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Time and Effort to Establish Therapeutic Rapport With Delusional Patients: Comment on “Delusional Infestation, Including Delusions of Parasitosis ”

Time and Effort to Establish Therapeutic Rapport With Delusional Patients: Comment on... Up to 90% of patients with delusions of parasitosis (DOP) seek help from dermatologists.1 It would be ideal for patients with DOP to be treated in conjunction with psychiatrists or other mental health professionals. However, patients with DOP often refuse a referral to see a mental health professional because they are unable to recognize the underlying psychiatric cause of their condition. Thus, dermatologists are faced with the challenge of how to effectively treat patients with DOP.2 The most important step toward successful treatment of DOP is to establish strong therapeutic rapport. Dermatologists must build and maintain a trusting alliance with patients with DOP. Only through this crucial step will dermatologists convince these patients to try an antipsychotic —the most definitive intervention that dermatologists can offer. The practice gap is that many dermatologists are unaware or do not accept that establishing therapeutic rapport is of foundational importance in treating patients with DOP. Without adequate rapport, simply giving a prescription for an antipsychotic would be useless, because patients with DOP are unlikely to comply. The article by Hylwa et al3 highlights this practice gap when the authors raise the question of whether biopsies are necessary in treating patients with DOP. The authors conclude that the biopsy results do not change a physician's clinical diagnosis. Dermatologists perform biopsies for a variety of reasons, including helping to make a previously unknown diagnosis, confirming their clinical suspicion, and excluding other less likely diagnoses. If a biopsy result does not alter the working diagnosis, it does not mean the biopsy is not of value. Laboratory tests, performing a culture swab, or examining patient specimen samples may have similar value. In addition, depending on how these steps are conducted, they can be immensely helpful in building therapeutic rapport. It demonstrates to the patient that their concerns are being taken seriously. In contrast, if a dermatologist adamantly refuses to do a biopsy or review specimen samples, this can easily lead to a power struggle between the dermatologist and the patient, thereby threatening to rupture therapeutic rapport. Therefore, beyond just making clinical diagnoses or prescribing antipsychotic drugs, dermatologists must be cognizant that the interpersonal and psychological aspects of the patient encounter are of critical importance to bring about the successful treatment of patients with DOP. To narrow this practice gap, formal education and specific training on DOP should be incorporated into dermatology residency programs and offered as continuing medical education courses. In addition to instruction regarding appropriate use of antipsychotic drugs, education should include teaching empathetic communication techniques that help dermatologists build therapeutic rapport. The development of psychodermatology clinics, wherein interdisciplinary services from dermatologists and mental health professionals are provided, will likely narrow this practice gap as well. Barriers to change may include dermatologists' discomfort interacting with or spending the necessary time with patients with DOP and reluctance to prescribe antipsychotics. Dermatologists are, however, in the unique situation to help these patients. If not for dermatologists, patients with DOP may never receive appropriate therapy for this potentially life-ruining disorder. Ultimately, dermatologists in some cases might consider performing a biopsy to confirm their clinical suspicion, to exclude other less likely diagnoses, and to instill rapport-building confidence that the therapy offered is the appropriate choice for the patient, thus optimizing the chance of success. Back to top Article Information Correspondence: Dr Koo, Department of Dermatology, University of California, San Francisco Medical Center, 515 Spruce St, San Francisco, CA 94118 (john.koo@ucsfmedctr.org). Financial Disclosure: None reported. References 1. Freudenmann RW, Lepping P. Delusional infestation. Clin Microbiol Rev. 2009;22(4):690-73219822895PubMedGoogle ScholarCrossref 2. Koo J, Lee CS. Delusions of parasitosis: a dermatologist's guide to diagnosis and treatment. Am J Clin Dermatol. 2001;2(5):285-29011721647PubMedGoogle ScholarCrossref 3. Hylwa SA, Bury JE, Davis MDP, Pittelkow M, Bostwick JM. Delusional infestation, including delusions of parasitosis: results of histologic examination of skin biopsy and patient-provided skin specimens. Arch Dermatol. 2011;147(9):1041-1045Google ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Dermatology American Medical Association

Time and Effort to Establish Therapeutic Rapport With Delusional Patients: Comment on “Delusional Infestation, Including Delusions of Parasitosis ”

Time and Effort to Establish Therapeutic Rapport With Delusional Patients: Comment on “Delusional Infestation, Including Delusions of Parasitosis ”

Abstract

Up to 90% of patients with delusions of parasitosis (DOP) seek help from dermatologists.1 It would be ideal for patients with DOP to be treated in conjunction with psychiatrists or other mental health professionals. However, patients with DOP often refuse a referral to see a mental health professional because they are unable to recognize the underlying psychiatric cause of their condition. Thus, dermatologists are faced with the challenge of how to effectively treat patients with DOP.2 The...
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Publisher
American Medical Association
Copyright
Copyright © 2011 American Medical Association. All Rights Reserved.
ISSN
0003-987X
eISSN
1538-3652
DOI
10.1001/archdermatol.2011.237
Publisher site
See Article on Publisher Site

Abstract

Up to 90% of patients with delusions of parasitosis (DOP) seek help from dermatologists.1 It would be ideal for patients with DOP to be treated in conjunction with psychiatrists or other mental health professionals. However, patients with DOP often refuse a referral to see a mental health professional because they are unable to recognize the underlying psychiatric cause of their condition. Thus, dermatologists are faced with the challenge of how to effectively treat patients with DOP.2 The most important step toward successful treatment of DOP is to establish strong therapeutic rapport. Dermatologists must build and maintain a trusting alliance with patients with DOP. Only through this crucial step will dermatologists convince these patients to try an antipsychotic —the most definitive intervention that dermatologists can offer. The practice gap is that many dermatologists are unaware or do not accept that establishing therapeutic rapport is of foundational importance in treating patients with DOP. Without adequate rapport, simply giving a prescription for an antipsychotic would be useless, because patients with DOP are unlikely to comply. The article by Hylwa et al3 highlights this practice gap when the authors raise the question of whether biopsies are necessary in treating patients with DOP. The authors conclude that the biopsy results do not change a physician's clinical diagnosis. Dermatologists perform biopsies for a variety of reasons, including helping to make a previously unknown diagnosis, confirming their clinical suspicion, and excluding other less likely diagnoses. If a biopsy result does not alter the working diagnosis, it does not mean the biopsy is not of value. Laboratory tests, performing a culture swab, or examining patient specimen samples may have similar value. In addition, depending on how these steps are conducted, they can be immensely helpful in building therapeutic rapport. It demonstrates to the patient that their concerns are being taken seriously. In contrast, if a dermatologist adamantly refuses to do a biopsy or review specimen samples, this can easily lead to a power struggle between the dermatologist and the patient, thereby threatening to rupture therapeutic rapport. Therefore, beyond just making clinical diagnoses or prescribing antipsychotic drugs, dermatologists must be cognizant that the interpersonal and psychological aspects of the patient encounter are of critical importance to bring about the successful treatment of patients with DOP. To narrow this practice gap, formal education and specific training on DOP should be incorporated into dermatology residency programs and offered as continuing medical education courses. In addition to instruction regarding appropriate use of antipsychotic drugs, education should include teaching empathetic communication techniques that help dermatologists build therapeutic rapport. The development of psychodermatology clinics, wherein interdisciplinary services from dermatologists and mental health professionals are provided, will likely narrow this practice gap as well. Barriers to change may include dermatologists' discomfort interacting with or spending the necessary time with patients with DOP and reluctance to prescribe antipsychotics. Dermatologists are, however, in the unique situation to help these patients. If not for dermatologists, patients with DOP may never receive appropriate therapy for this potentially life-ruining disorder. Ultimately, dermatologists in some cases might consider performing a biopsy to confirm their clinical suspicion, to exclude other less likely diagnoses, and to instill rapport-building confidence that the therapy offered is the appropriate choice for the patient, thus optimizing the chance of success. Back to top Article Information Correspondence: Dr Koo, Department of Dermatology, University of California, San Francisco Medical Center, 515 Spruce St, San Francisco, CA 94118 (john.koo@ucsfmedctr.org). Financial Disclosure: None reported. References 1. Freudenmann RW, Lepping P. Delusional infestation. Clin Microbiol Rev. 2009;22(4):690-73219822895PubMedGoogle ScholarCrossref 2. Koo J, Lee CS. Delusions of parasitosis: a dermatologist's guide to diagnosis and treatment. Am J Clin Dermatol. 2001;2(5):285-29011721647PubMedGoogle ScholarCrossref 3. Hylwa SA, Bury JE, Davis MDP, Pittelkow M, Bostwick JM. Delusional infestation, including delusions of parasitosis: results of histologic examination of skin biopsy and patient-provided skin specimens. Arch Dermatol. 2011;147(9):1041-1045Google ScholarCrossref

Journal

Archives of DermatologyAmerican Medical Association

Published: Sep 1, 2011

Keywords: delusions,delusions of infestation,delusions of parasitosis

References