Psychosomatics 39:491-500, December 1998
© 1998 The Academy of Psychosomatic Medine
Psychogenic Parasitosis
A Case Series and Literature Review
James R. Slaughter, M.D.,
Karen Zanol, M.D.,
Hushman Rezvani, M.D., and
Julia Flax, B.S.
Received November 20, 1997; revised March 4, 1998; accepted March 13, 1998. From the Department of Psychiatry & Neurology, University of Missouri–Columbia School of Medicine; the Department of Internal Medicine, Dermatology Division, University of Missouri–Columbia School of Medicine; and the School of Medicine, University of Missouri–Columbia. Address reprint requests to Dr. Slaughter, Department of Psychiatry and Neurology, One Hospital Drive, Columbia, MO 65212.
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ABSTRACT
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About 100 years ago, psychogenic parasitosis was first described in the literature. This peculiar symptom may complicate medical and psychiatric conditions or indicate the presence of a delusional disorder (somatic type). By using the authors' case series of 12 patients, which are reported in the article, and a review of the literature, an historical perspective and the authors' clinical orientation to evaluation and treatment of psychogenic parasitosis are presented.
Key Words: psychogenic parasitosis • delusions of parasitosis • delusional disorder • Review
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INTRODUCTION
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Around the turn of this century, case reports began to appear in the European literature describing a peculiar symptom in which patients considered themselves infested with parasites, when they in fact were not.1,2 Variously labeled a phobic disorder,1,2 a delusional disorder,3–5 tactile hallucinosis,6,7 and monosymptomatic hypochondriacal psychosis,8,9 psychogenic parasitosis continues to present diagnostic and therapeutic challenges to the clinician. In this article, we will trace the history of the symptom of delusions of parasites, report on our series of patients, and recommend a therapeutic intervention for these patients.
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HISTORICAL BACKGROUND
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Ekbom3 summarized 7 of his own cases of psychogenic parasitosis along with 15 previously reported cases in 1938. He theorized that abnormal sensations, parasthesias, lead to delusions that parasites were present. His summary gained notoriety, and psychogenic parasitosis was often subsequently referred to in European literature as "Ekbom's Syndrome."4 In 1946, in the English literature, Wilson and Miller5 reported 6 of their own cases and 45 prior cases, describing the disorder as "delusions of parasites." The researchers identified underlying etiologies, both organic (e.g., toxic psychosis) and functional (e.g., involutional melancholia). Wilson and Miller's observations of underlying causation is germane today, as psychogenic parasitosis is often the presenting symptom of a medical or psychiatric disorder.
Bers and Conrad,6 in 1954, and Berrios,4,7 writing 30 years later, noted the possible interplay between a tactile hallucination and then subsequent delusion. Berrios speculates that patients perceiving tactile sensations switch from considering the sensations "as if" insects were crawling on the skin to definitely crawling on the skin.
Riding and Munro8,9 differentiated between a fear of infestation (phobia) and a belief of delusional proportion, which they labeled "monosymptomatic hypochondriacal psychosis" (MHP). These authors did not restrict the MHP designation to psychogenic parasitosis, and MHP has been applied to other somatic delusions.10,11
Skott12 authored the most definitive summary of psychogenic parasitosis up to that point in 1978. She reported findings on 57 of her own patients, noting such variables as mean age at onset (age 64), female gender preponderance (42 women to 15 men ), and average length of symptoms prior to diagnosis (4 years). Other characteristics Skott reported were an association with mental retardation in 8 patients (14%); a folie á deux in 14 patients (25%); presumed organic disorder, such as dementia or diabetes, in 24 (42%); and significant psychiatric disorders, such as paranoia in 16 patients (28%) and depression in 8 (12%). Skott also considered personality traits significant in 22 patients, 15 (26%) with "hysteroid" traits, and 7 (17%) with "aesthetic" traits (tense, tiring easily). Skott observed that two patients had made prior suicide attempts. Though Skott's summary is thorough and remarkable in detail, Skott does not appear to allow for a nondelusional symptom of psychogenic parasitosis. We13 and others14–16 have observed the symptom in the absence of frank delusion.
Lyell17 in 1983 surveyed 374 British dermatologists about their findings in psychogenic parasitosis; 193 dermatologists reported their observations of 282 total patients. Lyell reported that females experienced the disorder twice as often as males across the life span, except prior to age 50, when female-to-male incidence was identical. Lyell's survey indicated that it was rare for the disorder to begin with a genuine parasitic infestation, present in only about 2% of cases. Lyell confirmed that patients often brought scrapings of their parasites in matchboxes, the so-called "matchbox sign."18 Lyell reported that entomologists and pest-control specialists had often seen the patient prior to the dermatologists, and a variety of pest-control remedies had been tried by patients prior to seeing the dermatologist. Lyell also drew attention to the role of shared delusions in his report of 27 groups of patients—24 pairs and 3 trios of patients. Lyell, as did Skott, reported the association of the symptom with both organic disease, such as diabetes and hepatitis, and emotional disorders, such as depression and schizophrenia.
In 1986 Reilly and Batchelor19 conducted a survey of British dermatologists similar to Lyell's, but the former's involved using a structured questionnaire. Their findings on returned questionnaires from 215 dermatologists involved 53 patients, age 20 to 92. Female-to-male ratio was once more noted to be 2 to 1, and 68% of the patients were 50 years of age or older. Reilly and Batchelor discovered associated dermatological conditions in 13% of the patients, such as chronic eczema and urticaria. Once more, underlying medical conditions were found in association with psychogenic parasitosis. Table 1 summarizes all the medical conditions associated with psychogenic parasitosis reported by Reilly and Batchelor,19 Lyell,17 Skott,12 and others3–5,14,20,21–32 identified by a MEDLINE search and a review of relevant articles' bibliographies.
In 1990 Musalek and Kutzer33 observed that 8.4% of their patients had the symptom "induced" by another, a shared delusion. In the researchers' sample, 82% of the patients were women, and the female-to-male ratio for inducing the symptom in another was 3.5 to 1.0, consistent with increased numbers of women experiencing the symptom.
Historically, the somatic treatment of psychogenic parasitosis has involved primary psychiatric interventions—treatment of depression and treatment of psychosis. When depression complicates psychogenic parasitosis, patients have been successfully treated with tricyclic antidepressants,13,17,19,20,34 selective serotonin reuptake inhibitors,13 and electroconvulsive therapy.13,17,19,20,34 When the symptom of psychogenic parasitosis reaches delusional proportions, that is, suggestion that the patient does not currently have parasites does not convince the patient, antipsychotics have been used. Perphenazine, haloperidol, pimozide, and resperidol have been reported to be effective.13,17,19,35–38 Haloperidol has been used successfully in patients at risk for noncompliance with treatment recommendations.13
We will now report our findings in 12 consecutive patients not previously reported. We will examine three cases in detail. We will then conclude with recommendations for evaluation and treatment based upon the literature and our experience.
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METHODS
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The patient population consisted of 12 consecutive patients evaluated in the dermatology outpatient clinic by one of us (KZ). One of us served as psychiatric consultant for these patients (JS), either evaluating them in person or in phone consultation with the dermatologist. The data were collected from a chart review, and measures were taken to preserve patient anonymity.
The dermatologist and psychiatric consultant rated whether the patient's symptom of psychogenic parasitosis represented a delusional conviction of infestation with parasites ("unshakable beliefs") or represented a "shakable belief," that is, the patient could imagine that they might not be infested. A suspected diagnosis of depression was based on symptoms noted in the chart. Treatment intervention was that which was recorded in the chart.
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RESULTS
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The average age of the 12 patients was 47.5 years (range: 27–70). This series involved eight men and four women. The average duration of symptoms prior to diagnosis was 36 months (range: 0.25–180 months). A surprising 11 of the 12 patients in this series were considered to be experiencing a shakable belief of infestation, that is, though considering it likely that they experienced a parasitic infestation, they could imagine that they might not be infected. Five of the patients were considered as having depression; one anxiety disorder, not otherwise specified; and one major depression with delusional features (psychogenic parasitosis). All patients received the strong suggestion of the dermatologist that they were not infested, after the results of negative findings by the entomologist were shared with the patient. Three patients appeared to respond well to suggestion but were not seen in follow-up to confirm lasting positive response. Of those nine patients seen at follow-up, three were completely "cured" of the symptoms, two were "markedly" improved, two were "much" improved, one was "moderately" improved, and one had a variable response and was considered a treatment failure after a 7-month course and is described later (Case 3). Five patients were treated with psychotropic medications. Three were treated with a selective serotonin reuptake inhibitor, two with a tricyclic antidepressant, one with a benzodiazepine, and one with neuroleptics. These findings are reported in Table 2.
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Case Reports
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Case 1: "Shakable Belief and Anxiety": J.L. is a 39-year-old, white woman who presented to dermatology clinic complaining of "white strands" on her face that "feel like they are moving—like hair being pulled through the skin." She brought several Ziploc (plastic) bags filled with samples, which microscopy revealed to be fibrous strands and epithelial cells. Physical examination demonstrated multiple hyperpigmented patches and a healing erythematous lesion on her right cheek. Otherwise, her skin was clear.
The dermatologist considered that J.L. had psychogenic parasitosis and reassured the patient that her complaints were taken seriously and that her samples would be sent to a professional entomologist.
J.L. returned to dermatology clinic the following week with another plastic bag filled with samples from her face. Though she reported having seen the parasites and watched them move, her belief that she had parasites was noted to be "shakable." The dermatologist discussed the possibility that such symptoms were of an emotional nature. J.L. stated that she would be willing to consider treatment for psychogenic parasitosis, as no parasites were noted in the entomologist's reports. She also agreed to an appointment with someone from psychosomatic medicine. The consulting psychiatrist considered that the symptom of psychogenic parasitosis was similar to panic disorder, a component of anxiety disorder, not otherwise specified. At the times she thought about her parasites, she noted a tendency for increased heart rate and marked sense of anxiety, but with no shortness of breath. She noted that she felt "shaky" and extremely upset.
The consultant initiated J.L. on Klonopin (clonazepam) 0.5 mg in the A.M. and 1.0 mg at bedtime. She called 5 days later, complaining of excessive morning drowsiness and was advised to decrease the nighttime dose of Klonopin to 0.5 mg. Upon follow-up, J.L.'s symptoms resolved, and she no longer reported parasites and noted her anxiety symptoms had resolved. Interestingly, she continued to report that she felt that she had previously been infected with parasites and that the parasites might recur.
Case 2: "Shakable Belief and Underlying Medical Condition": M.U. is a 69-year-old man with renal disease who presented to dermatology clinic with multiple excoriations over his posterior neck and scalp, lower back, and right medial buttock. In the course of his renal failure, he began to experience pruritus and paresthesias. He stated that 3 to 4 months prior to his dermatology evaluation, he began to observe "little tubes" protruding from his skin. These tubes were stated to be extremely pruritic, causing him to scratch. When he did scratch, M.U. believed that this incited a process in which three-cornered crystals would sprout legs and jump out of the tubes. After "exciting" the tubes, the crystals would leave "slag" (a byproduct of "welding") behind. M.U. also complained that physicians would not look at him and that they thought he was "going crazy." Physical examination revealed multiple open sores without induration over the posterior neck and scalp, lower back, and right medial buttock. Laboratory examinations were significant for an elevated BUN of 37 and creatinine of 7.2.
The evaluating dermatologist suspected psychogenic parasitosis and obtained samples of the "tubes" that she sent to an entomologist for examination. M.U. was educated about the likely diagnosis of psychogenic parasitosis complicating renal failure and was reassured that his samples would be thoroughly examined. He was given Bactroban (mupirocin) ointment to apply to open wounds as well as Sarna (camphor) lotion for pruritus. M.U. appeared to accept the explanation that he was likely not infected.
M.U. returned to the dermatology clinic 7 weeks later, significantly improved. He demonstrated only two superficial erosions on his posterior neck; otherwise, his skin was clear. The entomologist report was shared with M.U.—no worms, parasites, or "little tubes" were discovered in his samples. He responded extremely well to therapeutic reassurance and support. M.U. also stated that he believed that he would continue to improve. This belief was reinforced; the patient was encouraged to refrain from scratching and trim his nails. He was also to continue the Bactroban ointment for any open wounds and Sarna lotion for pruritus. He was discharged from the dermatology clinic markedly improved.
Case 3: "Delusions (Unshakable Belief) and Depression": L.K. is a 32-year-old woman who presented to dermatology clinic reporting a 3-month history of "bugs" infecting her fingers, lips, scalp, ears, nose, face, and genitals. She believed she had been infected by her husband, as she observed him frequently scratching his scalp. However, she stated her husband feels that "it [her condition] is all in her head." She noticed others scratching while around her and believed that they became infested by her presence. Multiple samples of the "bugs" were brought in plastic bags.
On physical examination, there were multiple superficial excoriations over her nose, forehead, ears, scalp, jaw, and upper trunk. It was also noted that her speech was pressured, and she continually interrupted the interviewer. The dermatologist believed the patient to have psychogenic parasitosis and reassured L.K. that her symptoms would be taken seriously and that her samples would be evaluated by an entomologist. Synalar (fluocinolone) solution was prescribed for scalp inflammation, and she was asked to return to clinic with her husband in 1 week.
L.K. returned to clinic with her husband, frantically claiming that "things were falling off" of her and that she always saw "red dots" at the outset of her symptoms. She denied pruritus, scratching, or seeing her "bugs." Her speech was again pressured and she was crying. She stated she was angry at her husband because she believed he blames her symptoms on her "nerves." On examination, she demonstrated numerous, crusted bloody excoriations, and her pubis had been shaved smooth. Her husband was examined, and no suspicious lesions were noted. The dermatologist spoke to L.K. and her husband, both alone and together. Her husband was noted to have excellent insight. L.K. was reassured and asked to await the results from the entomologist.
The entomologist report revealed that the samples contained skin debris plus some incidental insect parts (Culicoides species, which are unassociated with dermatoses). This species generally bites at dawn and dusk, and the adults usually die with the first frost. L.K. continued to worsen over the next several clinic visits, despite reassurance by the dermatologist. She also continued to bring in numerous samples and frequently stated that she believed that her husband is the "root of the problem." Frankly, L.K. became delusional and desperately sought help, but she displayed poor insight (unshakable at this point). She refused a psychiatric referral, but she agreed to 50 mg intramuscular (im) Haldol (haloperidol). The dermatologist noted that the goal would be to treat with neuroleptics until adequate insight was obtained, which would allow psychiatric referral. After the Haldol injection, she improved significantly. Her skin was nearly clear, no new samples were brought, and she felt that she no longer caused others around her to scratch. L.K. demonstrated some insight but still did not think that her illness was of psychiatric etiology. She also continued to question why she was taking medications when "all this started with my husband." Pimozide was started at 2 mg every day, with the plan to gradually increase the dosage. L.K. continued to improve over the next 4 weeks. However, insight remained minimal, and pimozide was doubled to 4 mg every day.
Six weeks after starting pimozide, L.K.'s progress halted. She continued to state that her husband scratches his scalp, which she believes to be the root of her problem. The dermatologist emphasized the success of Haldol therapy and recommended it once more, but L.K. deferred. She was instructed to increase the pimozide to 6 mg every day. Numerous phone conversations over the next several weeks revealed that L.K. had probably been noncompliant with the prescribed oral medications. She reported a different dosage each conversation and was unable to give the name of her pharmacy on several occasions, nor could she describe the pills. Her complaints persisted that her husband continued to scratch, as did others around her. Delusions also persisted, as she complained of "stuff" falling out of her hair and was convinced that something was in her house causing her problems. L.K. had seen another physician during this period who treated her with lindane for pediculosis. L.K. agreed to visit the psychosomatic clinic.
L.K. was seen by the consulting psychiatrist who diagnosed her with delusional disorder (somatic type) at her first visit. No symptoms of depression, mania, or anxiety were noted at this visit. The recommendation was to add Klonopin (0.5 mg twice daily and l .0 mg at hour of sleep) for anxiety associated with her delusion and sleep interference and to continue pimozide.
Four days later, L.K. paged the dermatologist, stating that she was much worse and needed to be seen that day. She presented to clinic with her hair matted down with calamine lotion, numerous superficial erosions, and various exogenous particles in her hair, but no parasites or nits were seen. Again, it was unclear if she was taking pimozide or Klonopin and, because of her worsening delusional state, L.K. was urged to consent to another Haldol injection. She refused the injection, stating she did not like the side effect of "tiredness." L.K. agreed to keep her appointment with psychosomatics.
L.K. then became quite erratic with follow-up to dermatology and psychosomatics. She continued to be preoccupied with "things falling off" of her and others scratching around her. In addition, she described the parasite's structure as having eyes and three legs. She was shown pictures of lice, scabies, and nits, but she denied that these looked like the "bug that was infecting her." L.K. claimed to be taking her medications but continued to be unable to describe what the medication looked like and could not recall the pharmacy name or telephone number. Again, im neuroleptics were advised but refused. She agreed to follow-up, however.
Many weeks later after missing several clinic visits, L.K. presented to psychosomatics clinic with continuing psychogenic parasitosis. She was also quite anxious about what she was experiencing and, perhaps, was depressed, though she denied emotional problems other than that created "by the bugs." She denied changes in sleep, appetite, interest, and activities, and she denied being depressed. Because she refused Haldol and had not responded or had been noncompliant with pimozide, an alternative neuroleptic, Zyprexa (olanzapine) 5 mg at bedtime, was prescribed.
During her subsequent visits to the psychosomatic clinic, her husband noted previous bouts of significant depression, during which she would remain in bed, not eat, and lose weight for periods of several weeks at a time. The patient, though denying depression, was considered to possibly be experiencing major depression with psychotic features (vs. bipolar disorder, depressed). The consultant prescribed Zyprexa 5 mg in the A.M. and 15 mg at bedtime, as well as Serzone (nefazodone) 100 mg in the A.M. and 100 mg P.M. for 1 week, then 100 mg A.M. and 200 mg P.M. thereafter. Laboratory examinations, including a thyroid panel, cell count with differential, chemistry profile, rapid plasma reagin, and folate levels, were normal.
Unfortunately, L.K. did not comply with medication recommendations, continued to seek the source of her infestation, and resisted recommendations for either im medications or an inpatient psychiatric admission. She was lost to follow-up. The last call regarding the patient came from her veterinarian. L.K. had been repeatedly bringing her dog into the veterinarian's office, requesting evaluation of her pet for parasites, though the dog was not found to be infested. The veterinarian was encouraged to refer the patient back to the psychosomatics clinic, but no further visits ensued.
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DISCUSSION
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Our current series of 12 new patients, and our previous experience with 20 patients,13 have resulted in the following findings. A majority of our patients with psychogenic parasitosis have shakable beliefs, not unshakable convictions, that is, delusions. Identifying those patients who can be reassured and offered treatment alternatives other than neuroleptics will reduce the potential for side effects from neuroleptics. Even when depression complicates patients experiencing psychogenic parasitosis, the depression might be treated without neuroleptic medication. When significant anxiety is present in patients with psychogenic parasitosis, it may be treated with standard doses of anxiolytics without recourse to neuroleptics. However, in those psychogenic parasitosis cases in which the patient has an unshakable delusion (the patient firmly believes he/she is infested with parasites), recourse to im Haldol, repeated every 3 to 4 weeks, administered by the dermatologist with psychiatric consultation back-up, is likely the treatment of choice. Failed follow-up and noncompliance with medication are significant risks with truly delusional patients, as demonstrated in Case 3 described earlier. Reassurance and an appeal to reason simply did not work.
Before proceeding further, we would like to acknowledge shortcomings of our report. The findings are retrospective. However, we felt that we would drive away patients of this nature if we tried to enlist them prospectively. The diagnoses of depression and delusion were often arrived at by the dermatologist without a structured interview or clinical psychiatric interview. However, the patients were encouraged to see a psychiatric consultant for evaluation. But more often than not, they declined.
The problem of psychiatric referral of psychogenic parasitosis patients should not be underestimated. Our patients were, in general, quite reluctant, if not resolutely against, seeing a psychiatrist. To partially address this issue, the psychiatric consultant (JS) agreed to see willing patients in the dermatology clinic. Wearing a white coat and following the dermatologist's visit, or seeing the patient at the same time as the dermatologist, about one-third of the patients were seen by the consultant. The psychiatrist's willingness to visit the patient in the dermatology clinic is helpful, as well as being available for "curb-side" consults for the dermatologist. With the assistance of the psychiatric consultant, the dermatologist administered neuroleptics, including Haldol, when patients were unwilling to be seen by the psychiatric consult.
We consider our experience with 32 patients over 2 years to be consistent with the phenomenology of cases reported in the literature. On the other hand, the literature tends to favor treatment of those cases with neuroleptics, often oral pimozide administration. In our experience, neuroleptics should, we believe, be avoided more often than not. (Perhaps previous authors were actually experiencing the benefit of reassurance and mild sedation, anxiolysis, from the neuroleptic. Benzodiazepine medications and topical ointments are obviously less prone to secondary side effects than neuroleptics.)
When patients are truly delusional (delusional disorder, somatic type) regarding their parasites, then neuroleptics are indicated. Case 3 illustrates the frustration involving family, patient, and clinician with attempted oral dosages. Though oral neuroleptics might be tried in an inpatient setting, where compliance may be monitored, in an outpatient setting we now favor the im route of administration.
One last area of interest for us has been the finding that patients can not only feel but also often see the "parasite," including drawing it, despite a "shakable" belief in the infestation. We have now had several patients, such as those in Cases 1 and 2, who can draw a picture of the organism or describe bits and pieces of it in detail, but who improve with reassurance and possibly as a result of anxiolytics. What do they see? What shall we label the experience? "Illusion" might best explain the phenomenon, as these patients actually are viewing the "parasitic" materials they bring with them in their plastic bags. The transformation of the material into "six-legged arthropods" is likely a phenomenon consistent with hysteria. In a very emotionally charged state, the patient quite literally sees what they strongly expect to see. That these patients can be convinced to discontinue visualizing the organism by an equally strong and authoritarian suggestion would be consistent with hysteria. "Shared delusions" would likewise be most consistent with hysteria.
How individuals "see" such nonexistent parasites is illustrated by Cases 1 and 2. Even though the patients reported visualizing organisms, they could imagine that what they thought they saw might not exist. They both exhibited an "itchy" feeling; in Case 2 this feeling was clearly related to an underlying medical condition. The itching predated the visualization. It is our belief that autosuggestion, that is, "I itch; therefore, I must have an infestation," leads to the visualization. Another of our cases illustrates the role of suggestion, but in this case the suggestion stems from someone other than the patient. A patient had been experiencing uncomfortable paresthesias in her hands for several weeks. She described these sensations to a co-worker, who then stated that she was probably infected with parasites. Within 24 hours, she was seeing them. Upon our suggestion that she was not infected, however, the patient no longer visualized the "six-legged arthropods" that she had drawn for us to illustrate what she was seeing.
We endorse a clinical approach to the patient that places less emphasis on delusions and more on other emotional issues, such as anxiety and depression, as well as underlying medical conditions, such as renal failure, as illustrated in Case 2. Reassurance and pharmacotherapy for conditions other than delusions are emphasized as most helpful. When delusions are present, however, they should be treated vigorously with im neuroleptics.
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142(3):
352 - 355.
[Abstract]
[Full Text]
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N. A. Qureshi, T. A. Al-Habeeb, and Y. S. Al-Ghamdy
Making Psychiatric Sense of Sand: A Case of Delusional Disorder in Saudi Arabia
Transcultural Psychiatry,
June 1, 2004;
41(2):
271 - 280.
[Abstract]
[PDF]
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