Longer Duration of Untreated Psychosis is Associated with Poorer Outcomes for Patients with Delusional Infestation

Insights into the Medical Evaluation of Ekbom Syndrome: An Overview

Ekbom syndrome, also known as delusional parasitosis (DP) or delusional infestation, is an uncommon psychiatric disorder distinguished by an enduring conviction of parasitic infestation, persisting notwithstanding the presence of medical evidence to the contrary. Primarily affecting middle-aged women, DP can manifest either as isolated psychological distress or as a component within a more intricate psychiatric framework, substantially influencing the quality of life for affected individuals. Its pathophysiological mechanism involves uncertain dopaminergic imbalances and dysfunction in the dopamine transporter system. Dermatologists often play a pivotal role in diagnosis, as patients first seek dermatological assessments of their signs and symptoms. However, DP frequently originates from underlying psychiatric disorders or medical variables, manifesting with neurological and infectious causative factors. The diagnostic complexity is attributed to patients' resolute convictions, leading to delayed psychiatric intervention. First-line DP treatment involves antipsychotics, with newer agents demonstrating promising prospects, but the lack of standardized protocols poses a significant therapeutic challenge. In this narrative review, both a comprehensive approach to this uncommon pathology and an update on the state of knowledge in this medical subfield focused on optimizing the management of DP are provided. The complexity of DP underlying its uncommon nature and the incomplete understanding of its pathophysiology highlight the need for further research through multicenter studies and multidisciplinary teams to enhance therapeutic efficacy and safety.

Delusional infestation: a retrospective cohort study of 49 patients over a 6-year period

Delusional infestation (DI) is the fixed false belief of pathogenic infestation of the skin or body despite no supporting medical evidence. It is a relatively rare condition with a reported prevalence of 1.48 per million people. Successful treatment can be challenging as patients are often reluctant to accept referral or involvement of psychiatric services. We report a retrospective cohort study of 49 consecutive patients with a diagnosis of DI, assessed in a regional psychodermatology service over a 6-year period. Low-dose antipsychotics (risperidone or olanzapine) were prescribed in 44 patients. We use our data to explore possible reasons why DI can be challenging to treat. Response to treatment and engagement with services is multifactorial. Our study emphasizes the importance of early assessment and supports the expansion of psychodermatology services in the UK.

Assessing and Improving Psychological Well-Being in Psoriasis: Considerations for the Clinician

Psoriasis is a common chronic, systemic inflammatory disease, affecting approximately 2% of the population worldwide. Psoriasis is associated with profound psychosocial comorbidity with a burden that extends well beyond the physical signs and symptoms. Psychosocial comorbidities strongly associated with psoriasis include anxiety and depression, suicidal ideation, and substance misuse. There is a substantial unmet need for access to psychological support for people with skin disease in the UK. Recent reports found that while up to 98% of patients felt that their skin disease had affected their emotional or psychological well-being, only 18% sought help. This care gap is largely due to a lack of awareness about the limited available services alongside poor recognition, diagnosis, and triaging. Addressing psychosocial support needs starts with early identification, which can be complex and challenging. Once patients who need further support are identified, outcomes can be improved through prompt and effective treatment of inflammation, cognitive behavioural therapy, meditation and mindfulness-based therapy (including motivational interviewing), and to some extent psychotropic medication. Finally, resources for mental health support are notoriously limited, with dire consequences for patients. It is imperative that a proportion of the new funding promised for mental health services is bookmarked for dermatology patients and adequate provision of multidisciplinary psychodermatology teams to best serve the needs of this population. Ultimately, psoriasis is a complex condition with multifactorial psychological and biological drivers. Psoriasis is associated with high levels of distress, which is often under-recognized. Fully addressing this condition requires a holistic approach to the physical and psychosocial aspects to maximise adherence, efficacy, and optimise patient quality of life.

Delusional infestation: an interface with psychiatry

Delusional infestation (delusional parasitosis) is a relatively rare condition but it has been of interest to a wide range of professionals, including entomologists, zoologists and dermatologists, as patients predominantly seek help from specialties other than psychiatrists. The illness requires a multidisciplinary approach and a strong bond of trust between the treating clinician and the patient to ensure the best possible outcome. This article discusses how clinicians in all specialties should approach patients presenting with the disorder and outlines differential diagnosis and associated laboratory tests. It considers the evidence base for treatment and the success of psychodermatology clinics that provide a ‘neutral setting’ for consultation to address the problem of patients’ non-engagement. Such clinics are few, and there is a need to develop disease-specific pathways in primary care and hospital settings to improve prognosis.

Oxidative-Antioxidant Imbalance and Impaired Glucose Metabolism in Schizophrenia

Schizophrenia is a neurodevelopmental disorder featuring chronic, complex neuropsychiatric features. The etiology and pathogenesis of schizophrenia are not fully understood. Oxidative-antioxidant imbalance is a potential determinant of schizophrenia. Oxidative, nitrosative, or sulfuric damage to enzymes of glycolysis and tricarboxylic acid cycle, as well as calcium transport and ATP biosynthesis might cause impaired bioenergetics function in the brain. This could explain the initial symptoms, such as the first psychotic episode and mild cognitive impairment. Another concept of the etiopathogenesis of schizophrenia is associated with impaired glucose metabolism and insulin resistance with the activation of the mTOR mitochondrial pathway, which may contribute to impaired neuronal development. Consequently, cognitive processes requiring ATP are compromised and dysfunctions in synaptic transmission lead to neuronal death, preceding changes in key brain areas. This review summarizes the role and mutual interactions of oxidative damage and impaired glucose metabolism as key factors affecting metabolic complications in schizophrenia. These observations may be a premise for novel potential therapeutic targets that will delay not only the onset of first symptoms but also the progression of schizophrenia and its complications.

Delusional infestation managed in a combined tropical medicine and psychiatry clinic

Background

Delusional infestation (DI) is a well-recognised delusional disorder presenting as the persisting belief in the presence of parasitic or other infestations. Combined clinics have been run by dermatology and psychiatry in a small number of centres. Here we report the first few years of a unique combined clinic run with experts in infectious diseases/tropical medicine and psychiatric management of DI.

Methods

We reviewed all patients seen at the combined assessment clinics run at the Liverpool School of Tropical Medicine between 19 December 2011 and 31 October 2016. Data were collected prospectively as part of clinical assessment. Descriptive analysis of these data was performed to examine clinical features at assessment, investigations performed and treatment outcomes.

Results

A total of 75 patients were assessed and 52 (69%) were given the formal diagnosis of DI. A history of travel was given by 64% of individuals but no significant tropical or infectious diagnosis was made. Of those who returned for follow-up, 61% reported improvement in symptoms. The Clinical Global Impressions Severity scale improvement was 1.36 for DI patients but only 0.63 for non-DI patients. DI patients were more impaired at baseline (5.0 vs 4.1). Health anxiety was the most common diagnosis seen in those not considered to have DI.

Conclusions

Combined clinics to treat DI are effective in improving patient outcome. A significant minority of patients referred do not have a diagnosis of DI.