Wednesday, March 14, 2007
The truth is out there
Tonight I had a patient who told us all he had Morgellons disease, a completely factitious disorder in which the patient has sores on his body from which he believes "fibers" can be extracted. These can vary in type, depending on the patient, with some believing they are organic fibre (cotton, etc) others believing they are actual worms. Apparently, some patients pull tiny bits of their own bodies out (muscle, nerve, connective tissue, etc.) in the desperate attempt to remove these foreign bodies. Some of the literature refers to a "positive matchbox sign," meaning the patient brings in a matchbox full of fibers he believes he has extracted from his body. Our patient believed he had worms in his body, and was very upset that we didn't believe him.
The difficulty with this disease is that these patients are undoubtably sick. Healthy, sane people, do not tear their own bodies to pieces seeking imaginary worms. There actually is a DSM-IV diagnosis which covers most these patients: under the delusional disorders is delusional parasitosis. Like any delusion, this is a powerfully fixed false belief, and patients refusing to believe they have a psychiatric diagnosis is probably the reason for another term for the condition. At least one article* (of the six total I could find in the medical literature) accepted the name Morgellons disease as a "a rapport-enhancing term for delusions of parasitosis." This article, in the finest rational skeptical language, mentions the fact that "Morgellons disease is not located in modern medical texts or online journals. But a Goggle search will produce approximately 15,400 hits." The author describes a patient he had claiming to have the disease, and mentions that he used the term with her to great effect. He also mentions the hub of the hype, a website which looks very scientific, but which is rather light on evidentiary support. His cautionary closing remarks: "we stress the importance of clarifying to all delusions of parasitosis patients that their condition is not a result of an infectious agent. However, we found the term to be of paramount importance in establishing patient confidence and in developing patient–physician rapport throughout this patient's care."
These patients need psychiatric care, and long term anti-psychotic therapy, but in our patient, we couldn't get him to understand this need. Since we lack inpatient psychiatric capability here, we transferred him to a larger, long term care facility.
So why the alien picture? There are some crazy, crazy theories out there regarding Morgellons disease, revolving around secret government labs and strange escaped biological experiments. And I can see an episode of the X-Files (back in the first few seasons, when it was good) with Scully insisting these patients are psychotic, while Mulder, playing fast and loose with the rules of evidence, agency conduct, etc, sneaks into some Area 51 clone in rural Tennesse, and is captured by a pair of unsmiling guards just short of opening a drawer marked "Top Secret: Morgellons." The truth is out there. Until we find it though, use risperidone.
*J Am Acad Dermatol. 2006 Nov;55(5):913-4.