Pimozide in delusions of parasitosis

Drug-induced Delusional Infestation

It is considered that certain drugs might induce delusional infestation, yet, to date, no studies have been performed to identify the pharmacodynamics associated with these treatments. The aim of this review is to summarize current available knowledge of drug-induced delusional infestation. A literature search was performed for primary studies on suspected drugs reported to induce delusional infestation. Included articles were evaluated systematically using the Naranjo criteria. In addition, drug mechanisms of action were compared. The final selection included 31 studies, in which a total of 26 classes of drugs were identified. Anti-Parkinson drugs were most frequently associated with delusional infestation, followed by antidepressants, antiepileptics, antibiotics, prescription stimulants, and a few other drug groups. The current available literature suggests that the onset of delusional infestation is initiated by drug-induced alterations in neurotransmitter levels, predominantly dopamine, in the central nervous system.

Emerging therapeutic potential of anti-psychotic drugs in the management of human glioma: A comprehensive review

Despite numerous advancements in the last decade, human gliomas such as astrocytoma and glioblastoma multiforme have the worst prognoses among all cancers. Anti-psychotic drugs are commonly prescribed to treat mental disorders among cancer patients, and growing empirical evidence has revealed their antitumor, anti-metastatic, anti-angiogenic, anti-proliferative, chemo-preventive, and neo-adjuvant efficacies in various in vitro, in vivo, and clinical glioma models. Anti-psychotic drugs have drawn the attention of physicians and researchers owing to their beneficial effects in the prevention and treatment of gliomas. This review highlights data on the therapeutic potential of various anti-psychotic drugs as anti-proliferative, chemopreventive, and anti-angiogenic agents in various glioma models via the modulation of upstream and downstream molecular targets involved in apoptosis, autophagy, oxidative stress, inflammation, and the cell cycle in in vitro and in vivo preclinical and clinical stages among glioma patients. The ability of anti-psychotic drugs to modulate various signaling pathways and multidrug resistance-conferring proteins that enhance the efficacy of chemotherapeutic drugs with low side-effects exemplifies their great potential as neo-adjuvants and potential chemotherapeutics in single or multimodal treatment approach. Moreover, anti-psychotic drugs confer the ability to induce glioma into oligodendrocyte-like cells and neuronal-like phenotype cells with reversal of epigenetic alterations through inhibition of histone deacetylase further rationalize their use in glioma treatment. The improved understanding of anti-psychotic drugs as potential chemotherapeutic drugs or as neo-adjuvants will provide better information for their use globally as affordable, well-tolerated, and effective anticancer agents for human glioma.

Management of the psychological comorbidities of dermatological conditions: practitioners' guidelines

Dermatological disease can be devastating for patients, and although dermatologists are focused on remedying the cutaneous manifestations of these conditions, it is easy to miss the psychological suffering lurking below. Studies reveal that psychiatric comorbidity in dermatology is highly prevalent. Undetected psychopathology can greatly decrease a patient's quality of life and even contribute significantly to the clinical severity of their skin disease. For these reasons, it is vital that practitioners learn to detect psychological distress when it is present, and it is equally essential that they understand the treatment options available for effective intervention. Without training in psychiatric diagnosis and psychopharmacology, dermatologists can easily feel overwhelmed or out of their comfort zone when faced with the need to manage such conditions, but with the negative stigma associated with psychiatric disease in general, a psychiatric referral is often refused by patients, and the dermatologist is thus left with the responsibility. Uncertainty abounds in such situations, but this review seeks to alleviate the discomfort with psychodermatological disease and share practical and impactful recommendations to assist in diagnosis and treatment. In a busy dermatology clinic, the key is effective and efficient screening, combined with a repertoire of pharmacological and non-pharmacological treatment options that can be dispersed through an algorithmic approach according to the specific findings of that screening. By implementing these recommendations into practice, dermatologists may begin to gain comfort with the management of psychocutaneous disease and, as a specialty, may expand to fill a hole in patient care that is truly significant for patients, their families, and our communities as a whole.

Delusional infestation: the case for improved mental state testing

OBJECTIVES

Delusional infestation may present as a primary disorder or secondary to another disorder (e.g. schizophrenia). In this report we focus on the issue of inadequacies in mental state examinations leading to diagnostic uncertainty.

METHODS

Case studies were identified for this review through searching the academic databases MedLine, PSYCInfo and PubMed. We developed a template that contained 36 headings and independently examined each case study report. Our percentage agreement for the first 42 case studies we reviewed was 91%.

RESULTS

We identified diagnostic uncertainty due to inadequacies in the reporting of mental state examinations.

CONCLUSIONS

Clinicians need to provide mental state information to an adequate standard that would allow confirmation of a diagnosis of delusions of infestation or exclude other possibilities.

Pimozide: parasitosis (delusional)

This Hospital Pharmacy feature is extracted from Off-Label Drug Facts, a publication available from Wolters Kluwer Health. Off-Label Drug Facts is a practitioner-oriented resource for information about specific drug uses that are unapproved by the US Food and Drug Administration. This new guide to the literature enables the health care professional or clinician to quickly identify published studies on off-label uses and determine if a specific use is rational in a patient care scenario. References direct the reader to the full literature for more comprehensive information before patient care decisions are made. Direct questions or comments regarding Off-Label Drug Uses to jgeneral@ku.edu.

Relevant issues in pharmacotherapy of psycho-cutaneous disorders

Psychiatric disorders frequently co-occur with dermatological conditions and psychotropic agents may be indicated in treating the underlying psychiatric symptoms. Use of psychotropics can be associated with significant cutaneous adverse effects as well as drug interactions with pharmacological agents used in treatment of the dermatological conditions. Knowledge of indication, contraindication, side effects, and interactions of psycho-tropics is essential for the practicing dermatologist in managing psycho-dermatological conditions. This review aims at discussing relevant issues in pharmacological management of psycho-cutaneous disorders.

Delusions of parasitosis

Patients with delusions of parasitosis (DOP) are more commonly recognized in dermatology practices today. However, dermatologists may feel uncomfortable treating these patients because of the psychiatric nature of their disorder. As a result of the fact that DOP patients strongly prefer to seek treatment from dermatologists rather than mental health professionals, it is important for dermatologists to be well equipped with a basic understanding of the disorder and with tools to assist this patient population. In this review, we discuss the epidemiology, presentation, differential diagnosis and treatment strategy for patients with DOP.

Morgellons in dermatology

Delusional parasitosis (DP) is the most frequent delusional disorder in dermatology. In DP there is a fixed belief of a usually skin-related invasion or infestation by a number of alleged infectious species (usually parasites and bacteria), whose identity has varied over the decades. Since 2002 worldwide an increasing number of patients have complained of unverifiable fibers and filaments in or on the skin, associated with numerous nonspecific complaints (arthralgias, altered cognitive function and extreme fatigue). This entity has been named "Morgellons disease" by the patients themselves, although medical evidence for its existence is lacking. As an example, we discuss a 55-year-old woman who complained of Morgellons disease and was treated as if she had DP. Currently the delusional assumption of infestation with Morgellons should be considered as a new type of DP with some kind of inanimate material. We therefore recommend in case of DP including Morgellons the use of the broader term "delusional infestation".

Delusional infestation

This papers aims at familiarizing psychiatric and nonpsychiatric readers with delusional infestation (DI), also known as delusional parasitosis. It is characterized by the fixed belief of being infested with pathogens against all medical evidence. DI is no single disorder but can occur as a delusional disorder of the somatic type (primary DI) or secondary to numerous other conditions. A set of minimal diagnostic criteria and a classification are provided. Patients with DI pose a truly interdisciplinary problem to the medical system. They avoid psychiatrists and consult dermatologists, microbiologists, or general practitioners but often lose faith in professional medicine. Epidemiology and history suggest that the imaginary pathogens change constantly, while the delusional theme "infestation" is stable and ubiquitous. Patients with self-diagnosed "Morgellons disease" can be seen as a variation of this delusional theme. For clinicians, clinical pathways for efficient diagnostics and etiology-specific treatment are provided. Specialized outpatient clinics in dermatology with a liaison psychiatrist are theoretically best placed to provide care. The most intricate problem is to engage patients in psychiatric therapy. In primary DI, antipsychotics are the treatment of choice, according to limited but sufficient evidence. Pimozide is no longer the treatment of choice for reasons of drug safety. Future research should focus on pathophysiology and the neural basis of DI, as well as on conclusive clinical trials, which are widely lacking. Innovative approaches will be needed, since otherwise patients are unlikely to adhere to any study protocol.

Psychopharmacology in dermatology

Many patients with skin disorders have psychologic issues associated with their chief complaints. Dermatologists who wish to help their patients with psychodermatologic conditions can greatly enhance their therapeutic armamentarium by becoming familiar with the use of a few selected psychotropic agents. This paper will review the current status and future directions of psychopharmacology for the major types of psychopathologies encountered in a dermatology practice (depression, obsessive-compulsive disorder, anxiety, and delusional disorder) with the intent of guiding dermatologists in the choice of a psychotropic agent for patients with psychologic component to their skin disorder.

Psychodermatology: a guide to understanding common psychocutaneous disorders

OBJECTIVE

This review focuses on classification and description of and current treatment recommendations for psychocutaneous disorders. Medication side effects of both psychotropic and dermatologic drugs are also considered.

DATA SOURCES

A search of the literature from 1951 to 2004 was performed using the MEDLINE search engine. English-language articles were identified using the following search terms: skin and psyche, psychiatry and dermatology, mind and skin, psychocutaneous, and stress and skin.

DATA SYNTHESIS

The psychotropic agents most frequently used in patients with psychocutaneous disorders are those that target anxiety, depression, and psychosis. Psychiatric side effects of dermatologic drugs can be significant but can occur less frequently than the cutaneous side effects of psychiatric medications. In a majority of patients presenting to dermatologists, effective management of skin conditions requires consideration of associated psychosocial factors. For some dermatologic conditions, there are specific demographic and personality features that commonly associate with disease onset or exacerbation.

CONCLUSIONS

More than just a cosmetic disfigurement, dermatologic disorders are associated with a variety of psychopathologic problems that can affect the patient, his or her family, and society together. Increased understanding of biopsychosocial approaches and liaison among primary care physicians, psychiatrists, and dermatologists could be very useful and highly beneficial.

Delusional parasitosis and the dopamine transporter. A new insight of etiology?

Delusional parasitosis (DP) is a psychotic condition in which a person has the unshakeable and mistaken belief (delusion) and/or aberrant perception (hallucination) of being infested with parasites. The disorder will be usually classified in a primary DP-group without a detectable cause (so-called pure forms), while secondary DP-groups are associated with general organic conditions, psychiatric illnesses and drugs (substance induced). Etiology and pathophysiology of DP remain however unknown. In the present paper we hypothesize for the first time a decreased striatal dopamine transporter (DAT)-functioning (corresponding with an increased extracellular dopamine-level) as etiologic condition for DP (primary and secondary groups). The DAT as key regulator of the dopamine-reuptake in the human brain is well known (regulation of the extracellular dopamine concentration). It is a presynaptic plasma membrane protein highly dense represented in the striatum. The hypothesis of a decreased DAT-functioning as etiologic condition by DP is revealed in case reports which show that DAT-inhibitors, such as cocaine, pemoline, methylphenidate and other amphetamine-derivatives can induce the clinical expression of DP. Several other associated causes of secondary DP-groups (medications, parkinson, chorea huntington, multiple system atrophy, diabetes, cerebrovascular diseases, alcoholism, traumatic brain injury, hyperuricemia, human immunodeficiency virus, iron deficiency, schizophrenia, depression) suggest that the clinical expression of DP may be related to a decreased striatal DAT-functioning (blocking, reduced ligand binding, reduced density, reduced activity). Our examined DP-cases (2-females) show means of magnetic resonance imaging a structurally damaged striatum. Furthermore, we presume that by the primary DP-group, the physiologically age-related decline of the DAT-density is pathologically elevated. Based on this hypothesis we show in the present paper the relation between DP and decreased striatal DAT-functioning, trying to give a new insight into the pathophysiologically mechanism involved. The hypothesis provides supporting evidence that increased levels of extracellular dopamine in the striatum of DP-patients is likely to be the result of decreased DAT-functioning and not increased rates of release. The hypothesis can be investigated simply by dopamine transporter imaging in patients with DP.

Psyche, opioids, and itch: therapeutic consequences

A patient's psychological condition can substantially affect the presence and severity of pruritus, a phenomenon thought to be mediated by the central nervous system's (CNS) opioid neurotransmitter system. Specific psychodermatologic disorders associated with psychogenic pruritus, including depression, anxiety, chronic tactile hallucinations, delusions of parasitosis, neurotic excoriations, and other cutaneous compulsions are likely controlled by this pathway. Therefore, in treating these conditions, medications specifically directed at the CNS can be the most effective therapies, whereas topical and supportive therapy may be important adjuncts in targeting the associated pruritus. Furthermore, the impact of an understanding clinician and a good physician-patient relationship cannot be underestimated in determining ultimate prognosis. This review will begin by discussing the relationship between the psyche and pruritus as well as the opioid neurotransmitter system. Following this, several disorders characterized by psychogenic pruritus will be described, and CNS-specific and adjunctive topical and supportive therapies for these conditions will be detailed.

Pimozide in dermatologic practice: a comprehensive review

Pimozide is an antipsychotic drug of the diphenylbutylpiperidine class. In the US, it is FDA-approved only as a backup treatment for Gilles de la Tourette syndrome, although it has been used in other countries for many years as a treatment for schizophrenia. In the past 20 years, pimozide has been found to be especially efficacious in the treatment of monosymptomatic hypochondriacal psychoses and is used by psychiatrists and dermatologists for this off-label purpose. In particular, pimozide is considered the treatment of choice for delusions of parasitosis. In addition, pimozide has been found to be efficacious in the treatment of body dysmorphic disorder, metastatic melanoma, trichotillomania, and trigeminal and postherpetic neuralgia. This review aims to familiarize physicians, especially dermatologists, on the uses of pimozide in dermatologic practice. A review of the literature was performed and the relevant information synthesized to give a complete overview of the drug and its therapeutic uses in dermatology.

Neurotropic and psychotropic drugs in dermatology

Several psychotropic and neurotropic agents are useful in treating patients with skin diseases such as obsessive compulsive skin manipulation, delusions of parasitosis, generalized pruritus, and post-herpetic neuralgia. The mechanism of action of these agents is based on their interaction with central and peripheral neuronal receptors. The medications discussed in this article include the tricyclic antidepressants, serotonin reuptake inhibitors, naltrexone, pimozide, and gabapentin. The pharmacology, mechanism of action, adverse effects, drug interactions, and monitoring guidelines are outlined for each of these drugs.

Therapeutic update: use of risperidone for the treatment of monosymptomatic hypochondriacal psychosis

Monosymptomatic hypochondriacal psychoses such as delusions of parasitosis are often difficult to treat. For the past two decades, pimozide has been considered the drug of choice. Although a few controlled studies have been done to support the efficacy of pimozide, the recommendation of treatment of choice is largely based on case reports. Pimozide has significant side effects, including cardiac and extrapyramidal abnormalities, which are of most concern in the treatment of the elderly. Although pimozide does appear to be effective in some cases of somatic delusional disorders, newer antipsychotics such as risperidone have also been shown to be beneficial in treating this perplexing cluster of disorders. Risperidone is generally considered safer than pimozide and should be considered as first-line therapy for monosymptomatic hypochondriacal psychoses.

Delusions of parasitosis and other forms of monosymptomatic hypochondriacal psychosis. General discussion and case illustrations

In this article, the epidemiology and differential diagnosis of monosymptomatic hypochondriacal psychosis are discussed in detail. The use of pimozide is also discussed and illustrated with case reports. Delusional patients are some of the most challenging cases based in dermatologic practice. This challenge is so much easier to meet if one knows how to approach these patients and feels comfortable in the use of pimozide.

Psychopharmacology for dermatologic patients

In the recent past, there has been great progress made in making psychopharmacologic agents both more efficacious and more user friendly. If dermatologists are to more effectively treat psychodermatologic patients who refuse to see a mental health professional, judicious and responsible use of psychopharmacology is still the most feasible way to treat many of these patients. This article illustrates the use of several commonly used psychopharmacologic agents. Even for psychiatrists, it is not realistic to try to master all psychopharmacologic agents that are on the market. Familiarity with the use of medications discussed in this article is likely to add significantly to the therapeutic armamentarium of a dermatologic practitioner.

Delusional parasitosis: a dermatologic, psychiatric, and pharmacologic approach

Delusional parasitosis is a syndrome in which the patient has the false belief that he is infested by parasites. Although this is a psychiatric disorder, patients usually seek care from dermatologists. DP has various causes. It may occur as the sole psychologic disturbance, or it may be associated with an underlying psychiatric disorder or physical illness. A dermatology-psychiatry liaison is advocated for establishing a viable differential diagnosis and selecting appropriate therapy. The antipsychotic agent pimozide is currently the most effective treatment when DP occurs as an encapsulated delusion. Pimozide therapy requires careful monitoring because this drug has several potentially serious adverse effects, and relapse often occurs on discontinuation of the drug.