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.

5 comments:

Thainamu said...

In some cases, there really are worms inside:

http://www.medgadget.com/archives/img/guinea-worm.jpg

Yuck!

medstudentitis said...

Being a person who believes in a choice number of conspiracy theories (e.g. who killed the electric car aka big evil GM) I understand where these people are coming from... the truth IS out there!

BoyintheMachine said...

(sigh) The new generation of physicians are supposed to bring a fresh viewpoint and outlook to the field. Alas, seems like the 'new' kids are nothing more than carbon-copy clones of the former regime.

Got a joke for you:

"A female MD makes an appointment at a clinic in a distant city for treatment of skin lessions that never heal, as well as strange fibers/threads which appear to be growing out of said lessions or else shed by them. Both her and her husband, also an MD, make the trip only to discover the Doctor has already filled out a prescription for a psychotropic drug, prior to their arrival, due to a golfing commitment. [No Pun, Honest Truth.] When she complains to the Doctor, his responce is; 'You are focussed on 'bugs', a classic symptom.' In her defence the female sufferer responded, 'I never once said bugs, I told the woman on the phone I had lession which did not heal combined with strange foreign contaminants.' Her husband interupted and told of the several times he has witnessed a strange foreign substance underneath her skin and or protruding from the wounds.

The Punchline:

The Doctor refused to look at the paitent's wounds, which could have been infected for all he knew, and offered to write a prescription for BOTH SUFFERER AND HUSBAND."

Here's another joke:

Similiar stories happen each and every day with regard to 'Morgellons' or any other disease not currently 'recognized' by modern medicine. If we [medical professionals] don't already know about it then it musn't be real!

[Tell me why is it that I knew more about the side-effects of Tetracycline than the man prescribing it to me for my acne? He told me he would do some research and get back with me. He never did. I guess I, then 13 years old, bruised his ego.]

Is DP real? Yep.
Is Morgellons real? Yep.

Why can't Doctors realize that Morgellons is diseas which is dangling the proof of it's reality right in front of their faces? The only answer as to why Doctors are refusing to examine the evidence is one based on fear.

The FIRST in anything always takes a lot of risks. The First Doctors to come forward with the professional opinion and support for the disease will be the ones to take on the most criticism and/ or consequences for going against 'the norm'. Meanwile, the vast number of cowardly Doctors will quietly wait until Morgellons is widely-recognized and then with a 'mock-sincerity' each shall decree, 'I suspected Morgellons was real all along.'

Nathan said...

boyinthemachine - I'll admit, part of the reason I wrote my post the way I did was to provoke commentary like yours. That said, I am disappointed with your style, for in telling a story of dubious veracity under the heading of a joke, you invite my condemnation of it as less than humorous, therefore allowing your retort that my post falls into the same category. I hope you don't play chess with such obvious maneuvering.

Assuming the truth of your story, all it does is condemn the over-quick actions of the physician involved. As far as tetracycline and your pediatric reminisces go, it is the same story.

All physicians are human, and all have failings. Citing one egregious example and one which pre-pubescent pique has rarified does nothing but demonstrate that fact.

That said, "Morgellons" sufferers would recieve more sympathy if there was any consistency to their complaints and if there were any demonstrable cause for them other than a psychiatric one. But one has not been demonstrated to date, and all the evidence points to these fibers being the result of overzealous psychiatric patients collecting lint. I remain, with the rest of the medical world, ready to be convinced by compelling evidence to the contrary, but the first duty of the scientist is to be skeptical, and while the physician adds compassion to this, he must treat disease rationally, even as he treats the patient empathetically.

Anonymous said...

I'm still pissed that the CDC descended to the level of calling it a disease. That makes it somehow more legitimate to the patients.

My father is a dermatologist and I grew up hearing about people with velvet boxes in which they keep their "bugs" - even seeing patients now (I shadow a doc), we call these patients "DOPers". And DOPers they shall always be, at least to me. Putting a name on it doesn't change the fact that it's a delusion.