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Twolettersthatdescribepatientswith‘‘Mor- apparentlyidenticalsymptomcomplex,Morgellons gellons disease,’’ appearing in this month’s issue of the Journal, serve to remind us that Browne’s description, in the literature references the spectrum of those with cutaneous dysesthesia is over the past 75 yearsand in the complaints of broad indeed. Though we cannot yet delineate the our patients today, is the extraordinary similarities pathway exactly, some of the mechanisms by which that they all describe—in the quality of the sensory the itch sensation is generated and transmitted are now changes experienced, in the level of the patient’s understoodand we feel that we have some sort of a distress, in the various and ingenious interpretations grip on winter itch, itching in the elderly, the infant of what may be happening in the skin, and in the with atopic dermatitis,or urticaria, lichen planus, ongoing and desperate search for relief. The patients and others of the recognized pruritic dermatoses.
are virtual carbon copies, one of the other.
Less well understood are other sensations that The clinical picture is unmistakable. The patient is patients may describe to us, such as crawling, biting, intensely anxious, is obsessively focused on his or stinging, pricking, burning, shooting, and so forth.
her symptoms, brings ‘‘specimens’’ of the offending These sensations may be focal or generalized, and agent, or agents, and is unshakable in his or her belief while some patients may present to us with no visible as to the cause. Usually there will be a logical change in the skin—those with brachioradial pruri- explanation of exactly how the infection or infestation tus,for example—others, reporting that the discom- was contracted, and the patient will have resorted to fort is relieved only by picking, squeezing, or pulling the most extreme measures both to eradicate it and hair, present with neurotic excoriations, prurigo to prevent contagionFurniture is discarded, clothing burned, and close physical contact denied.
A separate group of patients are those unfortunate Tragically, grandmothers will not touch their grand- few who have an inherent need to ‘‘know’’ and to children—for although the condition may occur at understand what is going on with their skin. These any age, and in both sexes, elderly women living patients, made very anxious by the vacuum in their alone are the most common demographic.
knowledge, and perhaps also by their inability to It is important for us to realize that, just as the attain relief from professionals will, with great inge- patient describes, the sensation that is experienced is nuity, ‘‘create’’ a ‘‘cause’’ for their symptoms, which in the skin. It is understandable, therefore, that the makes logical sense to them, and with which they patient is not open to the idea of pathology in the can be comfortable. Because of the nature of the mind, the nervous system, or the brain. It is also sensation, many of these patients believe themselves important for us to distinguish delusional beliefs from to have an infection or infestation, and we are of phobic concerns or obsessional worries, a distinction course all familiar with the syndrome of delusions of that caused some confusion in the pastand that is parasitosis, or Ekbom’s disease,as is described important, because both the psychopathology and the treatment are different between the three.
This conditionhas recently reverted to the name The syndrome may be seen in association with a given by Sir Thomas Browne in 1674, to an number of psychiatric conditions, including bipolardisorder, paranoia, schizophrenia, depression, andabuse of drugs, such as cocaine, amphetamines, or From the Department of Dermatology, University of Pennsylvania.
Funding sources: None.
ritalin. In the past, a delusion of parasitosis was often Conflicts of interest: None identified.
considered to be a monosympomatic hypochodria- Correspondence to: Caroline S. Koblenzer, MD, 1812 Delancey Pl, cal psybut it has been my experience that this is a rather restricted view, and that psychiatric co- morbidity, such as depression, anxiety, or personality 0190-9622/$32.00ª 2006 by the American Academy of Dermatology, Inc.
disorder, can usually be uncovered during a careful interview, when more florid psychopathology is not evident. The syndrome has also been reported in Murase et al, with the patient’s pain and discomfort, association with a number of medical conditions that their anger and frustration with dismissive doctors, are characterized by itching, such as renal disease, and the devastating changes wrought by the condition in the patient’s life, and so develop a therapeutic rela- Today, the informed dermatologist may be any- tionship. With regard to causation, Morgellons disease where from doctor number five to number ten or may be an acceptable appellation, but it may also be more in this patient’s search for relief, and the patient that the touted ‘‘mysteries’’ of this disease only prove will, in the interim, have raised both heaven and hell stimulus for further research by the patient. So, perhaps in a frantic attempt to solve the problem that has without going too far into the difference between a literally taken over his or her life. Today, the internet disease with a definite cause and a syndrome that may further complicates an already difficult situation, as have different ones, it may be reasonable for us to refer we see in the two letters in this Journal, as our to the symptom complex in question as ‘‘Morgellans patients share every facet of their condition, every theory as to cause, and every attempt at relief, My own approach has been to explain to the however far-fetched, with their fellow sufferers.
patient that from my examination, biopsy, and tests, I This sharing, and a tremendous amount of suffer- have been unable to find evidence to support any of ing, have given rise to the formation of ‘‘The the possible causes put forth by either the patient or Morgellons Research Foundation,’’ an organization the Web site, though I in no way doubt the patient’s devoted to ‘‘researching an emerging infectious dis- experience. I explain that though we cannot explain ease,’’with a medical board that boasts five MDs exactly what is going on, we believe that, in part, and an RN. Interestingly, none are dermatologists. An certain neuropeptides are involved. This then opens internet search for ‘‘bugs in the skin’’ will bring one to the way either to refer the patient to a psychiatrist the Foundation’s Web and as Murase et al with whom one can work—as someone familiar with point out, the information therein may be very these specialized pathways—or to prescribe appro- misleading to someone who suffers from delusions priate medication oneself. It is very important also, of parasitosis. One reads of cellulose fibers, fibers I believe, to pay attention to the skin in a positive with ‘‘autofluorescence,’’ fuzz balls, specks, granules, way, with baths, emollients, and the like. Of the strongyloides stercoralis, cryptococcus neoformans, psychotropics, I still find that pimozide, in a dose ‘‘alternative cellular energy pigments,’’ and various of anywhere from 0.5 mg to 2 mg once daily, works types of bacteria for which potent antibiotics are more quickly and more reliably than others of the prescribed, in the ever broadening spectrum of atypical antipsychotics, perhaps because of its known possible ‘‘pathogens.’’ In no case does one read of action on opioid pathways,although risperidone positive confirmatory tests, though many tests are and aripiprazole are also reportedly effectivIt is undertaken. As Murase et alnote, one also reads of very important to tell the patient at the outset that numerous associated medical and psychiatric disor- medication may be needed for months to years, and ders that are attributed to, rather than co-existent to stress the need not to discontinue, unilaterally—so with, or causative of the distressing symptoms.
often once control has been lost, it is hard to regain Frustration is extreme and suicidality is not unknown.
it. Coexisting psychomorbidities such as anxiety and Clearly, as more and more of our patients discover this site, there will be an ever greater waste of Although it is clear that one must always keep an valuable time and resources on fruitless research open mind, it would seem to me to be appropriate into fibers, fluffs, irrelevant bacteria, and innocuous for the treating physician to wait until the tried and worms and insecIt behooves us, therefore, as true drugs, such as those mentioned above, pre- dermatologists, not only to be aware of this phe- scribed in an adequate dose, and for an adequate nomenon, but also each to develop an effective way period of time, have failed in a particular case, before to work with these patients, and so enable the one becomes too involved in ascribing a pathogenic patients to be able to accept one of the medications function to cellulose fibers and the like, as is cur- that we know to be effective. This is a challenge indeed—so often the patient, feeling ‘‘brushed off’’or not understood, simply does not follow through either with medication or with psychiatric referral.
1. Greaves MW, Khalifa N. Itch: more than skin deep. Int Arch If one is to succeed in helping these patients, it is 2. Ward JR, Bernhard JD. Willan’s itch and other causes of important that one acknowledge to the patient that pruritus in the elderly. Int J Dermatol 2005;44:267-73.
what the patient describes is exactly what that patient 3. Schmeltz M, Handwerker HO. Neurophysiologic basis of itch.
is experiencing. One can then empathize, as did In: Yosipovitch G, Greaves MW, Fleischer AB, McGlone F, editors. Itch: basic mechanisms and therapy. New York: Marcel 12. Ekbom KA. Der presenile dermatozoenwahn. Acta Psychiatri 4. Stander S, Steinhoff M, Luger TA. Pathophysiology of pruritus.
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Marcel Dekker, Inc; 2002. pp. 183-216.
14. Munro A. Delusional parasitosis: a form of monosymptomatic 5. Pallanti S, Lotti T, Urpe M. Psychoneuroimmunodermatology hypochondriacal psychosis. Semin Dermatol 1983;2:197-202.
of atopic dermatitis: from empiric data to the evolutionary 15. Kellett CE. Sir Thomas Browne and the disease called the hypothesis. Dermatol Clin 2005;23:695-701.
Morgellons. Ann Med Hist 1935;7:467-79.
6. Wallengren J, Dahlback K. Familial brachoradial pruritus. Br J 16. Murase JE, Wu JJ, Koo J. Morgellons disease: a rapport- enhancing term for delusions of parasitosis. J Am Acad 7. Koblenzer CS. Psychocutaneous disease. New York: Grune and 17. Morgellons Research Foundation Web site. Available at: 8. Koblenzer CS. Neurotic excoriations and dermatitis artefacta.
18. Lee CS, Koo JYM. The use of psychotropic medications in 9. Musalek M. Delusional parasitosis. In: Koo JYM, Lee CS, editors.
dermatology. In: Koo JYM, Lee CS, editors. Psychocutaneous Psychocutaneous medicine. New York: Marcel Dekker, Inc; medicine. New York: Marcel Dekker, Inc; 2002. pp. 427-51.
19. Koblenzer CS. Psychotropic drugs in dermatology. In: James 10. Munro A. Delusional disorder. Cambridge: Cambridge Univer- WD, Cockerell CJ, Dzubow LM, Paller AS, Yancey KB, editors.
Advances in dermatology (vol 15). St Louis: Mosby, Inc; 2000.
11. Arnold LM. Psychocutaneous disorders. In: Sadock BJ, Sadock VA, editors. Kaplan and Sadock’s comprehensive textbook of 20. Savely VR, Leitao MM, Stricker RB. The mystery of Morgellons psychiatry. 7th ed. Philadelphia: Lippincott, Williams and disease. Infection or delusion? Am J Clin Dermatol 2005;7:


Microsoft word - kennedy-wiki abstract-2010-acute effects.doc

Acute Effects Ann R. Kennedy, D. Sc. University of Pennsylvania School of Medicine Department of Radiation Oncology This lecture topic is about the acute biologic effects associated with exposure to the types of radiation encountered by astronauts during space travel. The radiation environment encountered during space travel will expose astronauts to higher doses of radiation, and


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