The skin is an organ with a definite mind-body connection; for example, mental stress is known to worsen chronic skin diseases such as psoriasis and eczema. Even those of us without longstanding skin conditions likely have experienced how the psyche can affect the skin. Perhaps you have experienced the power of suggestion and felt itchy after watching someone dig at a mosquito bite or a rash. Or perhaps you noticed an unexplainable redness, spot, or itch after you heard your neighbor's child was diagnosed with scabies or lice, and it created just enough anxiety to spend a few hours searching on the Internet to reassure yourself that your symptoms aren't from a horrible infection or infestation. There are many individuals and families who will take it one step further and seek reassurance from their doctor or dermatologist. Typically, when we are offered a reasonable alternate explanation and reassured by a professional, it is enough to soothe our anxieties, and as soon as we stop thinking and worrying about the problem, it goes away.
It is not uncommon for me to see in the office, however, individuals for whom such assurances are not sufficient. Many of them drive long distances seeking help for their skin condition and have already seen multiple providers, including dermatologists and emergency room, infectious disease, and primary care physicians. In many of these situations, the complaint is a specific symptom, such as an unexplainable itch or the sensation of crawling or the experience of being bitten. When no culprit for the biting or stinging can be found, rather than accepting an alternate explanation or reassurance that the symptoms and findings are not consistent with known infestations, these patients are only distressed further and seek more specialized expertise to help them identify the creature that is causing their symptoms. Many of them have scars and marks on skin from scratching and/or attempting to "dig out" the parasite. In dermatological practice, this situation comes by multiple names: neurodermatitis, neurotic excoriations, delusions of parasitosis, and others.
Morgellons disease is an extremely controversial diagnosis that has emerged in the last decade. It is viewed by many health professionals as an extreme and specific type of neurodermatitis, characterized by the "fixed belief" of having threadlike fibers emerging from or embedded within the skin, with or without symptoms such as crawling, biting, and itching. Sufferers of Morgellons disease, however, would argue that theirs is a true diagnosis and the presence of such fibers can be proven. The Center for Disease Control (CDC), meanwhile, has termed it an "unexplained dermopathy" in which "[p]ersons who suffer from this condition report a range of cutaneous or skin symptoms including crawling, biting and stinging sensations; granules, threads, fibers, or black speck-like materials on or beneath the skin; and/or skin rashes or sores" (http://www.cdc.gov/unexplaineddermopathy/). A recent study performed at the Mayo Clinic (http://archderm.ama-assn.org/cgi/content/short/archdermatol.2011.114) looked into this diagnosis, and found that in 107 of 108 patients who complained of symptoms of Morgellons, there was no microscopic evidence of infestation on skin biopsy. In the single patient in whom a cause for his symptoms was determined to be an infestation, a pubic louse was found. Thus, the authors conclude that Morgellons disease is indeed likely a delusion or a disease of the mind.
I have been asked by more than one patient with Morgellons disease (usually self-diagnosed) if I believe it is a true disease. The long and short of it is, I sincerely believe that people who are suffering from the symptoms of Morgellons have genuine disease that can be treated. I cannot say that I believe Morgellons to be a unique diagnosis, but rather a syndrome of symptoms of multiple conditions that share similar features. For example, anyone who has suffered from scabies can tell you that the itching from this common infestation is maddening, and even months to years after effective treatment, even the slightest itch will bring on the concern of reinfestation. The anxiety this may cause affects different individuals differently – some may require reassurance from a medical professional, while others will only rest easy if they receive additional treatment. In the meantime, there will always be people in whom the anxiety plays such a large role in their symptoms that it heightens their senses and symptoms, leading to a vicious cycle where even multiple expert opinions offering a clean bill of health do not provide any comfort. There are numerous skin conditions where anxiety, stress, and other psychological factors play a large, if not dominating, role in the symptoms, but where true skin disease is also present. This can be even as simple as dry skin (also known as xerosis cutis), which in cold, dry climates is so symptomatic and at times debilitating that it is called "winter itch." I feel that the only successful way to treat these patients is through addressing both issues: that the skin can be a diseased organ, and that stress and anxiety can worsen disease. This can be difficult in patients who may lack insight into the latter, but through my experience, offering support that you will be available to help them cope with their condition, and that you are willing and eager to help them when others have labeled them as "crazy" can help to open doors to a therapeutic relationship and finally allow the healing to begin.