DERMATOETHICS CONSULTATION

Delusions of parasitosis: Ethical and clinicalconsiderations

Stephanie Fabbro, MD,a Julie M. Aultman, PhD,b and Eliot N. Mostow, MD, MPHc,d

Columbus, Rootstown, and Cleveland, Ohio

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CASE SCENARIO

A 55-year-old female patient with delusions of parasitosis presents to the dermatology office forfollow-up. Despite numerous biopsies and blood work, there is no evidence of parasitic infestation orother primary disease. Her symptoms have waxed and waned, but she is now experiencing a severeflare. Desperate, she asks about using ‘‘industrial-strength insecticides’’ hoping to be cured. Onexamination, multiple superficial erosions suggest excoriation as the primary process, with someoverlying crusts, erythema, and tenderness suggestive of secondary infection. Although you haverecommended psychiatric consultation, the patient has refused, asking, ‘‘Why would I go to apsychiatrist for a skin infection when you can do another biopsy or give me a medication?’’

What is the most ethical and clinically appropriate action?A. Do another biopsy to prove to the patient there is no underlying primary skin disease.B. Prescribe permethrin 5% cream and mupirocin ointment, explaining that the medication will help

‘‘get rid of any bugs and infection.’’C. Arrange a multidisciplinary consult with psychiatry to optimize management, guiding the patient

to understand her psychocutaneous correlation.D. Prescribe pimozide or an atypical antipsychotic such as aripiprazole. Explain to the patient that

antipsychotic therapy may help with physical and emotional discomfort. Follow up with a referralto a psychotherapist, or someone with a special interest in psychosomatic experiences, toimprove the patient’s overall health.

DISCUSSIONThis case demonstrates the dermatologist’s di-

lemma when treating patients with primary

the Division of Dermatology, Department of Internal Med-

ine, Ohio State University Wexner Medical Center, Columbusa;

amily and Community Medicine, College of Medicine, College

f Graduate Studies,b and Dermatology Section, Department of

ternal Medicine,c Northeast Ohio Medical University, Roots-

wn; and Department of Dermatology, Case Western Reserve

niversity School of Medicine, Cleveland.d

ing sources: None.

licts of interest: None declared.

ints not available from the authors.

psychiatric disease. We attempt to delineate thebest clinical and ethical action, using principle- andnarrative-based approaches in ethical reasoning.

ANALYSIS OF CASE SCENARIODermatologists may face clinical and ethical

quandaries when treating patients with primarypsychiatric diseases or psychiatric comorbiditiesas a result of a number of factors, including: lack

of training in psychocutaneous manifestations,discomfort in performing a psychiatric examina-tion, or inexperience prescribing drug classes(eg, antipsychotics or antidepressants), regard-less of published evidence in dermatologic

Correspondence to: Eliot N. Mostow, MD, MPH, Dermatology

Section, Department of Internal Medicine, Northeast Ohio

Medical University, 566 White Pond Dr, Akron, OH 44320.

E-mail: emostow@neomed.edu.

J Am Acad Dermatol 2013;69:156-9.

0190-9622/$36.00

� 2013 by the American Academy of Dermatology, Inc.

http://dx.doi.org/10.1016/j.jaad.2013.02.012

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disease. Likewise, it can be difficult for psychia-trists to treat patients who experience dermato-logic manifestations with psychiatric diseaseflares.1 Unlike patients with somatization, pa-tients with delusions of parasitosis have nocapacity for insight into the pathology of theircondition, and may not acquiesce to psychother-apy. Despite the challenges of treating delusionalpatients, dermatologists have an ethical respon-sibility to seek methods of effective manage-ment, along with an empathic recognition ofpatient value. We present ethical options that canalleviate these challenges and support the ther-apeutic relationship.

In maintaining an ethical standard of benefi-cence, clinicians are mandated to weigh medicalbenefits against potential harms. The ethicalchallenge is for clinicians and patients to have amutual understanding of treatment practices,especially if additional diagnostic measures aredone for facilitating patient understanding ratherthan confirming a diagnosis or ruling out organicdisease. If organic disease has been excluded,the possible harms of performing unnecessarybiopsies, including physical discomfort, in-creased patient frustration, distraction from theprimary problem, and costs may outweigh thebenefits of promoting patient contentment(Option A). Option A can be valuable clinicallyfor: first patient encounters; ruling out a validinfestation, systemic disease, or previous false-negative findings in histopathology; and address-ing specific clinical concerns. Unfortunately, ifthe primary diagnosis is nonorganic, Option A isnot ideal, given the patient’s false fixed belief.

Maintaining a fiduciary relationship mandatesphysicians to fulfill moral responsibilities, such asnot reinforcing the delusion by prescribingan antiparasitic (Option B) or encouragingmore biopsies (Option A). Providing an ambig-uous diagnosis may paradoxically perpetuatepatient fears, and affect their participation inthe therapeutic relationship. Although with goodintentions, lack of full disclosure violates thepatient autonomy. In this case, however, effortsto promote the patient’s well-being outweighdisclosure for the sake of autonomy. Disclosing adiagnosis that may be ignored or ignite hostilereactions can negatively impact or end the ther-apeutic relationship, and limit the opportunity tohelp the patient. Furthermore, delusional influ-ence can intrinsically impair autonomy, prevent-ing patient involvement in the treatment. Thus,

beneficent efforts to treat the delusions first,while not immediately disclosing the diagnosis,can act to strengthen rather than diminishautonomy.

Benefits of Option B include providing mu-pirocin to treat and alleviate discomfort for thesecondary infection.When the antiparasitic treat-ment fails and the bacterial infection resolves,patients may realize the problem is not parasitic,and may be more willing to explore alternativetreatments. Unfortunately, the delusional pa-tient’s lack of insight often prevents this fromoccurring. Although Option B can be a valuableinitial step in caring for patients who may beresistant to psychiatric treatment, placating pa-tients with continued organic medical treatmentwithout treating the underlying problem op-poses beneficence and nonmaleficence.

Certain patients with delusions may agree to apsychiatric consult if arranged as a multidisci-plinary meeting with the dermatologist, who isoften the primary physician (Option C). This isalso advantageous for dermatologists who maybe more comfortable prescribing antipsychoticsand providing psychotherapy referrals in a team-based approach, allowing improved individual-ized treatment plans. Unfortunately, the logisticsrequired to properly manage such a complexclinical situation can be difficult to achieve.However, allowing for both practitioners to bepresent may be the safest way to choose atherapeutic plan, contributing to a collaborativeunderstanding of diseases common to bothdisciplines.

When dermatologists are comfortable pre-scribing antipsychotics, Option D is an ethicallypreferable choice, whichmaintains direct lines oftherapy. When initiating the medication, clini-cians should inform patients of the nature of thedrug and its treatment indications, and respecttheir decisions, including refusal of pharmaco-logic therapy. It is not uncommon for dermatol-ogists to prescribe antipsychotics without fulldisclosure of the diagnosis, prognosis, and treat-ment options, including medication risks andbenefits. Nonetheless, it is important to discussthe risks and benefits openly with all patients,even if full disclosure of the diagnosis is withhelduntil more clinically appropriate. Simply explain-ing that pimozide decreases the cutaneous sen-sory threshold may damage the fiduciaryrelationship as patients learn independentlyabout the drug and its mechanism of action.

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Another method of initiating therapy is toexplain the limitations of clinical knowledge.Patients may be comforted to hear that althoughthere is no evidence of parasitic infestation ontheir skin, there is no scientific method to entirelyrule out their presence. Similarly, although theprimary indication for pimozide is for a psychi-atric disorder (namely, Tourette syndrome), wecannot be entirely sure of the mechanismthrough which it is efficacious for those withdelusions of parasitosis. This allows patients tounderstand there is a potentially efficacioustreatment for their condition, and that the path-ophysiology is not fully understood. This can beuseful when patients are adamant about havingno involvement of psychiatric professionals intheir care.2 Concurrently, patients should becounseled that pimozide, although frequentlyeffective, is not always a panacea.3 Finally, der-matologists should be responsible for stayinginformed on newer treatment options, safetyprofiles, and interactions of such drugs.

Although pimozide is often the standard ofcare for delusions of parasitosis in dermatol-ogy, recent literature may also promote theuse of atypical antipsychotics including aripi-prazole and risperidone, especially in refrac-tory cases. Atypical antipsychotics mayoccasionally be more efficacious than pimo-zide, which has several potential adverse ef-fects including akathisia, dystonia, and QTprolongation.4-6 There are risks with all anti-psychotics, however, including more recenttreatment options such as olanzapine, themost frequently encountered being metabolicsyndrome, but rarely neuroleptic malignantsyndrome and sudden death.7 Many clinicianshave found pimozide easier to manage thanthe newer antipsychotics, likely because ofboth a lower dose needed to achieve efficacyand a stronger proven record in dermatologyliterature.6 Regardless of physician preference,the coexisting medical history of the patientshould be considered when initiating psycho-tropic medications.

Although principle-based ethics reveals theimportance of full disclosure and promotion ofbeneficence, nonmaleficence, and even auton-omy, recent trends in ethical patient care may callfor a contemporary narrative approach. Thistechnique calls for decision-making that is relianton communicative and relational dimensions,rather than the abstract ideals of principle-based

ethics.8-10 The narrative approach requires phy-sicians to recognize patients as complex socialbeings whose past values, beliefs, and feelingsmay contribute to current beliefs surroundinghealth and disease (ie, delusions of parasitosis).

Besides the information gathered in a stan-dard medical interview, contextual narrative in-formation can be essential for distinguishingparasitosis from altered sensations caused byunderlying undiagnosed conditions (eg, lym-phoma), or from side effects of medications orinterventions (eg, renal dialysis) as the physicianprompts the patient to tell her story beyondgeneral clinical descriptors of the symptoms. Thestory can further reveal, for example, who thispatient is, her social support structure, the emo-tional effects this sensation has caused, and otherissues that have impacted her sense of well-being.

The narrative approach can further aid physi-cians in better understanding patient perspec-tives, including how they feel about tryingalternative medications to alleviate the discom-fort, or whether they are willing to talk to anotherprofessional who understands their discomfortand how it has negatively impacted their lives.Patients may tell stories of embarrassment, hope-lessness, or anxiety. By listening to these stories,and acknowledging patient suffering, a trustingrelationship ensues, along with a recognition ofresources needed and available (eg, consulta-tions, medications). If one follows principle-based ethics without considering the underlyingfeelings, values, or goals of patients, noncompli-ance and worsening disease may ensue. A nar-rative approach allows patients to reveal theirperceptions regarding treatment from a holisticperspective, and gives new meaning to thestandard ethical principles.8

Upon establishing a relationship through thenarrative approach, this patient may valueOptions C and D with little resistance to multi-specialty care. Alternately, the patient may preferto engage in a more paternalistic relationshipin which she receives anything to alleviate hersymptoms, including an antipsychotic. Althoughthe patient may not be interested in disclosureof specific indications, carefully describing therisks and benefits of the treatment remain essen-tial within the therapeutic relationship.11 Formore resistant patients, the narrative approachpermits physicians to explore these feelings ofhostility and determine whether a therapeutic

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relationship can even be established. Options Aand B do more harm to the hostile patient incomparison to not establishing any relationship,and may result in patients resigning themselvesto disease as a result of conflicting goals of care.Ultimately it is important to assess each patientand his/her individual narrative when decidingon a plan.

Although traditional dermatology does nottypically emphasize management of psychiat-ric overlap, because of the significant number

of patients with psychiatric comorbidities, der-matologists should be familiar with basic as-sessment of psychiatric disease. With patientswho present with delusions of parasitosis, itmay be prudent to implement a narrativeethics approach in tandem with principle-based ethics when establishing the therapeuticrelationship, to eliminate options such as Aand B, and to determine whether Options Cor D are clinically feasible and ethicallyappropriate.

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