Treating patients with delusional infestation with Dr. John Koo and Dr. Scott Norton

John Koo, MD, and Scott A. Norton, MD, MPH, join host Lorenzo Norris, MD, for this special edition of the Psychcast. This is a crossover episode with our sister podcast, Dermatology Weekly. Dr. Koo is a psychiatrist and a dermatologist at the University of California, San Francisco. He has no disclosures. Dr. Norton is a dermatologist with the Uniformed Services University of the Health Sciences in Bethesda, Md., and with George Washington University, Washington. He has no disclosures. They are featured in an
article on this topic online at MDedge.com/Psychiatry. Dr. Norris is associate dean of student affairs and administration at George Washington University. He has no disclosures.
Summary
Delusions of infestation are a monosymptomatic hypochondriacal psychosis in which the only delusion present is one of infestation, and patients do not have other symptoms of psychotic spectrum illness. Secondary delusions of infestation may occur in individuals who use drugs, such as methamphetamine or cocaine, or who have a primary psychotic disorder, such as schizophrenia. Delusions of infestation is related to Morgellons disease, which is defined as a skin condition characterized by the presence of “threads” or filaments that patients believe are embedded in their skin and might be accompanied by stinging and itching sensations. Patients with delusions of infestation usually present to a primary care physician or ED with symptoms of abnormal sensations of their skin, including crawling sensations. In addition, patients usually bring personal proof of their condition, such as a small bag of “specimens,” including pieces of lint, threads, or scabs. Some patients also bring in journals detailing the timing and associated factors of their symptoms. Dr. Norton advises that physicians treating the patients with delusions of infestation should mentally prepare themselves against initial bias and set aside time for longer visits or several follow-up visits. Dr. Norton starts with the premise that the patient has an actual infestation or other underlying cause of their pruritus and performs a thorough, full-body exam for dermatologic conditions, and examines the materials patients bring with them using a double-headed microscope - so that he and the patient can look at the specimens together. Dr. Koo often tells patients that they have Morgellons disease because it does not include the stigmatizing term of “delusional.” He reframes Morgellons as an infestation that cannot be cured by internal or external antiparasitic medications. He then pivots away from etiology to validation of their emotions and eventually to treatment. Dr. Koo usually often starts treatment with pimozide because it is an antipsychotic with FDA approval for Tourette syndrome - not schizophrenia. This perceived absence of a connection of the medication to psychiatric illness allows patients to be more open to taking the medication. For primary delusional infestation, Dr. Koo starts with pimozide. The dose, which is daily and taken orally, starts low at 0.5 mg and goes up by 0.5 mg every 2-4 weeks. The aim is to get up to 3 mg per day. Low doses of pimozide and other antipsychotics lead to decreased sensation of itching and formication. Dr. Koo refers to his treatment plan as a “trapezoid-like dosage strategy.” Once he gets the patient to 3 mg, he continues the medication until all the symptoms disappear and then continues the medication for an additional 3 months. Dr. Koo then slowly tapers the dosage over an additional few months. The keys to successful treatment include communicating with patients and working collaboratively with them. This approach builds trust and rapport.
References Brown GE et al.
J Clin Exp Dermatol Res. 2014;5:6. doi: 10.4172/2155-9554.1000241. Kohorst JJ et al.
JAMA Dermatol. 2018 May 1;154(5):615-7. Lepping P et al. J Am Acad Dermatol. 2017 Oct;77(4):778-9. Middelveen MJ et al. Clin Cosmet Investig Dermatol. 2018;11:71-90. Lepping P et al. Acta Derm Venereol. 2020 Sep 16.
doi: 10.2340/00015555-3625. Freudenmann RW et al.
Br J Dermatol. 2012 Aug;167(2):247-51. Wolf RC et al. Neuropsychobiology. 2020;79:335-44. *
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* Show notes by Jacqueline Posada, MD, associate producer of the Psychcast; assistant clinical professor in the department of psychiatry and behavioral sciences at George Washington University, Washington; and staff physician at George Washington Medical Faculty Associates, also in Washington. Dr. Posada has no conflicts of interest. For more MDedge Podcasts, go to mdedge.com/podcasts Email the show: [e-mail]

[@paulkrois2042]

As a parent of a son with issues around parasites, these doctors showed great compassion and knowledge of this problem. My son has been collecting samples and would definitely be glad for someone to hear him and listen to his plight. He also is strong in his conviction but with proper skills I would be hopeful they could help him. I only wish they were local doctors.

[@carolinemacrae6227]

Where does he get the samples from and what do they look like?

[@vuelee5313]

I'm willing to listen.

[@carolinemacrae6227]

Paul Crois you must be in uk like me. Only none of them listen to me or look at the samples. If they look they don't acknowledge the proof as evidence.

[@lucywang-angelrays613]

I had morgellons 2 years. not delusional. Fibers in different length different shape and differnt color constantly come out of my skin. Sometimes can feel fibers twisting under skin. I had blood gene test which cover 17500 pathogen no special finding. I remembered every details since my infection.

[@armandob.castenelli3525]

I'm so happy I'm listening to this. I was recently diagnosed with Delusional Parasitosis.😭 I am miserable going through this. I was exposed to fiberglass in my apartment back in February 2022. Almost a year going through this and although my apartment have been cleaned and have had friends come visit and stay over, they do not feel what I feel. I am currently under medication for a month, but don't see a difference. I still itch and still feel dust and rug fabrics hitting my skin and hair..😭😭😭😭😭😭

[@lunabe11e]

I read the CDCs study start to finish. I doesn’t seem as though they had a problem with participation. It’s a shame. I understand the medical approach makes it difficult to communicate with a patient who expects immediate answers. The testing of these fibers would interest me. Why aren’t we hearing from more specialist who have looked into testing?

[@Miss.information69]

I’m about to sue dr koo for malpractice this is misinformation

[@Moonbirdskies]

I have a sister dying of this. It’s killing her and the doctors keep putting her on lithium for schizophrenia. So thank you for this video but I’m not understanding the dosage. Are you giving Abilify and rispidal along with pimozide?

[@ManagingMorgellons]

The doctors literally tell us to keep a journal when we come in to be seen, and then when we present that journal you tell us everything is on our head.

[@lydiahubbell6278]

Not always! Better to have it

[@carolinemacrae6227]

Yes they always contradict themselves. Turrets is caused by streptococcus virus so is streptococcus virus also a dellusional fake condition? The viruses can cause dellusions but dellusions don't cause viruses. The virus is the problem. This man is treating a virus (that is proving to exist over twenty times by legitimate scientists who left cdc out of disgust) as a delusions. People have low concentration span on subjects that aren't bothering them at all. 5hey hear thus dr say turrets is delusional when it's not it's streptococcus virus and causes delusional behaviour because strep virus spirochetes attacks immune system. So he gives morgellons spirochetes same treatment which is why it doesn't work much because its a different spirochete. People don't get cured 5hey comit suicide after giving up admitting a problem,em and seeking help for it. Why is dr plonker saying its unheard of that anyone that are not women are getting MD. Are we really expected to believe that Lance with his manly physique is really a woman.

[@justdave4972]

I got video for your delusional B.S. anytime!

[@carolinemacrae6227]

@@justdave4972 you are talking BS because you don't make any sense. You make more sense if you are talking to yourself. Cdc pay loosers to insult people with diseases.

[@justdave4972]

All I'm saying is Morrgellons is very real as well as the internal movement and I got video to prove it and I'm not talking about a few hairs or whatever.. Calling someone delusional because a "Dr " of all people can't see it for themselves on command. Is just ignorant with a splash of just stupid considering their supposedly educated to try and detect,find out and believe in a patient enough to try and help find and hopefully help find a cure. And of I bet over 50% of a common patients complaints when they walk in the door. Can't be seen most can't even with first few test . So to see a actual spot/ wound. That got their some how and. To even have in front of your mind if you hear certain words or references. As a professional is just kinda pathetic. That's like a cop that thinks everyone's lying when they open their mouth. And some cops do still believe that. Their the ones that shoot people with out thought just vision.. And in neither job are you taught to expect everyone's lying first. Although I go to a university county hospital so you get a student first. Then the ego compensating Main Dr comes in for 2 minutes to basically critique and try to prove wrong anything that student dared to believe or God forbid diagnos after actually spending real time with the patients. And Honestly ya know self diagnosis IS treated like your stupid. And I believe that is generally taught. So either way they're talking out of their ass and against common sense. Atleast with Morrgellons Oh and to the Trump loving nut that says the CDC pays people to call people crazy or whatever you I'm sure suffer from a delusional problem and I'm sorry for that. But I speak of what I know and can prove. Not what other people pulled out of their butts and I bought into so I could justify my inability to think for myself. So it's just easier to regurgitate thoughts that aline with yours. No brains required

[@matthewclapp2028]

I have morgellons how is this not really real?

[@carolinemacrae6227]

Matthew Clapp Are you in britneys group like myself?

[@matthewclapp2028]

No what's that

[@lunabe11e]

I think these physicians are not discussing Morgellons. That wouldn’t b an area for them to weigh in on unless they were involved in research. My dad often plays diplomat to a non-science oriented audience. doctors aren’t as good as they think at speaking to patients abt facts😂. I grew up listening to all sorts of specialists, my dads colleagues and their passion is real. They good ones are dedicated to protecting each patient to the best of their knowledge. My mom dealt in mental health and that was another set of expertise all together. I get both sides❤❤

[@lunabe11e]

I just watched that Morgellons documentary and i think the research is flimsy and dated. These guys are good docs they just aren’t in a practice that treats unknown conditions. Experimental end of medicine is time consuming and costs. Many docs want to help as many of their patients as possible. Thats why time is important to them.

[@pippy2157]

Excellent interview & information. Helps me get to the root cause of delusions. Low estrogen causes HIGH dopamine.

[@carolinemacrae6227]

pippy It is misinformation, as 6ou well know because you are a part of it. You are the dellusion that is like the disease, put upon us. I only hope the world wakes up to yours and just daves lies before the world is completely contaminated with it.

[@carolinemacrae6227]

just dave qnd puppy are like so many liars the sites they're on says that they don't have any content.

[@terrencejohnson6607]

On Bible