Perspective
Morgellons Disease, or Antipsychotic-Responsive
Delusional Parasitosis, in an HIV Patient:
Beliefs in The Age of the Internet
Oliver Freudenreich, M.D., Nicholas Kontos, M.D.
Constantin Tranulis, M.D., Corinne Cather, Ph.D.
“Which was worse, the real condition or the self-created
one; and did it matter?”
— Don DeLillo: “White Noise” Viking Press © 1985
M orgellons disease (also referred to as Morgel-
lons syndrome or Morgellons) has been publi-
cized through the Internet as an unexplained syndrome
presenting with cutaneous dysesthesias associated with
foreign material like fibers or parasites.1 A lay person,
Mary Leitao, was instrumental in naming the disease after
her 2-year-old son developed sores and began to complain
about bugs. She established a nonprofit research organi-
zation, the Morgellons Research Foundation (MRF) and
lobbied for widespread recognition. Under public and po-
litical pressure (e.g., letters to the Centers for Disease
Control [CDC] from Senators Schumer and Clinton2) the
CDC has launched an epidemiologic investigation into this
unexplained dermopathy.3 Table 1 shows how this condi-
tion rose to relative prominence in less than a decade.
The phenomenological overlap, however, with delu-
sional parasitosis has not escaped attention.4 A brief look
at a proposed case definition (Table 2) shows the phenom-
enological overlap with regard to a core feature of delu-
sional parasitosis (the sense of something moving in or
under one’s skin), as well as a host of nonspecific symp-
toms. Is the creation of this new syndrome necessary or
useful?
Vila-Rodriguez and MacEwan5 have raised awareness
about the facilitative role of the Internet in the spread of
bizarre beliefs and shared delusional ideation, which raises
the question of whether the propagation of new syndromes
by laypersons is unavoidable in the age of the Internet.
Herein, the authors describe the case of a patient with
human immunodeficiency virus (HIV) disease and classic
Psychosomatics 51:6, November-December 2010
delusions of parasitosis, who diagnosed himself with
Morgellons disease, yet responded to antipsychotic medi-
cation. The authors propose an infectious-disease, vector-
based model to explain the emergence and rapid rise of
Morgellons and suggest principles of management for
cases of antipsychotic-responsive cases of Morgellons.
CASE REPORT
“Mr. A” was a 43-year-old man with a 20-year history of
human immunodeficiency virus (HIV) infection. Although
his adherence to highly-active antiretroviral treatment
(HAART) had been sporadic, he had no acute medical
problems, and his CD4 count was 328. His most pressing
medical complaint was worrisome fatigue. He was not
depressed (BDI–II [Beck Depression Inventory, 2nd Edi-
tion] score of 11); he had no formal psychiatric history, no
family psychiatric history, and he was a successful busi-
nessman. He was referred to the psychiatry department by
his primary-care physician (PCP) because of a 2-year-long
complaint of pruritus accompanied by the belief of being
infested with parasites. Numerous visits to the infectious-
disease clinic and an extensive medical work-up, including
brain imaging and consultations with a dermatologist, had
not uncovered any medical disorder, to the patient’s great
frustration. Although no parasites were ever trapped, Mr.
Received January 24, 2009; revised February 26, 2009; accepted March
3, 2009. From Massachusetts General Hospital (OF, CC); Cambridge
Health Alliance (NK); Louis-H. Lafontaine Hospital (CT); Harvard Med-
ical School, Boston, MA (OF, NK, CC); University of Montreal, Mon-
treal, Canada (CT). Send correspondence and reprint requests to Oliver
Freudenreich, M.D., MGH Schizophrenia Program, Freedom Trail
Clinic, 25 Staniford St., 2nd Floor, Boston, MA 02114. e-mail:
ofreudenreich@partners.org
© 2010 The Academy of Psychosomatic Medicine
http://psy.psychiatryonline.org 453
Morgellons Disease (Delusional Parasitosis)
TABLE 1. History of the Term “Morgellons Disease”
1674: English doctor, Sir Thomas Brown, uses the term,
“morgellons” to describe black hairs emerging from skin lesions
in children.
2001: Mary Leitao’s 2-year-old son develops sores and begins to
complain about bugs.
2002: Mary Leitao names this new entity, Morgellons.
Mary Leitao founds Morgellons Research Foundation (MRF)
2004: MRF is officially established as non-profit organization.
2006: CBS airs a story about Morgellons.
First scientific article published, with Leitao as co-author.1
CDC Task Force meets.
MRF provides case definition.
2007: CDC Morgellons website opens.
2008: CDC launches formal epidemiologic investigation.
2009: 13,561 registered families (as reported on 2/26/09).
TABLE 2. Symptoms of Morgellons Disease (from CDC and
MRF websites3,24)
Cutaneous Symptoms
Granules, threads, fibers, or black speck-like materials on or
beneath the skin
Movement sensations (crawling, biting and stinging)
Skin lesions (e.g., rashes or sores, which may be spontaneous or
self-generated)
Ancillary Symptoms
Musculoskeletal effects and pain
Fatigue
Cognitive dysfunction (mental confusion, short-term memory loss)
Emotional effects
Other (e.g., shifting visual acuity, arthralgias, dyspepsia)
“Filaments” are reported in and on skin lesions and at times ex-
truding from intact-appearing skin. White, blue, red, and black are
common among described fiber colors. Size is near microscopic, and
good clinical visualization requires 10-30⫻. Patients frequently de-
scribe ultraviolet light-generated fluorescence. They also report black
or white granules, similar in size and shape to sand grains, on or in
their skin or on clothing. Most clinicians willing to invest in a simple
hand-held commercial microscope have thus far been able to consis-
tently document the filaments. (Description of filaments “cut-and-
pasted” from the MRF website.)
CDC: U.S. Centers for Disease Control; MRF: Morgellons Re-
search Foundation.
A caused skin damage by probing for them and by apply-
ing topical solutions such as hydrogen peroxide to “bring
them to the surface.” After reading about Morgellons dis-
ease on the Internet, he “recalled” extruding particles from
his skin, including “dirt” and “fuzz.”
During the initial consultation visit with the psychia-
trist, Mr. A was apprehensive but cautiously optimistic
that a medication could help. The psychiatrist had been
forewarned by the PCP that the patient had discovered a
website describing Morgellons and “latched onto” this
diagnosis. However, it was notable that the patient allowed
454 http://psy.psychiatryonline.org
the possibility (“30%”) that he was suffering from delu-
sions (and not Morgellons), mostly because he trusted his
PCP, “who has taken very good care of me for many
years.”
The patient agreed to a risperidone trial of up to 2 mg
per day. Within weeks, his preoccupation with being in-
fested lessened significantly. Because of subjective fa-
tigue, he was switched to aripiprazole 5 mg per day. Al-
though not 100% convinced that he might not have
Morgellons disease, he is no longer pruritic and is no
longer damaging his skin or trying to trap insects. He
remains greatly improved 1 year later.
DISCUSSION
We will limit our discussion to the specifics of our case: a
patient with self-diagnosed Morgellons who responded to an
antipsychotic trial. We are not attempting to create a nosol-
ogy for all cases of Morgellons, which likely comprise a
heterogeneous group, including, but not limited to, patients
with somatic delusions. Some cases are likely better concep-
tualized as nonpsychotic somatoform patients who function
poorly because of abnormal illness behaviors characterized
by heavy investment in the “right” diagnosis.6
1. How did Morgellons emerge in society?
Diseases cannot occur outside a societal context. For
any symptom, a suffering person may reach out to society
for help. Depending on the conceptualization of the prob-
lem by the patient and physician, different remedies will
be sought. In cases where orthodox explanatory models
are perceived as unhelpful or even insulting (e.g., “delu-
sional disorder”), patients will turn to fringe models (e.g.,
Morgellons). To understand how a single somatic experi-
ence can be interpreted and acted on in different ways,
cognitive models of how we form ideas, including delu-
sions, and broader models about disease labels and how
we become patients, are perhaps best viewed as separate,
sequential events (Figure 1 [A]). Note, however, that the
two processes do interact: after all, the emergence of
Morgellons in an individual is not possible without the
emergence of Morgellons as a possibility in society.
2. How does a perception become a delusion?
Maher7 conceptualized delusions as an individual’s
attempt to explain perceptual abnormalities (depicted as
[A] in Figure 1). The delusional explanation is then main-
Psychosomatics 51:6, November-December 2010

FIGURE 1. From Perception to Diagnosis and Treatment: The
Role of Individual Beliefs, the Power to Assign
Diagnoses, and the Internet as Vector to Spread
Ideas, Including Explanatory Disease Models
A bly all been on the rise in Western society since the
Perception
Symptoms
Patient Power MD
Diagnosis Diagnosis
D
Internet
Treatment Treatment
B Fringe Orthodoxy
How does a perception become a disease? [A]: People interpret
perception in context of cognitive schemes (the “Problem”). [B]:
People choose between competing explanatory models (possible
“Solutions”) and seek help accordingly. [C]: POWER determines
legitimacy of models (“orthodoxy” versus “fringe.”)
How could Morgellons emerge? [C]: Today’s patients are more
empowered. [D]: The Internet as “vector” to spread ideas, good and
bad. Difficult containment; the fringe ceases to be perceived as fringe.
tained by the relief it provides by functioning as an orga-
nizing framework. This early, sensorial model made an
important contribution because it suggested that delusional
beliefs represent a special case of general belief-formation.
However, although perceptual abnormalities can precede
delusional belief-formation, this is not always the case. It
is currently thought that delusions may also arise from
attempts to explain negative affect, or from misinterpreta-
tions of external events due to information-processing bi-
ases associated with negative internal states.8 Contempo-
rary cognitive models of delusional-formation and main-
tenance suggest the following key elements: 1) preexisting
beliefs about the self as vulnerable and the world as threat-
ening; 2) cognitive biases that preferentially process in-
formation as threatening; 3) “safety behaviors” that block
the processing of disconfirmatory evidence; and 4) belief
that one’s own perceptions are infallible.9,10 In the current
case, a central clinical question is the identification of
factors that may have influenced this patient’s interpreta-
tion of a potentially benign somatic sensation (i.e., itching)
as sign of parasites. Predisposing cognitive schemas could
Psychosomatics 51:6, November-December 2010
Freudenreich et al.
include mistrust of the medical system, positive beliefs
about hypervigilance to somatic sensations, and beliefs
about the intolerability of physical discomfort. Although
psychotically exaggerated here, these schemas have nota-
1960s.11,12 Once formed, a Morgellons interpretation may
be maintained and strengthened by serving a short-term
anxiety-reduction function and by ameliorating social iso-
lation through engagement with a community of Morgel-
lons sufferers. The widespread acceptance of Morgellons
poses a peculiar problem of definition.
All attempts at defining delusions have tried to ac-
C
commodate our multicultural world by acknowledging
that beliefs are not delusional if they are shared by a
reference group. In today’s “virtual” world, delusions are
embodied in new forms and need new definitions to take
into account contemporary realities. How many patients
with delusional disorder need to sign up at a website for
the delusion to cease to exist as such, since the belief is
shared by so many?
3. How do we become patients?
Simply having medical complaints— or self-diag-
noses— does not turn people into patients. People become
patients when they seek care from a physician,13 and are
only afforded the privileges (and duties) of the sick when
a physician makes a diagnosis.14 For any complaint, com-
peting explanatory schemes of varying medical and/or lay
social legitimacy are available, but, to be granted both
patient and sick roles, a social negotiation must occur
between patient and physician. Ultimately, however, it is
the patient who decides whether to accept or reject the
physician’s explanation for his or her symptoms (see “B”
in Figure 1).
On the basis of Mr. A’s clinical picture and treatment
response, his presentation is well explained by the con-
ventional diagnosis of delusional parasitosis, rather than
Morgellons disease. However, there are a number of rea-
sons to account for the greater acceptance of a Morgellons
diagnosis than a “delusional disorder” diagnosis. Whereas
“delusional disorder” is a medical disorder conveying the
idea that the suffering is “all in your head,” the diagnosis
of Morgellons is sustained by laypersons’ lobbying, which
provides an explanation that is not stigmatizing to the
individual, labels conventional dermatologic medicine as
having failed its sufferers (which is consistent with the
patient’s experience with medicine, and, therefore, em-
powering), and creates a community of shared experience
http://psy.psychiatryonline.org 455
Morgellons Disease (Delusional Parasitosis)
through Internet blogs and chat-rooms. Whereas delu-
sional disorder is pathophysiologically invisible (i.e.,
“imagined”), Morgellons is purportedly visible (i.e., an
infectious agent), and thus claims a mainstream patho-
physiological substrate. Clearly, not all disease labels are
equally desirable. People crave patienthood if it legiti-
mizes their suffering, but psychiatry’s labels are frequently
stigmatizing and perceived as devaluing. Today, patients
are more autonomous and free to pursue labels not neces-
sarily accepted by orthodoxy. In no small measure, the
Internet has accelerated this shift of power away from
physicians as sources of expert knowledge (see “C” in
Figure 1). The Internet offers lay people further traits of
professions, such as networking, organization, and means
of lobbying before public officials.
4. What has led to Morgellons’ rapid rise?
There are other reasons why it is difficult to imagine
that the rapid rise of Morgellons could have occurred
without the Internet: The Internet provides easy spread of
ideas, along with a lack of containment. To use the lan-
guage of infections, the Internet can be regarded as a
“vector” that can spread information—without regard for
accuracy or usefulness. For example, the Internet was one
of the ways that inaccurate information regarding a causal
link between the measles/mumps/rubella (MMR) vaccine
and autism was disseminated and maintained. “Vaccina-
tions” or “antidotes,” in the form of skeptical, critical
websites could possibly stem the flow of inaccurate
(“bad”) ideas (e.g., http://morgellonswatch.com/); how-
ever, their efficacy is sometimes compromised by their
frequent origins within mistrusted authority structures
(e.g., “the medical establishment”).
See Table 3 for an infectious model of Internet-spread
of bad ideas based on vector-borne diseases. In this anal-
ogy, bad ideas are seen as pathogens. In a similar vein,
Lustig and colleagues15 have suggested that Morgellons
disease be regarded as an Internet meme: an idea compet-
TABLE 3. The Infectious-Disease Model of the Spread of
“Bad” Ideas in the Age of the Internet
Pathogen Inaccurate idea
Vector Internet
Vulnerable host Person in search of an explanation
Environment Hostile toward mainstream medicine, which
has failed patients
Vaccination/antidote Alternative (good) ideas from critical
websites
456 http://psy.psychiatryonline.org
ing in the marketplace of ideas for dominance—just as
infectious agents compete for dominance in an organism.
Ideas need “traction” in the same way that viruses require
hosts. In the case of MRF, that traction/host is provided by
the modern medical “gaze,” which emphasizes the eluci-
dation of obscure and complex symptoms by rational anal-
ysis of the visible body by means of the clinico-pathologic
and pathophysiologic methods of 18th- and 19th-century
Paris and German hospitals and universities.16,17 It is thus
not surprising that diseases without clearly established
focal lesions or biomarkers challenge the modern para-
digm, and, therefore, the modern physician. More impor-
tantly, such “diseases” represent a threat to the legitimacy
of many patients’ suffering, and they carry stigma.18 Even
with the quest for knowledge and remedies aside, the
preceding sheds light on the current preoccupation with
searching for “visible” lesions (e.g., through neuroimag-
ing) in psychiatry, as well as in any number of functional-
somatic syndromes, such as chronic fatigue syndrome and
fibromyalgia.19 One can thus understand the appearance of
Morgellons as a specific cultural variety of somatic syn-
drome20 engendered by a vicious cycle of somatic hyper-
vigilance on the part of the patient and an emphasis on the
visible and/or measurable as the dominant source of med-
ical knowledge in society.
5. How do we treat Morgellons?
Although it is perhaps counterintuitive, time-limited
treatment with an antipsychotic medication does not re-
quire physicians and patients to agree on etiology or di-
agnosis.21 By extension, open disagreement does not ob-
viate a positive therapeutic alliance. Often, the alliance can
be formed by joining with the patient around his or her
suffering as well as allowing for “doubt” on both sides. A
careful differential diagnosis of delusional parasitosis
(e.g., excluding “organic” conditions like scabies or can-
cer22) and spending time with the patient enhances the
credibility of the physician’s treatment recommendations,
which should be framed as time-limited treatment trials. It
is critical that these trials be undertaken in a collaborative
spirit, with the goal of alleviating suffering, rather than
proving who is “right,” a stance that will only increase
psychological reactance and thereby encourage rejection
of the antipsychotic. Flexibility on both sides is essential,
but does not require that the physician be disingenuous or
the patient passively cooperative. Although it is critical
always to acknowledge the patient’s ideas, it is imperative
that an objective, rational approach to the remediation of
Psychosomatics 51:6, November-December 2010

suffering prevails. It is an interesting observation that ob-
vious explanations (e.g., small, crusted blood specks on
the bedsheet from scratching or alumina from antiperspi-
rant) are vehemently dismissed by patients with delusional
parasitosis. Similarly, patients with Morgellons favor the
obscure and mysterious over the likely (e.g., preferring
nanofibers over dirt in excoriated wounds). Physicians,
however, should not feel pressured into dismissing the
obvious explanation and adopting a new syndrome like
Morgellons because of suffering alone.
Hence, offer proven treatments if patients fit classic
psychiatric syndromes such as delusional parasitosis (i.e.,
an antipsychotic); find ways to bring them into congruence
with both your and their conceptualizations; and focus on
the goal of relief, independent of cause. Acknowledge the
limits of medicine: a label of delusional disorder is no true
explanation (Erklärung in the Jasperian sense) at either the
etiological or pathophysiological level. In conclusion, pa-
tients who fit the profile of classic psychiatric syndromes
such as delusional parasitosis should be offered proven
treatments (i.e., antipsychotics23), regardless of their own
chosen label. Finding common ground is an overarching
concern, since delusional parasitosis becomes an untreat-
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In some respect, a diagnosis of delusional disorder is no
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Without the Internet, it is difficult to imagine the rise, in a
matter of years, of an obscure disease that lacks the im-
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This case and its discussion were first presented as a
poster at the 2008 Annual Meeting of the Academy of
Psychosomatic Medicine in Miami, FL.
The authors thank Dr. Michael Bostwick for his help-
ful comments.
None of the authors has any conflict of interest rele-
vant to this manuscript to declare.
Disclaimer: This article was written with the help of
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