HE CALLER SAYS THAT SHE IS BEING ATTACKED by invisible mites. The attack has been going on for
Tmonths and she has visited a half dozen
physicians, but none was able to help her. Two prescribed Kwell lotion (see Glossary), but the sensations persist. She has treated her skin with alcohol, vinegar, Lysol, bleach, kerosene, and various home remedies. She has boiled her bed linens and clothing daily. She can describe the life cycle of the pest and has been able to extract specimens from some of the wounds. She offers to send you samples. She says the irritation is driving her crazy and you are her last hope. How do you respond?
At some time nearly everyone experiences a
sensation of something burrowing in, crawling on, or pricking the skin (Potter 1992). These tactile perceptions may be caused by a variety of causes, because different stimuli evoke the same limited range of neurocutaneous responses. The conviction that insects are crawling on, biting, or burrowing in the skin, when no arthropod is involved, is termed “delusory parasitosis.” The medical profession defines “delusion” as referring to “a fixed belief” unswayed by evidence to the contrary. By comparison, the term “illusion” refers to situations in which the individual perceives stimuli as produced by arthropods but acknowledges other explanations once they are demonstrated. Although there are some problems with terminology, delusory parasitosis is the phrase used most commonly in the literature, so will be perpetuated here.
These cases typically are bewildering to pest control
operators, professional entomologists, and medical professionals, who shuffle these sufferers back and forth. Physicians examining the patient determine that the lesions were produced by an insect and recommend calling a pest control company to have the patient's house treated. Conscientious pest control operators perform an inspection and are unable to locate a pest, so refuse to make an insecticide application (St. Aubin 1981).
AMERICAN ENTOMOLOGIST • Volume 46, Number 1
Table 1. Common attributes of DP sufferersa
mailed samples to parasitologists for examination.
(E) She provided extensive descriptions of the
A. Most common in older people (Lyell 1983, Webb 1993, Trabert 1995, Goddard 1995, White 1997)
mites and their behavior. (H) She visited
B. Disproportionately female (St. Aubin 1981, Lyell 1983, Webb 1993, Trabert 1995)
numerous physicians, including a dermatologist,
an oculist, a neurologist, as well as the family
(1) quitting their jobs (Monk and Rao 1994, Goddard 1995 )
physician; “little help . was forthcoming from
(2) burn/destroy furniture (St. Aubin 1981, Lyell 1983, Gieler and Knoll 1990, Goddard 1995) (3) abandon homes (Waldron 1962, Lyell 1983, Driscoll et al. 1993, Goddard 1995)
this source.” (I) Duration of the infestation was 17
(4) obsessive laundering/dry cleaning (St. Aubin 1981, Lyell 1983) boil clothing and bed linens
years at time of publication. (J) Sensations were
described as “itching,” “crawling, scratching and
(5) use pesticides dangerously/repeatedly (Lyell 1983, Goddard 1995, White 1997); repeated
biting.” (K) She was referred for psychological
applications of insecticides to body (Monk and Rao 1994); have used Kwell, Elimite®
evaluation; “the patient, however, succeeded in
convincing the neurologist that she had no need
(6) use home remedies (St. Aubin 1981, Lynch 1993):
of his services,” and she published a 25 page
a. gasoline (St. Aubin 1981, Koblenzer 1993, Monk and Rao 1994) b. kerosene (St. Aubin 1981, Lynch 1993)
treatise to prove that she was not crazy. (L) “To
c. other solvents (St. Aubin 1981, Lynch 1993)
date, no treatment employed against the mite has
d. harsh cleaning compounds (St. Aubin 1981, Lyell 1983)
been completely effective.” (M) The delusion also
(7) mutilate body attempting to remove offending vermin (St. Aubin 1981, Lyell 1983, Zanol et
Traver’s (1951) article provides notable docu-
D. Provide skin scrapings, bits of debris (in paper, small jars) (Pomerantz 1959, Waldron 1962, Lyell
mentation of the effort expended extracting and
1983, Goddard 1995) “One characteristic sign in delusory parasitosis is the complainant's
“identifying” specimens. In addition to the above
eagerness to provide samples of their alleged parasites in small containers” (May and Terpenning 1991). Samples provided in adhesive tape, plastic bags, or vacuum bags (Webb 1993, Koblenzer
characteristics common to delusory parasitosis
1993, White 1997) “there are millions of them”-yet specimen cannot be obtained
sufferers, Traver described the pests as primarily
E. Can provide extensive, elaborate, involved descriptions of the pests, their life cycle, and behaviors
active at night and identified animals as the likely
(Lynch 1993, Monk and Rao 1994, Zanol et al. 1998)
infestation source, other commonalities (Hinkle
F. Social isolation (Koblenzer 1993, Trabert 1995), self-employed (Lyell 1983), abandon family to
1998). Reflecting the often cited bias of delusory
avoid infesting them (Lynch 1993, Monk and Rao 1994)
parasitosis cases toward women (Trabert 1995,
G. Emotional trauma such as job loss, divorce/separation (Lyell 1983, Grace and Wood 1987, Webb
White 1997), 22 (65%) of the past 34 delusory
H. Have seen numerous physicians, all to no avail (Driscoll et al. 1993, Lyell 1983)
parasitosis cases I have had were female and 12
I. Mean duration of delusion was 3.0 ± 4.6 years (median, I year) (Trabert 1995); “Years of
(35%) were male. Of these, three pairs involved
suffering” (Pomerantz 1959, Driscoll et al. 1993), 12-year history (Monk and Rao 1994), 40 years
folie a deux, the phenomenon occurring in up to
one-third of cases (Koblenzer 1993), in which
J. Complain of “itching, crawling, pinprick biting sensations” (White 1997), “formication” (Koo and
close associates experience the same delusion.
Although the prevalence of delusory parasitosis
K. Reject possibility of psychological or other explanations (Trabert 1995) “I'm not crazy.” “I am not
imagining this.” Vehemence indicative of DP (Zanol et al. 1998). “ Exceptional strength of
may be considered low by the medical profession
conviction regarding infestation” (Lynch 1993) almost diagnostic for DP (Webb 1993)
(Driscoll et al. 1993), the pest control industry and
L. Express desperation, “you are my last hope” (Nutting and Beerman 1983, Lynch 1993)
medical entomologists encounter it all too
M. Delusion eventually shared by another family member (St. Aubin 1981) in up to 1/3 of cases
frequently (Schrut and Waldron 1963, Kushon et
Citations are illustrative of some of the published descriptions.
Description of Delusory Parasitosis
a false belief that persists despite the
Descriptions of delusory parasitosis sufferers
are remarkably consistent (Koblenzer 1993) with
inflammation of the skin.
common attributes (Table 1). The most common
a permethrin cream used to treat for
symptoms include paresthesia, pruritus, (see
Glossary), and a biting sensation (Hinkle 1998).
abnormal redness of the skin.
The classic delusory parasitosis case remains
the sensation of ants crawling on
that of J. R. Traver (1951), a zoologist who
of unknown cause.
published her personal account of 17 years of
misinterpretation of perception of
dealing with an "infestation" in her own body; the
following descriptions correspond to common
prescription lindane formulations used in
delusory parasitosis attributes listed in Table 1.
According to Poorbaugh (1993), (A) she was 40
years old at onset of symptoms and suffered with
a sensation of pricking, tingling, or
them for another 40 years until her death at age
80. (B) She was female. (C) She used pesticides
both dangerously and repeatedly, applied home
wound or cut marks from
remedies to her body, and mutilated her body by
"digging out" mites with fingernails. (D) She
stinging or burning itch.
collected material from her scalp and body and
AMERICAN ENTOMOLOGIST • Spring 2000
al. 1993). Of the 21 cooperative extension Table 2. DP sufferers’ descriptions of what is infesting them
specialists providing estimates of their delusory
parasitosis cases, the average number was 17 per
1. Black and white, but change colors (Waldron 1962, St. Aubin 1981, Monk and Rao 1994)
year (range, 4-45), occupying 2.4% of these 2. Jump or fly (Waldron 1962, Monk and Rao 1994) specialists’ time (Hinkle 1998).
3. Have eight little legs and a small sucker (Gieler and Knoll 1990)
Many delusory parasitosis sufferers who come
4. Half moon shape, like the end of a fingernail (Lyell 1983, Hinkle 1998)
to entomologists already have received a 5. Moth-like creatures (Monk and Rao 1994, Hinkle 1998)
6. Waxy looking fuzz balls (Schrut and Waldron 1963, Hinkle 1998)
prescription for Kwell (lindane) from a physician,
7. Granules about the size of a grain of salt (Schrut and Waldron 1963, de Leon et al. 1992, Hinkle
implying that scabies had been diagnosed.
However, scabies is the default diagnosis for any
8. Long hairs that move independently (Hinkle 1998)
idiopathic dermatitis or pruritus (Pariser and Pariser
9. Tiny white worm with a brown bulb on its head (Hinkle 1998)
1987). Frequently, the placebo effect of such
10. Worm-like coating around the hair root, with a black bulb attached (Hinkle 1998)
medications will effect temporary remission of the
11. Greenish-grey cigar shaped things (Hinkle 1998) 12. Infest inanimate objects: automobiles, furniture, clothing, rugs (Grace and Wood 1987)
symptoms, but they almost invariably recur (St. Aubin 1981).
Typically, the cause is not any insect or other
Some contactants producing paresthesia are
arthropod but, instead, is some physical (Blum and
discussed by Fisher (1995) and include solvents,
Katz 1990, Potter 1992), physiological, or fabrics, and fabric finishes. Two particularly unusual psychological stimulus. Victims attempt to correlate
situations are when exposure to either water
what they see, or think they see, with their physical
(aquagenic pruritus) or air (atmokinesis) produces
perceptions. Thus, sufferers intently examine the
pruritus or paresthesia in susceptible individuals
area experiencing the sensation, digging out (Bernhard 1989, Bircher 1990). blackheads, hair follicles, and other normal skin
Demonstration of scarification is indicative only
components to account for the sensation (Lynch
of scratching; it proves nothing about the stimulus
1993). Descriptions by some delusory parasitosis
causing the scratching (Fig. 1). Self-excoriation is a
sufferers of their pests are listed in Table 2.
common feature of delusory parasitosis, despite the
individuals’ protestations that they do not scratch
Physical causes include any external stimulus
Scratching may produce papular eruptions. Any
that yields a sensation of paresthesia, pruritus,
repeated skin irritation produces a friction blister.
urticaria, or similar irritation. Blum and Katz (1990)
Repeated rubbing of an area often produces a bleb
summarized potential physical causes that could be
(small blister) which, when ruptured, yields an open
attributed to delusory parasitosis symptoms. These
sore that may become infected. Once the sore
included static electricity, chemicals such as some
begins oozing plasma and a scab forms, hairs and
pyrethroid insecticides, or mechanical irritants such
cloth fibers become entrapped in the sticky fluid.
as fiberglass filaments and paper shards. Volatile
These flecks are dislodged and called mites or
chemicals from manufactured building materials
insects because they look like they have “antennae”
such as paneling and carpeting can produce itching
and “legs” (Fig. 2). Hair follicles often are pulled
and stinging sensations (Jaakkola et al. 1994). There
out; the follicle accompanied by the associated
are many non-arthropod agents capable of sebaceous gland looks like a worm. producing delusory parasitosis symptoms; under
these circumstances an industrial hygienist can survey and make recommendations (Potter 1992).
Dry, sensitive skin is particularly susceptible to
these sensations. Particles impinging on the skin as a result of static electricity may be perceived as “bites” or “stings.” This is particularly true of materials with sharp projections such as paper, metal, and fiberglass fragments. Carpet fibers also may be attracted to lower portions of the body because of static electricity, and these too can feel like pinpricks. Electronic equipment generates an electrostatic charge, so office equipment and computer components can produce sufficient attraction to various materials to be irritating to susceptible individuals.
Most persons experiencing itching will rub or
scratch briefly and absentmindedly without consciously noticing the sensation. Others, however, focus on the itch until it occupies all of
their attention. Thus, delusory parasitosis sufferers
Scarification indicates scratching but
A scab with entrapped hairs and
become fixated on the perceived irritation.
fibers is said to look like a “bug.”
AMERICAN ENTOMOLOGIST • Volume 46, Number 1
Table 3. Some medical conditions producing delusatory parasitosis symptoms
of many infectious and noninfectious diseases, as
well as numerous other medical conditions (Blum
and Katz 1990). Those listed in Table 3 are not to
be taken as explanations for all delusory parasitosis
cases, merely as an indication of the range of
medical conditions with manifestations that reflect
Age-related neurological degenerative changes
can produce phantom limblike sensations, including
pruritus and urticaria, in some elderly patients
X (Bernhard 1992). This phenomenon may explain the
disproportionate number of delusory parasitosis
Allergies are one common cause of pruritus,
hemochromatosisa X - X - - hepatic diseasea X - X - X
erythema, and urticaria. Food and skin allergies may
produce these symptoms. Some common food
allergies include those to milk, egg white, soybean,
peanut, chocolate, wheat, food additives, mangoes,
oranges, nuts, and pineapple (Kabir et al. 1993,
X McGowan and Gibney 1993, Levy et al. 1994).
Atopic dermatitis can be caused by skin allergies
to such materials as latex, textiles, soap, detergent,
fabric softeners, shampoo, lotions, insect repellents,
deodorants, and any other substance that contacts
the skin (Simion et al. 1995). Most contain
fragrances, colorants, stabilizers, emulsifiers,
preservatives, and other components that may
sensitize susceptible individuals (Phillips 1992).
Numerous medical conditions have itching or
other skin irritations as symptoms, emphasizing the
importance of not dismissing such symptoms as
“just delusory parasitosis.” Prodromal sensations
should be investigated medically as indicators of
potentially life-threatening conditions (Pariser and
j Lyell 1983. k Scherbenske et al. 1989.
Pariser 1987). Nutritional deficiencies can produce itching as can high doses of many minerals and fat-
soluble vitamins (Phillips 1992, Zanol et al. 1998).
Some people claim they see the “creatures”
Paresthesia, erythema, urticaria,
jump (Waldron 1962). This is probably caused by
pruritus, and hives are listed as potential side effects
static electricity or magnetic charges of tiny
of most prescription and over-the-counter
particles (Ebeling 1978). Some people see dust and
medications (Table 4). Incidence of these symptoms
other motes floating in a shaft of sunlight and
may be increased by interaction of two or more of
claim they are tiny flying creatures. Even the
these drugs, as is particularly common in the elderly
random motion of particles floating on water is
(Doucet et al. 1996). Drug-induced delusory
parasitosis has been demonstrated definitively in
only a few cases (Aizenberg et al. 1991).
Delusory parasitosis may result from methamphetamine particularly are prone to produce
physiological causes such as allergies, nutritional
the sensation of insects crawling on or burrowing in
deficiencies, drug reactions, and other medical
conditions. Allergies can include inhalant allergies,
The 50 most commonly prescribed drugs in the
ingestant reactions, and contact dermatitis.
United States list at least one symptom commonly
Nutritional deficiencies or overdoses may produce
attributed to delusory parasitosis (Table 4). These
both systemic and dermal reactions (Eliason et al.
include erythema (56%), paresthesia (56%), pruritus
1997). Drug reactions include responses to single
(64%), urticaria (66%), and rash (92%). Although
drugs as well as multiple drug interactions.
these side effects may be rare, the fact that these
Medical literature from
data are based on more than 2 billion prescriptions
the past 5 years shows more than 100 different
indicates that these drugs are being used extensively
causes of itching including infection with bacteria,
and that an increasing proportion of patients will
fungi, viruses, nematodes, and various other
experience these ancillary reactions and possibly
pathogens and parasites (Phillips 1992). Pruritus,
attribute them to unseen “bugs” (Fig. 3).
paresthesia, and urticaria are common side effects
AMERICAN ENTOMOLOGIST • Spring 2000
Table 4. Fifty most commonly prescribed U.S. drugs and some side effectsa
a Sandow 19998, based on more than two billion 1997 U.S. prescriptions.
Drugs disproportionately prescribed for the
effects: the elderly take multiple medications
elderly such as those for heart conditions, simultaneously (prescription and over-the-counter), glaucoma, osteoporosis, impotence, and arthritis
frequently receive prescriptions from more than one
particularly may be predisposed to cause these side
effects (May and Terpenning 1991). These drugs
instructions or forget how often they have
include insulin, estrogen, arthritis medications, medicated themselves, and drug pharmacokinetics hypertension drugs, beta blockers, MAO inhibitors,
vary by patient age. Persons over 65 years old
represent only 12% of the population but receive
Several factors contribute to the predisposition
more than 30% of all prescription drugs (Jones
of elderly people to experience adverse drug
1997). Older adults average three prescription
AMERICAN ENTOMOLOGIST • Volume 46, Number 1
medications per day, 15 different prescriptions per (Schino et al. 1996). There are strong socio- year, and consume 70% of all over-the-counter psychological implications of self-grooming, drugs. Approximately 25% of their hospital reflecting group status, individual self-image, and admissions are a result of incorrect prescription drug psychological well-being. Touching, scratching, and usage. One in five Americans over the age of 60 rubbing are viewed as forms of self-assurance, regularly takes pain medication and one in four who consolation, and validation of the psyche (Schino et does so experiences side effects caused by the al. 1991, Troisi et al. 1991). This dynamic is displayed medication; one in ten is hospitalized as a result in meetings, in one-on-one confrontations between (Chrischilles et al. 1992).
individuals, and in other human interactions.
Herbal remedies and nutritional supplements may
produce untoward side effects including pruritus and
depression, and tiredness can manifest themselves
urticaria (Huxtable 1990, Cetaruk and Aaron 1994).
as itching and tingling (Gieler and Knoll 1990,
Additionally, they may interfere with or potentiate
Gupta et al. 1994, Gupta 1995, Woodruff et al.
prescription and over-the-counter medications, 1997). Although it is generally recognized that stress resulting in unanticipated effects.
can induce headaches, high blood pressure, acne,
Although this is by no means an exhaustive heart attacks, and ulcers, delusory parasitosis
review of medication side effects, it does show that
sufferers are reluctant to acknowledge that their
Side effects of Prozac®,
symptoms experienced by delusory parasitosis dermatologic symptoms could be related to stress
sufferers may have valid physiological causes, either
in medical conditions or in the drugs prescribed for
Social isolation is one predisposing feature of
their treatment. Psychologists and dermatologists delusory parasitosis. Some delusory parasitosis cases
have noted that organic causes must be excluded
involve lonely people who need interactions with
parasitosis—erythema, paresthesia, pruritus, rash,
before a diagnosis of psychogenic pruritus can be
other humans (May and Terpenning 1991). Elderly
made (Freyne and Wrigley 1994, Gupta 1995).
people who live alone, seldom get out, seldom have
Because of the numerous potential physiological
visitors, or feel they have no purpose in life are
causes of pruritus, urticaria, and paresthesia, it is
prone to fixating on themselves and their health
understandable that physicians often do not attempt
(Bernhard 1992, Freyne and Wrigley 1994). For
to treat underlying causes but, instead, prescribe many of these people, the illness itself is an palliatives or advise the patient to pursue important security factor (Laihinen 1991), allowing entomological possibilities (which fits with the them to seek attention and evoke sympathy. patient's inclinations, anyway). In these days of
Bell's Syndrome (the Power of Suggestion).
managed care, physicians have neither the time nor
Often, the fact that several people are experiencing
incentive to do a thorough medical workup or the same sensation is used to demonstrate that it is attempt to determine causation of obscure and non-
not psychological. Scratching behavior is an
atavistic primate response with high psychological
In teenagers and young adults, recreational drug
contagiousness (de Leon et al. 1992). Thus,
use may be a more likely explanation for delusory
situations in which more than one person is
parasitosis symptoms (Zanol et al. 1998). Drugs such
complaining of the symptoms are not necessarily
as cocaine and methamphetamine particularly are
evidence that there is a common cause behind the
noted for producing “formication,” or the sensation
of ants crawling in or on the skin (Ellinwood 1969,
Siegel 1978, Elpern 1988, Marschall et al. 1991). parasitosis cases will attest to this. Despite finding Cocaine use is admitted by 19% of all 18-25 year olds
no arthropod in any samples provided, there is a
and 26% of all 26-34 year olds; hallucinogens such as
strong urge to take a shower following these
methamphetamines have been used by 12% of 18-25
examinations. Consciously, one realizes that there is
year olds and 16% of 26-34 year olds (SAMHSA
no infestation, but subconsciously one often feels
1996). Ekbom’s (1938) syndrome caused by drug use
the “creepy-crawlies” after looking through the
was featured in an episode of “The X Files” (Hinkle
victim’s scurf. In fact, the author, while reading
1998), thus assuming its place in popular culture.
through the delusory parasitosis literature in
preparing this article, found herself absentmindedly
scratching; before the manuscript was completed,
Scratching is a common primate displacement
her arms and legs bore distinct scarification.
activity in response to tension, anxiety, and stress
Responses of the Entomologist or Pest
Table 5. Some web sites dealing with delusory parasitosis
It always should be determined whether, in fact,
an arthropod is involved (Table 5). Monitoring may
include using cellophane tape to entrap the culprit
while it is attacking the skin, glueboards to survey
the environment, or a hand-operated vacuum
cleaner to sample the area in which attacks are
AMERICAN ENTOMOLOGIST • Spring 2000
occurring (Potter 1992). Typical culprits include recommendations for their suppression (Waldron thrips brought in on flowers, bird or rodent mites 1972). Unfortunately, it typically is impossible to from nests in the building, or cryptic pests such as convince the individual that there are no “bugs” bed bugs or fleas (Webb 1993). If a causative agent present, and recommendations to visit a health care is identified, the source can be eliminated and the professional virtually always are rebuffed (Lynch problem solved. Otherwise, no pesticidal 1993). applications should be made (Potter 1992).
Entomologists should have the courage of their
Monitoring and careful investigation of the convictions. Once it has been determined that there
situation may indicate that, although no arthropod are no arthropods involved in the case, this should is involved, there are physical causes such as be conveyed to the individual tactfully but firmly. insulation being blown through air-handling The letter may be worded to make the point that, systems or nylon fragments from newly installed “Although examination of the specimens you carpet (Blum and Katz 1990, Potter 1992). provided yielded no evidence of arthropod Frequently, such modifications as improved involvement, the symptoms you are experiencing sanitation, installation of antistatic devices, and are real and deserve further investigation.” The increased humidity will reduce complaints.
objective is to persuade the sufferer to go to a
If no entomological cause can be identified, the physician where, it is hoped, he or she may receive
individual should be referred to a physician and appropriate health care (Lynch 1993, Hinkle 1998).
encouraged to pursue the possibility of one of the As Elliott (1944) observed over half a century ago,
previously mentioned medical conditions serving as investigating delusory parasitosis is “an intriguing
the basis of the symptomatology (Kushon et al. field for useful research, an opportunity for
1993). Meanwhile, the sufferer should be advised to teamwork on the part of the pest control operator,
discontinue using self-prescribed treatments. These the medical entomologist, the dermatologist, and
materials, applied topically, are not good for the the psychiatrist.”
skin and may aggravate the problem. In particular,
pesticidal shampoos and lotions should not be used Acknowledgments
more than stated specifically on the label; these are
I thank F. M. Oi, of the USDA-ARS, Center for
potent compounds that will increase skin sensitivity Medical, Agricultural & Veterinary Entomology, when overused.
Gainesville, Florida, who supplied the persistent
Responsible pest control firms have policies encouragement that resulted in this article. Grateful
against treating for pests until a culprit has been appreciation goes to the more than 70 Cooperative identified. This is legally and ethically appropriate Extension Specialists around the country who (St. Aubin 1981). Customers, however, frequently participated in our delusory parasitosis survey, as do not understand, expecting that the pest control well as the other contributors who alerted me to operator will “just spray something.” Pressure to valuable literature and sources. I am grateful to the comply may be extreme. By applying pesticides, the on-line discussion group Entomo-l for providing pest control operator is validating the customer’s diverse accounts of and perspectives on delusory perception that there is a pest present. Unwarranted parasitosis. Acknowledgment (without appreciation) pesticidal applications increase the building’s goes to the hundreds of delusory parasitosis pesticide load. Pesticide exposure can increase sufferers who have provided me this experience. symptom manifestations, both as psychological
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The intention in writing this article was to develop a concise understanding of the relationship between Autistic Spectrum Disorders (ASD) and ADD/ADHD; the road was far from short and generated its fair share of questions on the way. Nevertheless, I succeeded, albeit momentarily, to adjust the circles to some semblance of a straight line. The first of my circles, oddly enough, began right at t
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