is crawling with various sorts of things and they cannot be convinced otherwise.

A few years ago, the CDC decided to investigate what they have labelled “unexplained dermatopathy”.  This week, the results of their study were published in PLoS ONE.

The investigators focused on Northern California, where there seemed to be many case reports.  They sifted through charts and invited those who described the syndrome to join the study.  What they found was that cases were rare, but were associated with significant disruption in quality of life.  They also found a significant incidence of neuropsychiatric disorders.  A remarkably large percentage of patients had hair samples testing positive for drug use, but the specific drugs are not reported, nor is the validity of the hair sampling technique.

In sum, there was a set of patients who reported disturbing skin sensations and wounds, who were disproportionately unhappy and may have been using drugs.  But which way does the arrow of causation go?  Does a mystery disease cause people to become depressed and use drugs, or does psychiatric disease and/or drug use cause a delusional syndrome? Delusions and hallucinations caused by psychiatric disease and substance use are well-documented.  The other way ’round is a bit murkier.

Some clues are found in the study.  Many cases began around the same time the internet picked up on morgellons suggesting a folie a deux/plusiers —a shared delusion (this also suffers from a correlation vs. causation problem).  Also, the skin changes among patients were diverse, too diverse to be easily explained by a single non-psychiatric cause. Pathology findings most commonly showed skin changes due to sun exposure and trauma such as scratching.  Finally, the “fibers” and other objects emerging from the skin were found to be common substances like threads from clothing and were not emerging from the skin but rather were enmeshed with skin debris.

This will not be the last word on this particular variant of delusional parasitosis.  The definition of a delusion is a fixed, false belief, one that is not dislodged by data or knowledge.  The inability to accept the diagnosis is part of the illness itself.  The challenge to clinicians will be to treat these patients delicately, with respect, acknowledging their real distress and attempting to guide them toward proper treatment.

References

Pearson, M., Selby, J., Katz, K., Cantrell, V., Braden, C., Parise, M., Paddock, C., Lewin-Smith, M., Kalasinsky, V., Goldstein, F., Hightower, A., Papier, A., Lewis, B., Motipara, S., Eberhard, M., & , . (2012). Clinical, Epidemiologic, Histopathologic and Molecular Features of an Unexplained Dermopathy PLoS ONE, 7 (1) DOI: 10.1371/journal.pone.0029908

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9 Comments

  1. Smokey

     /  February 2, 2012

    Real delusional parasitosis is extremely rare. Talk about a zebra. An undiagnosed infection is far, far more likely that delusional parasitosis. Of the three psychiatrists that I know, only one has had one case of delusional parasitosis in their entire career. 20 years ago, anyone claiming that a stomach bug was eating away at their stomach lining, would have gotten the same misdiagnosis. Sorry, the CDC are hardly going to be the last word on Morgellon’s whatever it turns out to be, and the study they did has many holes even a lay reader could drive a truck through. Look how badly they screwed up Lyme Disease, Swine Flu, etc, It will be interesting to see what it turns out to be, but my guess is that it will be labeled as an innocuous delusion until an expensive treatment is found, whereupon it will transform into a terrible affliction causing extreme embarrassment when out in public. Ask your doctor if Morgelica is right for you.

    • Real delutsional parasitosis is “extremely rare”? Could you quantify that, and explain why its putative rarity has anything to do with this?

  2. Fred

     /  February 2, 2012

    These patients are seeing licensed medical doctors, so-called LLMDs (Lyme-literate Medical Doctors) that are examining their fibers and diagnosing them as Morgellons. These doctors are feeding the delusions and fears of the patients. In fact, it seems as if some of these doctors are ‘creating’ the delusions by teaching their patients that these carpet fibers are living organisms, not lint.

    See the following PubMed article. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3047951/

    The concentration of Morgellons was in Texas and California. This is coincidentally where these two Lyme-literate practitioners have practices. The one has since relocated from Texas to the more ‘endemic’ San Francisco Bay area, and more recently relocated again to Washington, DC.

    How can these two medical professionals examine their patients, inspect their black, red, blue and “twisted” fibers, along with the ulcers and other skin lacerations and diagnose them as having mysterious creatures living and crawling around inside their body, eventually gnawing their way out? Yet, the $600,000 CDC study which analyzed patient fibers basically came up with carpet lint, not alien organisms.

    Aside from whatever ails these patients, it is inherently wrong, seemingly criminal, that the doctor seems to be intentionally diagnosing these carpet fibers as foreign creatures. It instills fear and creates hysteria in an already vulnerable patient population. It sure makes for a heck of a lot of great Internet blogs, though – free advertising for the group of doctors and their organizations, ILADS and lymedisease.org (formerly known as CALDA).

    Despite this study and after personally examining the red and black twisted fibers for himself, Dr. Stricker is still asserting that “The people who say it’s delusional are going to look very, very stupid when the evidence comes out,” he said.” http://sfappeal.com/news/2012/01/sf-doctor-cries-foul-on-cdc-report-suggesting-skin-disease-is-imaginary.php

    How exactly is this supposed to work, Smokey? Are we supposed to believe their study results over what the CDC investigation reports, especially considering that the physician, Dr. Stricker has already been banned from participation in NIH studies and ousted from a University for falsifying study results involving AIDS/HIV patients? http://grants.nih.gov/grants/guide/notice-files/not93-177.html and http://www.forbes.com/forbes/2007/0312/096.html

  3. Collin

     /  February 9, 2012

    In an article on SBM, you say that the worst lie is “I don’t know, but I’ll make something up”. Yet you don’t seem to realize that calling someone delusional IS making something up. I occasionally get a very convincing smell hallucination. I know it isn’t real, but it doesn’t go away unless I treat it. I spray room freshener up my nose (briefly), or I dab my nose with a kleenex with room freshener on it.

    I often have depression, vague abdominal pain, and brain fog, and I also have a history of mental illness. If I came to you complaining of the smell, I would fit the profile for being delusional. Except it’s not a delusion. It smells like tar and raisins. If I were delusional, I’d believe that the tar and raisins exist. I don’t, of course. But if I felt let down by the medical profession and turned to quacks, eventually I might.

    It’s a sensation started by nothing physical, yet something physical ends it. People with formication find relief by scratching. They get open sores, and fibers, or even parasites, get into them. There’s nothing strange about that; people with gunshot wounds probably fare a lot worse.

    The question is how did the itch progress to the point that the patients scratch themselves raw? Perhaps because, given their mental instability, doctors had refused to prescribe an analgesic. They had instead assumed that since the itch started without physical cause, nothing physical can stop it either. And they prescribed an anti-psychotic, which did no good because it wasn’t a psychosis at that time. Rather it became a psychosis later because of repeated obstinance from the doctor. (If not for their mental instability, they would’ve left that doctor and filed a lawsuit.)

    All this is caused by the assumption you expressed on SBM, that honesty and compassion are opposites. And the possibility that something physical is happening to the patient’s nervous system to cause the formication hasn’t been addressed, even though it’s well-known that alcohol can cause formication. And the CDC report even states that many patients were addicted to alcohol, and also that many were frequently exposed to solvents.

    And to top it all off, someone pointed out a math error in the CDC report, and I just downloaded the PDF from Plos, and the error is still there.

  4. PalMD

     /  February 9, 2012

    The sensation of unusual smells is common and rarely delusional. It is generally a problem with the olfactory apparatus or olfactory center in the brain, and sometimes indicative of temporal lobe seizures.

    The apt analogy would be for you to say that you are convinced that the smell is being caused by armadillos. You can’t seem to find the armadillos, but you know it’s them, just no one else does.

  5. Collin

     /  February 10, 2012

    I just got done saying I know the smell isn’t real. What IS real is the rest of my comment. And to prove it, I’m reposting. We can go around like this UTCCH, or you can give a real response to what I wrote. This is a blog, not your private scrapbook.

    “But if I felt let down by the medical profession and turned to quacks, eventually I might.

    It’s a sensation started by nothing physical, yet something physical ends it. People with formication find relief by scratching. They get open sores, and fibers, or even parasites, get into them. There’s nothing strange about that; people with gunshot wounds probably fare a lot worse.

    The question is how did the itch progress to the point that the patients scratch themselves raw? Perhaps because, given their mental instability, doctors had refused to prescribe an analgesic. They had instead assumed that since the itch started without physical cause, nothing physical can stop it either. And they prescribed an anti-psychotic, which did no good because it wasn’t a psychosis at that time. Rather it became a psychosis later because of repeated obstinance from the doctor. (If not for their mental instability, they would’ve left that doctor and filed a lawsuit.)

    All this is caused by the assumption you expressed on SBM, that honesty and compassion are opposites. And the possibility that something physical is happening to the patient’s nervous system to cause the formication hasn’t been addressed, even though it’s well-known that alcohol can cause formication. And the CDC report even states that many patients were addicted to alcohol, and also that many were frequently exposed to solvents.

    And to top it all off, someone pointed out a math error in the CDC report, and I just downloaded the PDF from Plos, and the error is still there.”

  6. Collin

     /  February 10, 2012

    P.S. Just in case you’re starting to write something about treating formication, I don’t have formication, and I never said I did. If that’s what you think I said, you need to pull your white coat off of your eyes.

  7. MonkeyPox

     /  February 10, 2012

    This is a blog, not your private scrapbook.

    HAHAHAHAHAHAAAA!!!

  8. Collin

     /  February 10, 2012

    Aside from whatever ails these patients, it is inherently wrong, seemingly criminal, that the doctor seems to be intentionally diagnosing these carpet fibers as foreign creatures.

    What a straw man! You think you can throw out the whole investigation because some crackpot puts a spooky spin on it? It’s a simple case of doctors mentally torturing patients, and Strickler was probably paid to obfuscate it.

    A patient complains of an itch. It could be a drug overdose, it could be an allergy, — heck, it could be a damn sex-feeling for all we know. A simple skin lotion could take the itch away, but that would leave the doctor feeling like only a physician, instead of a god. So the doctor refuses to acknowledge that the itch exists. The itch gets worse, and the patient scratches more and more. The doctor refuses to acknowledge that the scratches exist. The patient, driven by the ever-increasing itch, makes bigger and bigger open sores, and lint and dirt get stuck in them. And eventually, after years of being refused treatment — voila! a massive unknown infection!

    And do we hold the doctors responsible for driving the patients crazy? NOOO it must be the lint. Send the lint to the CDC to look for spooky parasites.

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