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Successful Treatment of Morgellons Disease With Pimozide Therapy
Abstract
Patients seen with complaints of fibers extruding from the skin associated with nonspecific dermatologic and neuropsychiatric symptoms have been diagnosed as having Morgellons disease. The cause of Morgellons disease and its relationship to delusional infestation (DI) remain controversial. A heterogeneous diagnosis, DI is the most common delusional disorder in dermatology and shares features with Morgellons disease.11 +Harth
WHermes
BFreudenmann
RW Morgellons in dermatology. J Dtsch Dermatol Ges 2010;8
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RF Pimozide in delusions of parasitosis. J Clin Psychiatry 1983;44
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CS Pimozide at least as safe and perhaps more effective than olanzapine for treatment of Morgellons disease. Arch Dermatol 2006;142
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K Pimozide treatment for delusion of infestation. Act Nerv Super (Praha) 1986;28
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RWLepping
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... Antibiotics effective against Agrobacterium such as cefepime, carbapenems, tetracyclines, and ciprofloxacin [19] can also be tested in MD patients. Reid (2010) reported success with using Pimozide after trials of Azithromycin and prednisolone failed, however, only one patient was treated in this paper [23]. Pimozide is an antipsychotic drug with antipruritic properties which has been effective in the treatment of delusions of infestation [24]. ...
... Antibiotics effective against Agrobacterium such as cefepime, carbapenems, tetracyclines, and ciprofloxacin [19] can also be tested in MD patients. Reid (2010) reported success with using Pimozide after trials of Azithromycin and prednisolone failed, however, only one patient was treated in this paper [23]. Pimozide is an antipsychotic drug with antipruritic properties which has been effective in the treatment of delusions of infestation [24]. ...
... Pimozide is an antipsychotic drug with antipruritic properties which has been effective in the treatment of delusions of infestation [24]. However, individuals with MD are often resistant to treatment with antipsychotics, hence, the antipruritic effect of pimozide can be presented in order to destigmatize the medication [23]. This medication may be effective in the treatment of MD due to the psychologic symptoms that are associated with the disease, which often occurs after onset of skin lesions and may be as a result of neuroborreliosis [25]. ...
Morgellons Disease (MD) is a multisystem disorder with a primary symptom characterized by emerging of small fibres from the skin. For years, many doctors thought MD is a psychiatric disorder and treated the patients with antipsychotic drugs, behavioural therapy and counselling. However, recent studies suggest that MD is a completely different entity from psychiatric disorders. Morgellons pathophysiology remains a mystery even up to now. It was previously considered to be a delusional disorder due to its similarity to delusions of parasitosis or delusional infestation described many years ago. This constellation of symptoms has not been well studied in different populations, however, a study in North California found a prevalence of 3.65 per 100,000 for MD, with Caucasian and female predominance.
... • electroconvulsive therapy is an acceptable treatment for MD 30,52 • establishing rapport to gain confidence and trust helps convince patients to take antipsychotic drugs 30,39,41,49,54,58,60 • using the word "Morgellons" in dialogue with patients can help establish rapport and trust 30,39,41,54,58,60 • it is acceptable for dermatologists to diagnose delusional disorder and prescribe antipsychotic medication 51,56 • use of deceptive dialogue and strategies aimed at convincing patients to take antipsychotic drugs is a justifiable practice 41,50,54,60,65 • if a patient's friend(s) or family member(s) also observe a subject's dermatological lesions and believe the evidence, then they too are considered to share the delusional belief, and the delusion is considered to have been transmitted from one individual to another; 30,51,54,68 the belief shared by two people that there are organisms present in the skin is called folie à deux (madness of two); folie à trois, folie à quatre, or folie à cinq are shared beliefs by three, four, or five people, respectively; and shared belief in a family is folie à famille. 30,51,54,68 A PubMed search using the keyword "Morgellons" identified 18 publications consisting of case studies of between one and six patients. ...
... • electroconvulsive therapy is an acceptable treatment for MD 30,52 • establishing rapport to gain confidence and trust helps convince patients to take antipsychotic drugs 30,39,41,49,54,58,60 • using the word "Morgellons" in dialogue with patients can help establish rapport and trust 30,39,41,54,58,60 • it is acceptable for dermatologists to diagnose delusional disorder and prescribe antipsychotic medication 51,56 • use of deceptive dialogue and strategies aimed at convincing patients to take antipsychotic drugs is a justifiable practice 41,50,54,60,65 • if a patient's friend(s) or family member(s) also observe a subject's dermatological lesions and believe the evidence, then they too are considered to share the delusional belief, and the delusion is considered to have been transmitted from one individual to another; 30,51,54,68 the belief shared by two people that there are organisms present in the skin is called folie à deux (madness of two); folie à trois, folie à quatre, or folie à cinq are shared beliefs by three, four, or five people, respectively; and shared belief in a family is folie à famille. 30,51,54,68 A PubMed search using the keyword "Morgellons" identified 18 publications consisting of case studies of between one and six patients. ...
... • electroconvulsive therapy is an acceptable treatment for MD 30,52 • establishing rapport to gain confidence and trust helps convince patients to take antipsychotic drugs 30,39,41,49,54,58,60 • using the word "Morgellons" in dialogue with patients can help establish rapport and trust 30,39,41,54,58,60 • it is acceptable for dermatologists to diagnose delusional disorder and prescribe antipsychotic medication 51,56 • use of deceptive dialogue and strategies aimed at convincing patients to take antipsychotic drugs is a justifiable practice 41,50,54,60,65 • if a patient's friend(s) or family member(s) also observe a subject's dermatological lesions and believe the evidence, then they too are considered to share the delusional belief, and the delusion is considered to have been transmitted from one individual to another; 30,51,54,68 the belief shared by two people that there are organisms present in the skin is called folie à deux (madness of two); folie à trois, folie à quatre, or folie à cinq are shared beliefs by three, four, or five people, respectively; and shared belief in a family is folie à famille. 30,51,54,68 A PubMed search using the keyword "Morgellons" identified 18 publications consisting of case studies of between one and six patients. ...
Morgellons disease (MD) is a skin condition characterized by the presence of multicolored filaments that lie under, are embedded in, or project from skin. Although the condition may have a longer history, disease matching the above description was first reported in the US in 2002. Since that time, the condition that we know as MD has become a polemic topic. Because individuals afflicted with the disease may have crawling or stinging sensations and sometimes believe they have an insect or parasite infestation, most medical practitioners consider MD a purely delusional disorder. Clinical studies supporting the hypothesis that MD is exclusively delusional in origin have considerable methodological flaws and often neglect the fact that mental disorders can result from underlying somatic illness. In contrast, rigorous experimental investigations show that this skin affliction results from a physiological response to the presence of an infectious agent. Recent studies from that point of view show an association between MD and spirochetal infection in humans, cattle, and dogs. These investigations have determined that the cutaneous filaments are not implanted textile fibers, but are composed of the cellular proteins keratin and collagen and result from overproduction of these filaments in response to spirochetal infection. Further studies of the genetics, pathogenesis, and treatment of MD are warranted.
... Examination of her skin revealed no anomalies apart from infection in the lesions. Treatment of the infections and pain led to little improvement of her general condition and her anxiety worsened [1]. Dermatologists in situations such as these face the dilemma of whether or not to tell the patient that she appears to have a delusional disorder and suggest psychiatric referral. ...
... The remaining 45 texts were from the period 2006-2013, and for the most part belonged to dermatology and psychosomatic literature. Other disciplines represented were nursing, entomology, otorhinolaryngology, oral surgery, psychiatry, clinical hypnosis, and clinical microbiology [1,[3][4][5][6][7][8][9][10][11][12][13]. Among the 45 articles, there was no contribution by bioethicists. ...
... To those who subscribe to the psychiatric explanation of Morgellons and are convinced or consider it likely that it is a variety of DP/DI, the main difficulty is obtaining consent and compliance to psychiatric treatment, especially antipsychotics. In order to obtain consent to and compliance with the treatment, some authors stress the importance of building a relationship with the patient so that they trust the physician [9,15,49]; however, several authors also suggest that non-disclosure of the diagnosis of DP/DI and/or avoiding telling the patient that the treatment targets their delusional beliefs and not their somatic symptoms helps in obtaining consent [1,9,13,15,22,32,37,42,45]. ...
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.
... Management of the condition often involves addressing the underlying psychological cause and providing symptomatic relief for the patient [3,4]. In some cases, this involves the use of topical or systemic medications [16][17][18][19][20] in combination with psychotherapy [1,20]. ...
... "someone to talk to") [24]. Aside from intensive psychotherapy, such as CBT [20,26], a number of treatments have been proposed and used in clinical practice, including pharmacological interventions [16][17][18][19][20]. As a psychotic spectrum disorder, treatment may involve the use of first and second-generation antipsychotics, which in some cases can induce remission [16,18,20]. ...
The purpose of this report is to present a case of a 63-year-old man with orbital Morgellons disease. A 63-year-old man presented reporting 15 years of daily egress of different foreign bodies apparently found in the superior fornices of both eyes, exhibiting a classic manifestation known as the matchbox sign. He described the symptoms starting after a facial trauma. The patient stated that at several points over the 15-year course of his condition, he was so distressed that he had contemplated suicide. On multiple exams by a range of ophthalmic professionals, there was no evidence of foreign body. Further investigation involving MRI and plain radiographs demonstrated similar lack of findings. A trial of gabapentin was performed without improvement in symptoms. He discontinued care 5 months later. Morgellons disease is a poorly understood condition, particularly ophthalmic presentations of the disease. Despite extensive investigation, the exact cause of Morgellons disease remains unclear, and there is no definitive treatment for the condition. We highlight the importance of empathetic listening in building trust, as a means of helping the patient to seek psychological help.
... To help patients overcome this barrier, clinicians can highlight the additional analgesic and antipruritic effects of some antipsychotics, acknowledge the impactful nature of symptoms, and avoid characterization of the disorder as delusional in nature. These techniques can lessen stigma and help build rapport with patients [1,9]. ...
... Dermatology Online Journal || ReviewVarious low dose antipsychotic agents are efficacious for Morgellons, especially when utilized in combination therapy(Table 1),[1][2][3][4][7][8][9].Table 1.Summary of treatment modalities used in studies for Morgellons. Legend: Summary of treatment modalities used in studies for Morgellons. ...
... The FGA drug pimozide was historically favored for management of MD due to the early success of the drug in a small RCT in the 1980s. In multiple case studies and series, low-dose pimozide treatment for several months yielded significant improvement to complete resolution of MD lesions [12,13]. However, pimozide is no longer considered the drug of choice due to adverse events (AEs) such as QT interval prolongation, extrapyramidal side effects, drug-drug interactions, and depression [1,5]. ...
... If there appears to be patterning in success, it is with approaches dedicated to reclaiming internal environment; my recommendation is to focus on understanding these approaches while having a general understanding of all approaches. There have been suggestions of successful approaches with antipsychotics (Koblenzer 2006, Reid & Lio 2010; as some believe Morgellons to be the result of neurotoxicity (see Amin 2001 to present andalso Keleher 2008 to present), I wonder how these drugs might affect neurologic symptoms (could these potent drugs simply be covering symptoms and not treating the condition?). ...
Patients with DI pose a truly interdisciplinary problem to the medical system " (Freudenmann and Lepping 2009). " i'm not crazy. i'm sick " I had symptoms from the Morgellons spectrum, recovered and documented my experience (see Keleher 2008a). Since overcoming my symptoms, I have tried to help those still suffering from this horrific condition through published research, blogging and other communications. Recently I reviewed the approach to Morgellons patients outlined in Freudenmann and Lepping 2009; their perspective of Delusional Infestation (which they suggest Morgellons falls within) is based on a number of suggested truths. After discussing some of the article's framework, I introduce an alternative approach built on communication between patient and medical practitioner and avoiding delusional terminology.
... The name came from a monograph entitled "A Letter to a Friend" by Sir Thomas Brown in 1690 describing an illness characterized by "outbreaks of harsh hairs" on the backs of children in 20,21,[31][32][33] Many physicians continue to equate Morgellons disease with delusions of parasitosis. [34][35][36][37] It is unknown when this disease first appeared, but descriptions of delusions of parasitosis date back to the 1950s and 1960s. Some of these early cases mention "threads" or other debris coming from skin and failure of psychotherapy, and thus may have been cases of Morgellons disease. ...
Bovine digital dermatitis is an emerging infectious disease that causes lameness, decreased milk production, and weight loss in livestock. Proliferative stages of bovine digital dermatitis demonstrate keratin filament formation in skin above the hooves in affected animals. The multifactorial etiology of digital dermatitis is not well understood, but spirochetes and other coinfecting microorganisms have been implicated in the pathogenesis of this veterinary illness. Morgellons disease is an emerging human dermopathy characterized by the presence of filamentous fibers of undetermined composition, both in lesions and subdermally. While the etiology of Morgellons disease is unknown, there is serological and clinical evidence linking this phenomenon to Lyme borreliosis and coinfecting tick-borne agents. Although the microscopy of Morgellons filaments has been described in the medical literature, the structure and pathogenesis of these fibers is poorly understood. In contrast, most microscopy of digital dermatitis has focused on associated pathogens and histology rather than the morphology of late-stage filamentous fibers. Clinical, laboratory, and microscopic characteristics of these two diseases are compared.
DI patients are not routine and should be approached holistically. Rarely is there a DI patient with a single problem; there are often many contributing factors, each with a variable history ranging from predispositions to trauma. Thus, it is important to understand where the patient is in the progress of their illness. A physician faces several decision points when progressing toward a differential diagnosis. Although there are many similarities among DI patients, each patient is slightly different. They possess a complex mix of somatic and psychiatric conditions, and untangling these can be challenging.
Morgellons disease (MD) is a rare and contentious health condition characterized by dermatological symptoms including slow‐healing skin lesions ‘attributed’ to fibres emerging from or under the skin. Patients also report sensations of crawling, biting and infestation with inanimate objects. This review examines the aetiology, patient characteristics, epidemiology, historical context, correlation with Lyme disease, role of internet, impact on quality of life and treatment approaches for MD. Despite ongoing debate, MD is not officially recognized in medical classifications, with differing views on its aetiology. Some link MD to Lyme disease, while others view it as a variant of delusional infestation. The literature suggests both psychiatric and environmental factors may contribute. The manuscript explores the association with substance abuse, psychiatric comorbidities, infectious agents and the role of internet communities in shaping perceptions. MD's impact on quality of life is significant, yet often overlooked. Treatment approaches are varied due to limited evidence, with low‐dose antipsychotics being considered effective, but patient beliefs may influence adherence. A patient‐centred, multidisciplinary approach is emphasized, considering both the physical and psychological dimensions of MD. Addressing the controversies surrounding MD while focusing on patient well‐being remains a critical challenge for healthcare professionals.
Morgellons Disease (MD) is a multisystem disorder with a primary symptom characterized by emerging of small fibres from the skin. For years, many doctors thought MD is a psychiatric disorder and treated the patients with antipsychotic drugs, behavioural therapy and counselling. However, recent studies suggest that MD is a completely different entity from psychiatric disorders. Morgellons pathophysiology remains a mystery even now. It was previously considered to be a delusional disorder due to its similarity to delusions of parasitosis or delusional infestation described many years ago. This constellation of symptoms has not been well studied in different populations, however, a study in North California found a prevalence of 3.65 per 100,000 for MD, with Caucasian and female predominance.
Morgellons disease (MD) is a rare dermatopathy characterized by nonspecific symptoms and the production of multicolored fibers and granular tissue from diffuse skin ulcerations which are described as being either pruritic or painful. The etiology of MD is currently unknown; previous studies have suggested both psychiatric and infectious causes, with increasing interest over the previous decade in elaborating a possible pathogenesis for the disease secondary to infection by Borrelia species. We report a middle‐aged Caucasian female who developed symptoms of MD in the days following exposure to a tick bite after spending an afternoon hiking through a wooded area. She was subsequently treated with a course of Doxycycline and found on two‐week follow‐up to have complete remission of her symptoms. This case report further supports the theory for an infectious etiology of MD and encourages future studies into its pathophysiology. Eruptive lesion with embedded fiber from patient’s right thigh.
Morgellons disease is a rare disease with unknown etiology. Herein, we report the first case of Morgellons disease in Korea. A 30-year-old woman presented with a 2-month history of pruritic erythematous patches and erosions on the arms, hands, and chin. She insisted that she had fiber-like materials under her skin, which she had observed through a magnifying device. We performed skin biopsy, and observed a fiber extruding from the dermal side of the specimen. Histopathological examination showed only mild lymphocytic infiltration, and failed to reveal evidence of any microorganism. The polymerase chain reaction for Borrelia burgdorferi was negative in her serum.
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.
Morgellons disease is a psycho-dermatologic condition in which patients report fibers or filaments "growing" out of their skin. This case report highlights an oral ulceration in a young woman associated with Morgellons disease, a condition that has not been previously described in the dental literature. An increasing number of individuals are self-reporting this condition and oral health care providers must be familiar with this disorder. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011; 112: e19-e23)
Morgellons disease is a controversial and poorly defined symptom cluster of skin lesions and somatic symptoms, most notably 'fibers' in the skin. Because of widespread coverage in the media and on the Internet, there are an increasing number of patients presenting to dermatologists. We present three patients who believed that they had fibers in their skin. We offer a discussion of delusions of parasitosis to demonstrate similarities between these conditions. It has been suggested by a limited number of healthcare providers that an unknown infectious agent underlies this symptom complex yet no available evidence supports this assertion. Laboratory values that would be reflective of an infectious process (e.g. elevated white blood cells, sedimentation rate, C reactive protein) are routinely normal and biopsies often reflect only nonspecific findings such as acute and chronic inflammation with erosion or ulceration. Patients with Morgellons disease generally lack insight into their disease and reject the need for psychiatric help. The goal is to build trust and refrain from minimizing what the patient experiences. Attentive examination of the patient's skin and fragments they present is necessary to rule out a true underlying pathologic process and to establish a trusting relationship. A supportive, non-confrontational approach is ideal. The patient is best treated by a team of practitioners of several specialties, including dermatologists, psychiatrists, and counselors.
Several cases of QT prolongation and ventricular tachyarrhythmia have been reported with pimozide, a potent neuroleptic useful in the management of motor and phonic tics associated with Tourette syndrome. To further elucidate the mechanism underlying these clinical observations, the effects of pimozide on monophasic action potential duration (MAPD(90)) and on potassium currents involved in the repolarization of native isolated ventricular myocytes were examined.
Studies were undertaken in eight isolated guinea pig hearts that demonstrated reverse rate-dependent prolongation of cardiac repolarization by pimozide 100 nmol/L. Action potential duration increased 24% from baseline 115 +/- 2 to 142 +/- 4 msec with pimozide 100 nmol/L during pacing at 250 msec cycle length, while a 10% increase from 97 +/- 2 to 107 +/- 3 msec was seen with pacing at a cycle length of 150 msec. Experiments in native isolated ventricular myocytes (n = 20) demonstrated concentration-dependent block of the rapid component (I(Kr)) of the delayed rectifier potassium current: tail current was decreased by 50% at 15 nmol/L.
Pimozide possesses cardiac electrophysiological effects similar to those of class III antiarrhythmic drugs. These effects are concentration-dependent and observed at recommended dosages of the drug. Since pimozide is strongly metabolized by CYP3A4, special care should be taken to avoid potential pharmacokinetic interactions leading to high plasma levels of pimozide and proarrhythmia.
Pimozide is an antipsychotic drug of the diphenylbutylpiperidine class. In the US, it is FDA-approved only as a backup treatment for Gilles de la Tourette syndrome, although it has been used in other countries for many years as a treatment for schizophrenia. In the past 20 years, pimozide has been found to be especially efficacious in the treatment of monosymptomatic hypochondriacal psychoses and is used by psychiatrists and dermatologists for this off-label purpose. In particular, pimozide is considered the treatment of choice for delusions of parasitosis. In addition, pimozide has been found to be efficacious in the treatment of body dysmorphic disorder, metastatic melanoma, trichotillomania, and trigeminal and postherpetic neuralgia. This review aims to familiarize physicians, especially dermatologists, on the uses of pimozide in dermatologic practice. A review of the literature was performed and the relevant information synthesized to give a complete overview of the drug and its therapeutic uses in dermatology.
Delusional parasitosis (DP) is the most frequent delusional disorder in dermatology. In DP there is a fixed belief of a usually skin-related invasion or infestation by a number of alleged infectious species (usually parasites and bacteria), whose identity has varied over the decades. Since 2002 worldwide an increasing number of patients have complained of unverifiable fibers and filaments in or on the skin, associated with numerous nonspecific complaints (arthralgias, altered cognitive function and extreme fatigue). This entity has been named "Morgellons disease" by the patients themselves, although medical evidence for its existence is lacking. As an example, we discuss a 55-year-old woman who complained of Morgellons disease and was treated as if she had DP. Currently the delusional assumption of infestation with Morgellons should be considered as a new type of DP with some kind of inanimate material. We therefore recommend in case of DP including Morgellons the use of the broader term "delusional infestation".
Pimozide was tried in the treatment of delusion of parasitosis (a type of monosymptomatic hypochondriacal psychosis), a syndrome that is found with increasing frequency. Ten patients were selected on the basis of unambiguously defined psychopathological criteria. Pimozide therapy was assessed by means of placebo control and the double-blind method using a rating scale evolved for this particular therapy. The results have quite definitely proved the effect of small doses (two to eight mg per day) of pimozide compared to the administration of a placebo. The very few side-effects observed could easily be influenced. The dynamics of the regression of the psychopathological symptoms suggest that the efficacy of pimozide therapy is decisively linked to the central dopamine receptor blocking effect of the drug.
Of the patients who present with cutaneous dysesthesia, those who believe that their discomfort is caused by invasion by some foreign agent are the most difficult to treat. Parasitic infestation may still be the most common delusion, but we now learn of a variety of other foreign elements subsumed under the rubric Morgellons disease and reported in detail on the Morgellons Web site (http://www.morgellons.org). For the patient, the false belief serves as a defense against the need to acknowledge psychological issues, so he or she may not readily accept psychotropic medication.1 Meehan et al2 describe sensitive and thoughtful interactions that enabled each of 3 patients to accept treatment with olanzapine, which resulted in a speedy resolution of their symptoms.
Many patients with skin disorders have psychologic issues associated with their chief complaints. Dermatologists who wish to help their patients with psychodermatologic conditions can greatly enhance their therapeutic armamentarium by becoming familiar with the use of a few selected psychotropic agents. This paper will review the current status and future directions of psychopharmacology for the major types of psychopathologies encountered in a dermatology practice (depression, obsessive-compulsive disorder, anxiety, and delusional disorder) with the intent of guiding dermatologists in the choice of a psychotropic agent for patients with psychologic component to their skin disorder.