What is the primary care management of patients with delusional parasitosis, also referred to as Morgellons disease (Delusional Disorder, Somatic Type)?

From the Guidelines

Management of patients with delusional parasitosis, including those who identify their condition as Morgellons disease, requires a compassionate, multidisciplinary approach, with initial treatment typically involving second-generation antipsychotics such as risperidone or olanzapine, as evidenced by general psychiatric guidelines 1. The primary care physician should establish a strong therapeutic alliance with the patient, avoiding direct confrontation about the delusional nature of their beliefs.

• Initial treatment typically involves prescribing second-generation antipsychotics, with risperidone (starting at 0.5-1 mg daily, gradually increasing to 2-4 mg daily) or olanzapine (starting at 2.5-5 mg daily, increasing to 5-10 mg daily) being first-line options, as these medications have been shown to be effective in reducing psychotic symptoms 1.
• Regular follow-up appointments should be scheduled every 2-4 weeks initially to monitor medication efficacy and side effects.
• Dermatological symptoms should be addressed with moisturizers and topical corticosteroids if skin damage is present from scratching or self-extraction behaviors.
• Referral to psychiatry is essential, though this should be framed carefully as part of comprehensive care rather than suggesting the problem is "all in their head."
• Cognitive behavioral therapy can be beneficial as an adjunct treatment.
• Laboratory tests including complete blood count, comprehensive metabolic panel, thyroid function tests, and toxicology screening should be performed to rule out organic causes, as recommended in general psychiatric guidelines 1. The primary care physician should maintain regular contact with the patient even after psychiatric referral to preserve trust and ensure continuity of care, which is crucial for managing delusional parasitosis and improving patient outcomes.

From the Research

Primary Care Management of Delusional Parasitosis

The primary care management of patients with delusional parasitosis, also referred to as Morgellons disease, involves a collaborative approach among dermatologists, psychiatrists, and parasitologists 2.

Diagnosis and Treatment

• Patients with delusional parasitosis are convinced that they are being infested with animal parasites, despite no objective evidence to support this belief 2.
• The diagnosis and treatment of delusional parasitosis require a close collaboration among healthcare professionals 2.
• Establishing a reliable and meaningful therapeutic relationship can sometimes relieve symptoms in patients with mild delusional parasitosis 2.
• Symptomatic medication may be prescribed for the relief of pruritus, pain, and other symptoms 2.
• In more severe cases, psychopharmacological agents, such as atypical antipsychotic drugs, may be necessary 2, 3, 4, 5.

Treatment Options

• Atypical antipsychotic drugs, such as olanzapine, have been shown to be effective in treating delusional parasitosis 3, 4, 5.
• Parenterally administered antipsychotics, particularly risperidone, may produce better results in patients with delusional parasitosis 3.
• Olanzapine has a more benign adverse effect profile than typical antipsychotic agents and eliminates the need for electrocardiographic monitoring 5.
• A treatment team approach involving a psychiatrist, dermatologist, and family practitioner may be beneficial in managing patients with delusional parasitosis 6.