Ekbom Syndrome is the clinical term for the condition commonly known as “delusory parasitosis,” characterized by the * J conviction that one’s body is infested with insects or mites
in spite of no evidence thereof. Individuals suffering from this condition typically contact entomologists for identification of the presumed insects on them, presenting samples of skin material, hair, lint, and other debris for examination. Despite the absence of any insects, these individuals persist in their belief that their bodies are infested by “bugs” (Fig. 1).
FIGURE 1 Lesions where Ekbom sufferer has attempted to extract putative “bugs” from the skin.
There are many commonalities uniting these cases. Often these individuals are overwrought and one of their first comments is, “I am desperate, you have to help me.” Frequently they will recite a litany of attempted controls including extreme sanitation and hygiene efforts (bathing many times every day, cleaning the home with undiluted bleach), boiling of clothing, spraying various pesticides, hiring numerous pest control companies, burning or discarding furnishings, and so on. Not infrequently, they have moved out of the home and are living in a motel or even in their cars.
Generalizations include the typical sufferer being an older female, widowed, or living alone. However, this is certainly not true in all cases, or even in the majority of cases. There may be several people suffering with the same condition, all experiencing dermal symptoms that they attribute to insects.
One of the primary symptoms of Ekbom Syndrome is formication, which is the sensation of insects (specifically ants) crawling on the skin. Unfortunately, this symptom is a common side effect of recreational drug use, particularly methamphetamines and cocaine. In popular press, these phenomena are designated ” meth mites ” and “crack bugs,” respectively. Skin sensations such as formication are also possible side effects of some over-the-counter and prescription drugs, as well as many medical conditions (e.g., diabetic neuropathy).
Ekbom Syndrome is a diagnosis based on exclusion. If no arthropod can be determined to be causing the symptoms, likely the cause is psychological. Because this is a syndrome, clusters of phenomena from the following list are also indicative of the condition.
COMMONALITIES IN EKBOM SYNDROME
• The causative organism is assumed to be a facultative parasite; that is, it can successfully develop in an inorganic environment (furniture, an automobile) and then switch to being a human skin parasite.
• Despite the sufferer’s assertion that there are millions of the organisms infesting his body and environment, the sufferer is unable to successfully provide a valid specimen.
• Material presented to the entomologist typically includes lint, scabs, skin scales, hairs, and other dermal debris. In efforts to provide actual insects, sufferers sometimes dust out windowsills and provide the trash for examination.
• While calling the organism “invisible,” the sufferer is nonetheless able to describe its physical appearance.
• The organisms change color and shape. They may be variously described as granular, fibrous, thread-like, slimy, and so on.
• The sufferer provides an elaborate description of the creature’s life cycle (which reflects an amalgam of what he has read on various websites about parasites).
• The creatures exhibit a range of locomotory abilities, including crawling, flying, burrowing, and hopping.
• The sufferer associates the infestation’s source with someone or something they find objectionable, and can pinpoint specifically when the infestation was acquired. This may be the neighbor’s dog digging in the front yard, a foreigner on the bus, a former lover, or rats in the attic, for instance.
• The infestation is presumed to have originated from an animal.
• While some sufferers describe the “infestation” as affecting the entire body, generally it is localized, specifically to the scalp. Sufferers sometimes pull out their hair or shave their heads as a result.
• Sufferers employ drastic and dramatic treatment strategies for both their bodies and their environments. In addition to bathing several times a day and applying various cleansers, they subject their bodies to a range of bizarre folk remedies, and often apply hazardous materials such as bleach, kerosene, gasoline, and pesticides to their skin. Likewise, the home is often cleaned with ferocious intensity; some sufferers claim that they spend their entire waking hours in housecleaning. Many recount systematically moving through the home, spraying undiluted bleach on all surfaces. In addition to hiring professional pest control companies to treat the home, often the sufferer has repeatedly applied additional pesticides (including agricultural products not appropriate for indoor use).
• Household items that are presumed infested are discarded or burned. In some cases, virtually the entire household is eliminated, with the sufferer reduced to sleeping on air mattresses covered with sheets of plastic.
• Eventually sufferers resort to abandoning the home, moving from one location to another, in efforts to evade the “bugs.”
• Because physicians fail to solve their problems, sufferers “doctor shop,” going from one medical professional to the next. Frustration often results in bitterness and animosity toward healthcare personnel.
• Sufferers eventually quit their jobs, either because the condition is so debilitating that they can no longer function at work, or because their fixation on their condition consumes time and effort formerly invested in their job, or because they fear infesting their coworkers.
• Their reluctance to be around people, for fear of infesting them, as well as their peculiar behaviors eventually result in social isolation. Many sufferers refuse contact with family members, convinced that their infestation is contagious.
• Eventually the delusion is shared by others, such as cowork-ers or members of the household. Often this is cited as evidence that the infestation is real, since it is presumed that occurrence of similar symptoms in multiple sufferers indicates a valid infestation. However, this phenomenon is so common that it is designated folie a deux, or if more than two people are involved, folie a plusieurs.
• The condition may result in insomnia, because the sensations are noticed more at night. Exhaustion and frustration produce desperation and may cause the individual to express thoughts of suicide, as in “I can’t take this anymore.” Even in cases where the condition is not life threatening, it severely impacts quality of life.
• Without psychological intervention, the “infestation” can last for decades.
DIFFERENTIATING DELUSORY (EKBOM) COMPLAINTS FROM VALID ARTHROPOD PROBLEMS
Overall, descriptions presented about the creature’s biology and behavior are not consistent with known arthropod natural history. Possible arthropods that might produce symptoms similar to those experienced by Ekbom sufferers include bed bugs, thrips, lice, fleas, springtails, mosquitoes, scabies, and bird or rodent mites. Using appropriate surveying tactics, the entomologist or pest control operator should be able to determine if any of these creatures are involved. If the sufferer claims to feel the “bug” on the skin, then application of clear tape should entrap it.
A newly emerged syndrome called ” Morgellons” involves presumed infestation of the skin by fibers. Because Morgellons does not involve insects, it is not synonymous with Ekbom Syndrome, but likely is a variant within the same delusional complex. Additionally, Ekbom Syndrome should not be confused with Wittmaack-Ekbom Syndrome, which is synonymous with restless legs syndrome.
CONCLUSION
Individuals suffering from Ekbom Syndrome will continue to contact pest control operators and entomologists, because of their conviction of being infested by insects.
Anyone dealing with individuals suffering from Ekbom Syndrome should refrain from validating the perception of insect infestation. For instance, skin lesions should be referred to by appropriate descriptive terms, but not as “bites.” Innocuous insects provided in samples should be properly identified, and the point made that they neither bite nor infest human skin, and therefore cannot account for the observed symptoms. Unfortunately, entomologists are limited in what they can do for Ekbom sufferers. They can provide identification of submitted samples and, most importantly, encourage sufferers to pursue medical explanations for their condition with their physician.
