Delusions of Parasitosis

[rev ronin]

How would you handle this:

70's YOF with unrelated musculoskeletal complaint. Hx benign but space-occupying brain tumor, successfully removed more than a decade ago. Now with conversational delusions of parasitosis, which manifest as her trying to dig subcuteneous fish (small ones) out of her face that were, per her, previously placed by the NSA.

I'm worried about the self harm aspects of digging at one's facial skin, but the patient otherwise appears competent to manage her own affairs, with a good intellect preserved despite age.

Obviously not going to try and confront/"fix" her, but what does harm reduction and beneficence look like in such a situation?

[EMEDPA]

3 minutes ago, rev ronin said:

How would you handle this:

70's YOF with unrelated musculoskeletal complaint. Hx benign but space-occupying brain tumor, successfully removed more than a decade ago. Now with conversational delusions of parasitosis, which manifest as her trying to dig subcuteneous fish (small ones) out of her face that were, per her, previously placed by the NSA.

I'm worried about the self harm aspects of digging at one's facial skin, but the patient otherwise appears competent to manage her own affairs, with a good intellect preserved despite age.

Obviously not going to try and confront/"fix" her, but what does harm reduction and beneficence look like in such a situation?

r/o meth associated psychosis and if neg, referral to psych...

[rev ronin]

3 minutes ago, EMEDPA said:

r/o meth associated psychosis and if neg, referral to psych...

Heh. No, no meth. Also, no ability for me to refer to psych, since this is not related to the musculoskeletal issue for which I'm seeing her.

[ventana]

Brain mri with contrast r/o mass

 

[iconic]

Should probably be treated as OCD plus antipsychotic 

Edited September 14, 2023 by iconic

[ohiovolffemtp]

I just had a similar case, likely due to pt's MS.  Interestingly enough, the patient is a semi-retired MD who presented me with a 1.5 page description of their experiences.  They'd also prescribed themselves ivermectin and requested I continue that Rx.   The patient did respond to me saying that I wouldn't prescribe for something I couldn't see.  It took me 45 minutes + on a busy night in the ED and examining their face, mouth, and perianal region (with appropriate RN chaperone) to convince them that I couldn't see what they felt and said they saw.

[rev ronin]

39 minutes ago, ohiovolffemtp said:

I just had a similar case, likely due to pt's MS.  Interestingly enough, the patient is a semi-retired MD who presented me with a 1.5 page description of their experiences.  They'd also prescribed themselves ivermectin and requested I continue that Rx.   The patient did respond to me saying that I wouldn't prescribe for something I couldn't see.  It took me 45 minutes + on a busy night in the ED and examining their face, mouth, and perianal region (with appropriate RN chaperone) to convince them that I couldn't see what they felt and said they saw.

Yeah, this is more along the lines of an answer I'm looking for. I can't do a workup or refer, so I basically have my time, community resources, and the option of calling adult protective services. This is literally not my problem as a clinician, an interesting status that is actually quite prevalent in occupational medicine, but it remains my problem as a decent human being.

[iconic]

I don't understand why a psych referral is not possible - you can just verbally advise the patient that they should follow up with psych. I see these issues shoved under the carpet all the time with no one advising the patient to follow with psychiatry for their issue. 90% of patients we see are self-referred. If I am seeing someone with a concerning medical issue, I am not just going to ignore it and never mention to the patient to follow up with someone on the issue; whether they end up doing so is up to them.

Edited September 14, 2023 by iconic

[Reality Check 2]

Any local family members? Would patient sign a release to speak to family or caregiver? 
Talk to them about concerns and advise next steps.

Maybe find a phone number of someone locally who might see her and give her the number.

I just went thru a horrible dementia encounter with a lady who is so far gone and not capable of even understanding a release to sign. Her husband is lost and doesn’t know what to do. She will be dangerous soon.

He will have to go to court to get a guardianship.

I am risking HIPAA just calling the husband but I have leadership support to do this because it is the right thing to do.  

I am grateful you are a decent human being first and foremost 

[rev ronin]

Just now, iconic said:

I don't understand why a psych referral is not possible - you can just verbally advise the patient that they should follow up with psych. I see these issues shoved under the carpet all the time with no one advising the patient to follow with psychiatry for their issue 

I can certainly give verbal advice, but that's necessarily confrontational, isn't it? "Hey patient, you need to see a psychiatrist for those there delusions, you know?" By maintaining therapeutic alliance, I think I may be doing more good for this patient as an occ med PA (due to the rest of the situation that I'm not going to go into detail about for patient privacy reasons). I can certainly call the PCP, once the patient establishes with one, but how can I get this patient effective help in my situation while maintaining trust?

[rev ronin]

 

Any local family members? Would patient sign a release to speak to family or caregiver? 
Talk to them about concerns and advise next steps.

Excellent ideas. No caregiver, patient lives alone successfully aside from this issue. No family locally or that patient calls on for help.

[iconic]

4 hours ago, rev ronin said:

I can certainly give verbal advice, but that's necessarily confrontational, isn't it? "Hey patient, you need to see a psychiatrist for those there delusions, you know?" By maintaining therapeutic alliance, I think I may be doing more good for this patient as an occ med PA (due to the rest of the situation that I'm not going to go into detail about for patient privacy reasons). I can certainly call the PCP, once the patient establishes with one, but how can I get this patient effective help in my situation while maintaining trust?

I don’t think it’s confrontational whatsoever or in anyway different from advising the patient to follow up with their PCP for blood pressure; if the patient has no insight into their delusions, then ofc they may dismiss that recommendation. If they have significant picking, you can frame it as seeing a specialist for OCRD behaviors. I don’t think there’s any reason to stigmatize mental disorders. I’m not sure how else you can help the patient with the issue, unless you plan on starting treatment yourself. 

[sas5814]

I get about 1 case of this every 6 or 8 months. I am direct with them but not confrontational. I tell them what is going on in a calm and sympathetic manner. I think being direct and honest isn't confrontational.

The first one I saw in my most recent job was told flat out by derm they needed to see psych. I asked our in house psychiatrist how to approach this and she just said "anti psychotics" which wasn't particularly helpful to me as a PCP.

I can't imagine how confusing or frustrating it must be for people to tell you your reality isn't real.

[SedRate]

7 hours ago, Reality Check 2 said:

I just went thru a horrible dementia encounter with a lady who is so far gone and not capable of even understanding a release to sign. Her husband is lost and doesn’t know what to do. She will be dangerous soon.

He will have to go to court to get a guardianship.

I am risking HIPAA just calling the husband

Is getting guardianship necessary given her incapacity? If she is not able to consent nor of sound mind, aren't discussions always with the MPOA? 

Or is it different because she's not acutely ill? 

[Reality Check 2]

1 hour ago, SedRate said:

Is getting guardianship necessary given her incapacity? If she is not able to consent nor of sound mind, aren't discussions always with the MPOA? 

Or is it different because she's not acutely ill? 

He has no POA, No Advanced Directives, No auth to speak to husband.

He has NOTHING and will have to fight to get it

Meanwhile she is not participating in her care. She was nasty to me and abruptly stopped a mental status exam at question 4 of 9 and refused to participate. She masks her incapacity with anger.

Her husband is behind the 8 Ball and will struggle legally until she is declared incapacitated.

The laws in the US are basically nonexistent for family members to protect their own. It is pathetic.

[TWR]

Johnathan, I would try to get family involved.  Someone needs to be aware of her situation and do a psych consult.                                                        

Edited September 14, 2023 by TWR

[ohiovolffemtp]

On 9/13/2023 at 10:34 PM, iconic said:

I don't understand why a psych referral is not possible - you can just verbally advise the patient that they should follow up with psych. I see these issues shoved under the carpet all the time with no one advising the patient to follow with psychiatry for their issue. 90% of patients we see are self-referred. If I am seeing someone with a concerning medical issue, I am not just going to ignore it and never mention to the patient to follow up with someone on the issue; whether they end up doing so is up to them.

In my patient's case I had her follow-up with her neurologist, since delusions of parasitosis is a known manifestation of MS.   The problem I've found is that in the rural critical access hospitals where I now work, there are minimal to no outpatient mental health resources.  If there are resources, they are counseling, not psychiatry.

[iconic]

3 hours ago, ohiovolffemtp said:

In my patient's case I had her follow-up with her neurologist, since delusions of parasitosis is a known manifestation of MS.   The problem I've found is that in the rural critical access hospitals where I now work, there are minimal to no outpatient mental health resources.  If there are resources, they are counseling, not psychiatry.

That sounds reasonable. Neurologists will often treat psych issues, especially if there are no resources. Counseling could be beneficial too. Everyone in psychiatry that I know now sees patients virtually and I have had patients from very rural areas, who otherwise would have never been seen in the office. 

[sas5814]

On 9/14/2023 at 12:34 AM, iconic said:

I don't understand why a psych referral is not possible - you can just verbally advise the patient that they should follow up with psych. I see these issues shoved under the carpet all the time with no one advising the patient to follow with psychiatry for their issue. 90% of patients we see are self-referred. If I am seeing someone with a concerning medical issue, I am not just going to ignore it and never mention to the patient to follow up with someone on the issue; whether they end up doing so is up to them.

you can't refer someone to psych who refuses a referral. I just had another of these patients and I spent 30 minutes looking at all kinds of skin lesions and places where there was nothing and saw...nothing. Patient 100% angry demanding I treat him for "parasites".

I asked what kind because there are hundreds. No answer.

I asked him to bring me one. "They are pretty small." We have microscopes for just that. Arms crossed...looks at ceiling.

Visit over. There aren't enough hours in the day to convince someone their reality isn't real.

He has a real problem but I can't drag him , lead him, or cajole him to that realization.

[CornellSPA]

One possibility could be Morgellons disease -often fibers can be seen under the skin, and is accompanied by many psychiatric symptoms!

The mystery of Morgellons disease: infection or delusion:

//pubmed.ncbi.nlm.nih.gov/16489838/

https://pubmed.ncbi.nlm.nih.gov/29467580/

[Reality Check 2]

Morgellons is fascinating - from a distance - very odd beliefs

These cases are not fun.

Currently have a lady who believes she has Havana Syndrome - never been to Cuba - but believes persons unknown are targeting ONLY HER with damaging sound waves. 

Folks next to her and even her child are not affected.

I have no idea where to go with this.

[ohiovolffemtp]

Ask her why she feels she's important enough to be targeted?

[sk732]

Rock and a hard place - I sometimes use the tack of "I think your brain is playing tricks on you because we can't see any evidence of (parasites, sound wave problems with those around you, including me, etc) and think you should see someone smarter than me about this".  Kinda like the old days with fibromyalgia - psych and rheum together after other causes within your wheelhouse are ruled out.  In Rev's case, because this is an incidentaloma for a completely different reason, "I'm going to treat you for this MSK thing, but I think you need some other testing done by someone other than me about this other issue."   I take it they're no longer being followed by Neuro/Neurosgx?

Reminds me of being sent to an endodontist for a diagnostic root canal for a tooth that had a queried autoimmune bone resorption thing going on - dude drilled the tooth and said "Yup, that's what it is, I'm going to put a temporary crown on it and your tooth fairy can extract..."  and when I went "Umm, I'm here and frozen, you're a tooth fairy too, why not just extract it now?"  "I'm an endodontist, consulted to just look inside - that's what I do and did, I don't extract teeth."