Body dysmorphic disorder vs delusional disorder somatic type (delusional infestation.)

[mistermahdy]

Having a hard time making the diagnosis clinically between these two. the delusion of bugs has caused enough impairment to cause the patient to change their day to day habits, give up on life, caused isolation despite multiple fumigations and derm visits. I can be more detailed if needed but i'll keep things like this for now.

Per DSM V delusional disorder: " Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd." This statement alone I feel makes her not fit into the delusional disorder because of the evident impairment.

Is it possible to have both of these at once? o.0 The treatment for both are very different, BDD even with psychotic thinking, uses SSRI's while delusional infestation appears to respond to antipsychotics.

Lookin for protips, thanks.

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[Merely]

What is ASA? It says you’re ASA member

 

[clausewitz2]

Having a hard time making the diagnosis clinically between these two. the delusion of bugs has caused enough impairment to cause the patient to change their day to day habits, give up on life, caused isolation despite multiple fumigations and derm visits. I can be more detailed if needed but i'll keep things like this for now.

Per DSM V delusional disorder: " Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd." This statement alone I feel makes her not fit into the delusional disorder because of the evident impairment.

Is it possible to have both of these at once? o.0 The treatment for both are very different, BDD even with psychotic thinking, uses SSRI's while delusional infestation appears to respond to antipsychotics.

Lookin for protips, thanks.

That sounds exactly like impairment stemming from the ramifications of the delusion actually.

Neuroleptics are used as second/third line for OCD spectrum disorders all the time so it doesn't make that much of a difference.

Which is worse in terms of functional impact - anxiety related to the belief or intense preoccupation with it and inability to talk/think about other things? If the first SSRIs, if the later neuroleptics. Psychosis is not a risperidone-deficiency and BDD is not a fluvoxamine-deficiency.

Edit: also this is classic Ekbom's syndrome, thinking in purely DSM terms is a mistake.

 

[clozareal]

The DSM-5 doesn't offer much guidance on this differential diagnosis:
"In somatic symptom disorder, the individual's beliefs that somatic symptoms might reflect serious underlying physical illness are not held with delusional intensity. Nonetheless, the individual's beliefs concerning the somatic symptoms can be firmly held. In contrast, in delusional disorder, somatic subtype, the somatic symptom beliefs and behavior are stronger than those found in somatic symptom disorder."

 

[Mass Effect]

Maybe this is just me being concrete, but I don't see how you can make a diagnosis of BDD when the dysmorphia is due to a delusion of bugs. Maybe you could make an argument for OCD with appearance preoccupation, but I don't get the BDD.

 

[Mass Effect]

The DSM-5 doesn't offer much guidance on this differential diagnosis:
"In somatic symptom disorder, the individual's beliefs that somatic symptoms might reflect serious underlying physical illness are not held with delusional intensity. Nonetheless, the individual's beliefs concerning the somatic symptoms can be firmly held. In contrast, in delusional disorder, somatic subtype, the somatic symptom beliefs and behavior are stronger than those found in somatic symptom disorder."

That's because it's ridiculous that these two diagnoses exist when they're almost identical. This is the problem with the DSM. There is no reason these are two different pathologies.

 

[splik]

this is delusional parasitosis (or as clauswitz says, Ekbom syndrome. I like eponyms but unfortunately, this syndrome has also been incorrectly ascribed to restless leg syndrome as well, diminishing the utility). In older patients, consider underlying cerebrovascular disease. In younger patients, consider underlying stimulant (or less commonly) opioid use disorder. BDD is not even on the differential.

The DSM has a rider, which is that the diagnostic criteria should not be a substitute for common sense. Which is to say none of the criteria in the DSM are necessary for you to make a diagnosis if your clinical impression tells you otherwise.

The treatment of delusional parasitosis is often with high dose SSRIs and exposure and response prevention anyway. Neuroleptics can sometimes be helpful (again etiology is important here - I am much more likely to use neuroleptics if the parasitosis is related to methamphetamines, and much more likely to use SSRIs if related to cerebrovascular disease).

 

[clausewitz2]

this is delusional parasitosis (or as clauswitz says, Ekbom syndrome. I like eponyms but unfortunately, this syndrome has also been incorrectly ascribed to restless leg syndrome as well, diminishing the utility). In older patients, consider underlying cerebrovascular disease. In younger patients, consider underlying stimulant (or less commonly) opioid use disorder. BDD is not even on the differential.

The DSM has a rider, which is that the diagnostic criteria should not be a substitute for common sense. Which is to say none of the criteria in the DSM are necessary for you to make a diagnosis if your clinical impression tells you otherwise.

The treatment of delusional parasitosis is often with high dose SSRIs and exposure and response prevention anyway. Neuroleptics can sometimes be helpful (again etiology is important here - I am much more likely to use neuroleptics if the parasitosis is related to methamphetamines, and much more likely to use SSRIs if related to cerebrovascular disease).

I thought restless leg was Willis-Ekbom syndrome

 

[Mass Effect]

this is delusional parasitosis (or as clauswitz says, Ekbom syndrome. I like eponyms but unfortunately, this syndrome has also been incorrectly ascribed to restless leg syndrome as well, diminishing the utility). In older patients, consider underlying cerebrovascular disease. In younger patients, consider underlying stimulant (or less commonly) opioid use disorder. BDD is not even on the differential.

The DSM has a rider, which is that the diagnostic criteria should not be a substitute for common sense. Which is to say none of the criteria in the DSM are necessary for you to make a diagnosis if your clinical impression tells you otherwise.

The treatment of delusional parasitosis is often with high dose SSRIs and exposure and response prevention anyway. Neuroleptics can sometimes be helpful (again etiology is important here - I am much more likely to use neuroleptics if the parasitosis is related to methamphetamines, and much more likely to use SSRIs if related to cerebrovascular disease).

Agree with the diagnosis of delusional parasitosis. OP, I don't understand the appearance connection. I thought you were trying to say the delusion of bugs was affecting appearance, but as I read your original post again, you make no mention of that.

 

[whopper]

ASA= American Sexy Association.

I tried to join but I wasn't sexy enough.

Seriously, in situations like this make sure the bug thing is a delusion. I've had a few patients who really did have the bugs in question and their PCP blew it off as delusional without really investigating it.

 

[WisNeuro]

Seriously, in situations like this make sure the bug thing is a delusion. I've had a few patients who really did have the bugs in question and their PCP blew it off as delusional without really investigating it.

Or possibly some PTSD-like symptoms secondary to a previous infestation. I've seen a case of someone who had a pretty severe bedbug infestation, who became very hypervigilant and thought that every red mark, itch, etc was a recurrent infestation.

Also, if the patient says anything about Morgellon's, good luck with that one.

 

[thoffen]

We are acting as if these entities have very well established treatments with good outcomes. Fact is clear delineations for these illnesses with pathophysologic understanding is poor, and few are motivated to actually attempt or continue the recommended treatments. The evidence comes from case studies, case series, and almost no RCTs.

But I agree that this is clear delusional parasitosis. I always quibble with the DSM exception of "functioning is not markedly impaired". In my experience with delusional disorder in general, the delusional system can have enormous impact on somebody's life as they modify their behavior in attempts to avoid the delusions. People become unemployed, they move, they rack up debt seeking medical evaluations, they lose people in their life who are exhausted with their delusions, etc. In all cases, outside of the delusional system, none I've seen had impairment in their functional capacity. Their functional impairment was voluntary as direct consequence of the delusions. But, at best, if some patients were excepted by being too impaired, they'd usually be categorized as "other specified psychotic disorder", although there are some cases of delusional disorder patients having hallucinations so long as they are not prominent in the illness which might push toward a schizophrenia diagnosis based on functional impairment.

 

[clausewitz2]

Or possibly some PTSD-like symptoms secondary to a previous infestation. I've seen a case of someone who had a pretty severe bedbug infestation, who became very hypervigilant and thought that every red mark, itch, etc was a recurrent infestation.

Also, if the patient says anything about Morgellon's, good luck with that one.

While it doesn't kill as many people as the pro-ANA community, I agree with you about the difficulty if someone has gotten hooked up with the Morgellon's community. Even the gangstalking/targeted individual/voice-to-skull people have been more willing to engage in my own experience.

At the same time if the alternative identity I have to offer is "you're a mental patient" I get why they'd rather insist on fibers.

 

[Sushirolls]

this is delusional parasitosis (or as clauswitz says, Ekbom syndrome. I like eponyms but unfortunately, this syndrome has also been incorrectly ascribed to restless leg syndrome as well, diminishing the utility). In older patients, consider underlying cerebrovascular disease. In younger patients, consider underlying stimulant (or less commonly) opioid use disorder. BDD is not even on the differential.

The DSM has a rider, which is that the diagnostic criteria should not be a substitute for common sense. Which is to say none of the criteria in the DSM are necessary for you to make a diagnosis if your clinical impression tells you otherwise.

The treatment of delusional parasitosis is often with high dose SSRIs and exposure and response prevention anyway. Neuroleptics can sometimes be helpful (again etiology is important here - I am much more likely to use neuroleptics if the parasitosis is related to methamphetamines, and much more likely to use SSRIs if related to cerebrovascular disease).

High dose SSRI? When did they replace antipsychotics for Delusional Parasitosis of any etiology? Any literature on this?

 

[WisNeuro]

While it doesn't kill as many people as the pro-ANA community, I agree with you about the difficulty if someone has gotten hooked up with the Morgellon's community. Even the gangstalking/targeted individual/voice-to-skull people have been more willing to engage in my own experience.

At the same time if the alternative identity I have to offer is "you're a mental patient" I get why they'd rather insist on fibers.

The people with somatic beliefs as intractable as this, just like many in the "chronic lyme," fibro, and other similar communities are definitely suffering. Unfortunately it's a tough thing as a clinician to deal with. How do you validate their suffering in a way that they will really hear it, and not feed into their false beliefs? These are people you can order every diagnostic test under the sun, and despite 100% of those tests coming back negative, they simply believe that the healthcare establishment is failing them. You can try to refer out for therapy/counseling, but I'm sure you can imagine that very few are willing to accept a psychological explanation. It's tough, and the internet has simply made these things even more intractable as these people can now connect with similar others and share their "research."

 

[clausewitz2]

The people with somatic beliefs as intractable as this, just like many in the "chronic lyme," fibro, and other similar communities are definitely suffering. Unfortunately it's a tough thing as a clinician to deal with. How do you validate their suffering in a way that they will really hear it, and not feed into their false beliefs? These are people you can order every diagnostic test under the sun, and despite 100% of those tests coming back negative, they simply believe that the healthcare establishment is failing them. You can try to refer out for therapy/counseling, but I'm sure you can imagine that very few are willing to accept a psychological explanation. It's tough, and the internet has simply made these things even more intractable as these people can now connect with similar others and share their "research."

I think it is especially tricky because there is probably some very small fraction (I would guesstimate maybe 5%) who probably are dealing with some poorly understood systemic condition that simply hasn't been well-described or characterized yet. I mean, we used to think Parkinson's and multiple sclerosis were psychosomatic conditions, and while the psychological/psychiatric aspects of those disorders are often not addressed as well as they should be, therapy alone is not going to resolve an acute MS flare or a PD tremor.

On the other hand, being cognizant of this probably helps me sound more convincing and sincere when I tell these folks that I am not qualified or able to resolve the problem they identify but am able to help them with the business of figuring out how to get on with their life.

 

[WisNeuro]

I think it is especially tricky because there is probably some very small fraction (I would guesstimate maybe 5%) who probably are dealing with some poorly understood systemic condition that simply hasn't been well-described or characterized yet. I mean, we used to think Parkinson's and multiple sclerosis were psychosomatic conditions, and while the psychological/psychiatric aspects of those disorders are often not addressed as well as they should be, therapy alone is not going to resolve an acute MS flare or a PD tremor.

I'm willing to believe that a small portion may have something that we do not have tests sensitive enough for. But, the majority are those that have been having various psychiatric problems for decades. I see it often enough in my neck of the woods with chronic lyme. Their symptoms precede any actual lyme exposure by years, if not decades. These are also patients who fail PVT/SVT's at a clip similar to certain VA clinics. The SSDI siren is strong in this group.

 

[mbgr2014]

While it doesn't kill as many people as the pro-ANA community, I agree with you about the difficulty if someone has gotten hooked up with the Morgellon's community. Even the gangstalking/targeted individual/voice-to-skull people have been more willing to engage in my own experience.

At the same time if the alternative identity I have to offer is "you're a mental patient" I get why they'd rather insist on fibers.

Now the bit about gangstalking is a really interesting one. I only discovered this a few weeks ago and happened to step into a Gangstalking protest?/public meeting? outside the California state capitol... thought about it for a few minutes and left because I didn't want to become part of someone's delusion.

 

[SourceOfDenial]

While it doesn't kill as many people as the pro-ANA community, I agree with you about the difficulty if someone has gotten hooked up with the Morgellon's community. Even the gangstalking/targeted individual/voice-to-skull people have been more willing to engage in my own experience.

At the same time if the alternative identity I have to offer is "you're a mental patient" I get why they'd rather insist on fibers.

Last time I checked there seemed to be more scientific basis for spirochete infection driving morgellons than there was 10 years ago. Even my derm colleagues are more open to it being a derm condition than a psych condition compared to a few years ago. I was surprised to say the least.

I get the provider concern over these communities, but I think the onus should be on us to do a better job understanding these illnesses rather than crapping on these groups. A group with a stigmatized and poorly understood condition coming together to advocate for what they think is best for themselves seems pretty reasonable.

 

[clausewitz2]

Last time I checked there seemed to be more scientific basis for spirochete infection driving morgellons than there was 10 years ago. Even my derm colleagues are more open to it being a derm condition than a psych condition compared to a few years ago. I was surprised to say the least.

I get the provider concern over these communities, but I think the onus should be on us to do a better job understanding these illnesses rather than crapping on these groups. A group with a stigmatized and poorly understood condition coming together to advocate for what they think is best for themselves seems pretty reasonable.

There is a single research group that seems to think they have evidence of an association with spirochetes; this opinion appears to be a minority one at best in Dermland. Previous studies analyzing samples of the fibers have demonstrated them to be made of cellulose for the most part.

But that was sort of the point of my post and the follow up a little downthread - making them feel as if the are being lumped into a stigmatized group is of course going to make anyone want to seek out an alternative, more supportive community instead.

I expect we have a similar approach in focusing on the misery and not engaging closely with the somatic complaint of we are working with these folks, but definitely correct me if you come at it differently.

 

[thoffen]

I think the point about some patients in this category legitimately having illness that is unrecognized is of course necessary. But I think there needs to be a unified approach regardless. Whether or not a medical illness exists, the patients experience the same distress and same dynamics with providers. In either case, it's important to always keep an open differential but only do the medical evaluations that are actually indicated. And the best results come from a close relationship with the medical provider who will both provide frequent empathic contact and appropriate boundaries around evaluation and treatment. This basically goes for any medical complaint that aligns with primary gain. Whether it's an individual with medical illness who uses it to satisfy primary gain, a person delusional about illness, a somatiform or conversion illness, or frank factitious disorder. The reality is the primary gain is at the least a wish that is worth empathizing with, but the way in which it is being gratified may not be healthy. Sometimes you can help people understand what they are gratifying without feeling judged for doing so and help them find another way to address their wish or cope with its inevitable frustration. But that outcome is never compatible with trying to dump the patient on someone else, be it psychiatrist or medical specialist.