History of Morgellons disease: the same name for different psychodermatologic diseases?

Review of literature and clinical practice experience for the therapeutic management of Morgellons disease

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: a narrative review

Morgellons disease is characterized by the persistent delusion of skin infestation, ultimately inflicting wounds and impairing quality of life. There is insufficient and conflicting research pertaining to this condition, imposing challenges on clinicians in understanding, diagnosing, and treating it. In this review, we summarize the available literature on Morgellons disease including its historical evolution, epidemiology, proposed pathophysiology, underlying structural and functional brain pathologies, typical and atypical clinical presentations, diagnosis, and treatment. A comprehensive review of the literature was conducted on PubMed, Embase, and Scopus using specified keywords. Selected articles were screened by two independent reviewers based on set inclusion and exclusion criteria. Conflicts were resolved by a third reviewer as needed. No limit to the date of selected articles was set due to the scarce literature available on the subject. Morgellons disease is an underdiagnosed entity, owing mostly to the lack of an established pathophysiology and treatment guidelines. While many authors classify it as a type of delusional infestation (DI), others correlate MD with an underlying spirochetal infection, namely Lyme disease. Neuroimaging studies have revealed abnormalities in the "fronto-striato-thalamo-parietal network", a finding common to patients with DI, in addition to alterations in structures related to the "Itch Processing Pathway". Patients tend to extract fibers from their skin lesions and place them in a match box hence the term "match box sign". The diagnosis is that of exclusion, requiring extensive work up to rule out secondary causes and differential diagnoses. Treatment is largely based on the use of antipsychotics, with or without cognitive behavioral therapy. Despite being a diagnosis of exclusion, clinicians must be aware of this entity and have a profound understanding of the pathogenesis underlying it. Upon clinical suspicion, secondary Morgellons should always be ruled out through a thorough history taking, physical examination, and laboratory exams. Despite the challenges brought by the heterogeneous presentation of the condition and the paucity of research revolving around it, the great impact that Morgellons disease has on patients' quality of life forms a pressing need for its adequate detection, diagnosis, and treatment.

Classification of psychodermatological disorders: Proposal of a new international classification

INTRODUCTION

Several classifications of psychodermatology disorders have been proposed, with most of them based on two to four main disorder category groups. However, there is, to date, no classification that has resulted from a consensus established by psychodermatology experts. The DSM-5-TR (Diagnostic and statistical manual of mental disorders (5th ed.), Text Revision) and the ICD-11 (International classification of diseases (11th revision)) also do not provide a systematized approach of psychodermatology disorders. Taking into consideration that classifications are a key pillar for a comprehensive approach to the pathologies of each branch of medicine, the proposal of a classification in psychodermatology appeared as a central need for the recognition of psychodermatological disorders, in an attempt to improve their recognition and, in that sense, to find a common language for the development of this subspecialty that crosses dermatology and psychiatry.

METHODS

Previously published classifications in psychodermatology were critically reviewed and discussed by expert opinion from an international multidisciplinary panel of 16 experts in psychodermatology and a new classification system is proposed, considering classical concepts in general dermatology and psychopathology.

RESULTS

Two main categories of disorders are presented (a main group related to primary mental health disorders and another main group related to primary skin disorders), which are subsequently subdivided into subgroups considering pathophysiological and phenomenological similarities, including key aspects of dermatological examination, namely the presence of visible skin lesions (primary and secondary skin lesions) and psychopathological correlates.

CONCLUSION

This new classification aims to unify previous classifications, systematize the disorders that belong to psychodermatology and highlight their tenuous boundaries, to improve their management. It has been built and approved by the Psychodermatology Task Force of the European Academy of Dermatology and Venereology (EADV), the European Society for Dermatology and Psychiatry (ESDaP) and the Association for Psychoneurocutaneous Medicine of North America (APMNA).

Morgellons Disease: The Spread of a Mass Psychogenic Illness via the Internet and Its Implications in Hand Surgery

Somatic manifestations of mental illness sometimes occur in patients presenting to hand specialists. These conversion disorders can also occur in groups, a phenomenon known as "mass psychogenic illness." The increasing penetrance of the Internet and social media in modern society has greatly facilitated the interaction of patients with others with similar disorders. One example relevant to hand surgery is "Morgellons disease," a disorder popularized in 2002 and characterized by a firm belief in foreign material extruding from the skin, leading to nonhealing, self-inflicted ulcerations and excoriations. A series of 4 patients collected through an informal survey of hand surgeons regarding experience with Morgellons disease is reviewed and discussed. All patients in the series presented with a chief complaint of foreign material extruding from the hand. In 1 case, the complaint was made by a young patient's mother. In none of the patients were foreign bodies identified, although 2 patients demonstrated significant ulcerations and scars from self-excoriation. Three patients had a somatic condition affecting the hand or upper extremity, 1 directly related to self-excoriation and 2 unrelated. Treatments, workups, and ultimate outcomes varied among patients. Patients presenting with Morgellons disease often undergo multiple unnecessary tests and are at risk of inappropriate procedures. It is therefore important that providers have a compassionate understanding of the involved psychology. Herein, we offer an approach to the recognition of and treatment strategies for these patients.

Historical and clinical considerations on Ekbom's syndrome

Ekbom's syndrome represents a relatively uncommon neuropsychiatric condition characterized by the recurrent and bizarre fixed delusional belief to be infested by small organisms or even unanimated materials ('Morgellons disease'), without any objective evidence of infestation/parasitosis. The condition, mainly diagnosed in a nonpsychiatric setting, is supposed to be largely underestimated and, hence, undermanaged. The present comprehensive review aims at investigating Ekbom's syndrome, from a historical, epidemiological, clinical and therapeutic perspective, by providing diagnostic-treatment strategies in managing this condition in routine psychiatric clinical settings. The prototypical patient is a middle-aged woman (or a younger subject in those cases in which substance and/or alcohol abuse is implicated), often single, divorced or widowed (loneliness component and social withdrawal), who has already consulted several specialists due to skin lesions associated with a firm and delusional belief to be infested. The identification and diagnosis are challenging due to poor patient's insight, poor knowledge and collaboration between specialists and differential diagnoses to be considered before asking for a psychiatric referral. Management and treatment strategies mainly derive from isolated case reports or observational studies with a small sample size. Further randomized clinical trials should be performed to evaluate the efficacy of newer antipsychotic drugs, including long-acting injectable formulations.

History of Morgellons disease: from delusion to definition

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.