Delusional Parasitosis, also known as Ekboms’ Syndrome, is an extremely interesting psychological disorder.
Sufferers of this condition believe that their skin is exhibiting symptoms of pruritus due to being infested with insects or other parasites. This illness can be difficult to diagnose and treat due to the delusional nature of the afflicted individual.
Ekbom’s Syndrome or Delusions of Parasitosis, DoP, manifest in the individual’s firm and unrelenting belief that they have been the victim of an infestation, usually by insects or worms. The patient typically has no obvious cognitive impairment or abnormal organic factors present. The classification of Ekbom’s Syndrome can be arduous and complicated. This illness is primarily considered to be a hypochondriacal psychosis that is monosymptomatic. DoP has been associated with other psychological disorders including schizophrenia, bipolar disorder, obsessive compulsivity, anxiety disorders, as well as depression.
Sufferers are most often white middle-aged or older women. However, Delusional Parasitosis has been reported in men as well as all age groups. The patient believes that parasites such as helminth worms or some type of insect has crawled onto and burrowed itself into their skin. The individual usually explains this during an appointment they have made with their family physician or a dermatologist.
As Ekbom’s Syndrome takes hold of a person, they grow more and more certain they have been infested with parasites or insects of some form, and as such, they state they can feel them crawling on their skin or even burrowing into it. Patients may present with bruising on the skin, nodular pruritus or itching, scars, and ulcers. The individual may have injured themselves in some way by attempting to extract the perceived parasite. The affected person will seek the help of a family doctor, a dermatologist, or in some cases the emergency room in an attempt to receive treatment.
A hallmark symptom of Delusional Parasitosis involves the patient’s collecting of evidence to prove their theory of parasitic infestation. They will often bring fibers, dust, scabs, or other types of debris excoriated from their skin in with them to their appointment for inspection. These items are often collected in a matchbox by the patient which led to it being referred to by health care professionals as the “match box sign”. Other times they may collect the items in saran wrap or on an adhesive tape which is referred to as the “saran wrap sign.”
Sufferers of Ekbom’s Syndrome often lack primary skin lesions when physically examined, but instead present with linear erosions with crusting as well as skin ulcers. A true parasitic infestation will not be the cause of the damage to the skin. The individual will also be free of any primary systemic diseases that could account for the symptoms such as thyroid issues.
In order to determine the correct diagnosis, patients should be asked about their symptoms, how long they have been experiencing the symptoms and their concerns regarding why they are experiencing these particular symptoms. True causes of infestations must be excluded, including scabies, pediculosis, and primary systemic causes of itching. For example, the health care provider should thoroughly exhaust all testing to determine that underlying issues such as hepatitis, HIV, anemia, neurological disorders, thyroid problems, or dermatologic issues are not causing the symptoms.
Unfortunately, the cause of Delusional Parasitosis is unknown. The pathophysiology of Ekbom’s Syndrome appears to be related to neurochemical pathology. The fact that DoP often accompanies users of psychoactive agents like amphetamines or those suffering from other disorders including depression, sensory impairment, and schizophrenia drives this conception that it is neurological in nature.
In fact, Ekbom Syndrome is an alternative diagnosis for ectoparasitosis, chronic pruritus, and prurigo as well.
Many times, the individual will resist suggestions from their health care team that the issue is psychological rather than a physical infestation. In 35 percent of patients with Delusional Parasitosis, the belief that they are infested is unshakable. In 12 percent of cases, the delusion is shared with a significant other, a child, a spouse, or even a pet. This phenomenon is called folie à deux which means craziness for two in French.
With Ekbom’s Syndrome, the successful treatment of the patient is heavily reliant upon the strong formation of a therapeutic alliance with their physician. Without an alliance, it is difficult, if not impossible, to convince the patient that the condition is rooted in a psychological foundation and that they must take their prescribed medications. In fact, the first meeting with the health care provider will usually set the tone for all subsequent encounters. It is also imperative that the individual feels that their autonomy is respected at all times.
In recent years, there has been a push toward combining both psychiatric and dermatologic approaches in the treatment of Delusional Parasitosis. The use of a multidisciplinary team has also become a popular option. Since many individuals also suffer from compounding comorbidities, such as trichotillomania and dermatitis artefacta, the use of multiple health care team members can successfully provide integrative therapies for the patient.
To end the delusional belief of being infested, the patient will need to be prescribed psychotropic medication. However, it is paramount that the patient understands that the medication they are taking is for the delusional thinking and not to kill any parasites they are harboring. If the doctor allows the individual to believe the medication is to rid them of the perceived parasites, it will only further validate these untrue beliefs. Even writing a prescription for an antiparasitic drug can strengthen the patient’s delusion, making it that much harder to fully eradicate the idea that they have a parasite.
Historically, several types of psychiatric medications have been utilized by physicians including aripiprazole, citalopram, and clozapine. The current treatment of choice is risperidone, escitalopram, aripiprazole, or olanzapine. After the prescribed medication has ended the delusions of parasitic infestation, the medication should be continued for several months. This course of treatment can aid in preventing a relapse. Occasionally a patient will think that the psychiatric medication must have killed the invading bugs, resulting in the delusions starting again.
If Ekbom’s Syndrome is left untreated, the patient may have permanent marks marring their skin from scratching or attempting to remove the perceived parasites on their own. This illness can also disrupt their relationships, their job, and nearly every aspect of their lives by their constant feelings of distress.
Patient education is also a crucial aspect of treatment. Health care providers should reassure sufferers that they are not alone. The patient needs to understand that the physician, along with other multidisciplinary team members, is there to help them, listen to them, and sincerely hopes to help them get better. The patient should never be forcefully confronted about the delusional thinking. It’s also important to take extreme care never to say anything that confirms their delusion.
The prognosis for Delusional Parasitosis patients is good provided the individual takes the initiative to seek and receive treatment. If the individual agrees to start medication and undertake the prescribed treatment, they should get better. Unfortunately, many patients are so convinced by their delusional thinking that they refuse treatment altogether.
However, some cases are brought on by the abuse of substances such as methamphetamine, cocaine, or withdrawal after prolonged abuse of alcohol. Avoiding these substances can aid in ensuring you do not develop this issue. Individuals with certain psychological disorders including schizophrenia, bipolar disorder, or depression among others may also be at an elevated risk for developing Delusional Parasitosis.
Individuals predisposed to hypochondriasis, an issue that causes them to worry constantly about their health, may also exhibit a higher risk of developing this problem. These persons may see an article or television program about parasitic infections leading them to start believing they have it as well. This can become an issue for those that already suffer from obsessive compulsive disorder too.
Individuals live in fear that any small itch or sensation on their skin is in actuality a horrible infestation of parasitic invaders. The people that suffer from this disease thoroughly believe they have insects or worm-like creatures burrowing into their skin. As a result, they scratch themselves and cause bruising, scabbing, and in some cases permanent scarring. This illness is difficult to diagnose and requires a lengthy physical examination as well as a large battery of tests to rule out a plethora of other possible causes.
Delusional Parasitosis can be very difficult to treat since the patient is completely and utterly convinced they have parasites. They need to be cared for by a physician that can foster a trusting relationship to help the person understand and cope with the diagnosis. Otherwise, the patient will continue to believe their delusions and refuse to begin treatment.
Through the prescription of psychiatric medications and an understanding that their thought process is incorrect, the patient can begin to get better. Medication should be continued for a time period after the deluded thinking has ended to safeguard against relapse. The prognosis for individuals with Ekbom’s Syndrome that complete treatment is good provided they follow the directions of their multidisciplinary health care team.