Current Psychiatry Reports

, Volume 13, Issue 3, pp 178–186 | Cite as

Ekbom Syndrome: A Delusional Condition of “Bugs in the Skin”

  • Nancy C. HinkleEmail author


Entomologists estimate that more than 100,000 Americans suffer from “invisible bug” infestations, a condition known clinically as Ekbom syndrome (ES), although the psychiatric literature dubs the condition “rare.” This illustrates the reluctance of ES patients to seek mental health care, as they are convinced that their problem is bugs. In addition to suffering from the delusion that bugs are attacking their bodies, ES patients also experience visual and tactile hallucinations that they see and feel the bugs. ES patients exhibit a consistent complex of attributes and behaviors that can adversely affect their lives.


Parasitization Parasitosis Dermatozoenwahn Invisible bugs Ekbom syndrome Bird mites Infestation Delusional infestation Delusions of infestation Delusory parasitosis Delusions of parasitosis Dermal invasion Parasites Skin parasites Morgellons Mite infestation Anxiety-induced psychosis Depression-induced psychosis 



No potential conflict of interest relevant to this article was reported.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Ekbom KA. Der präsenile dermatozoenwahn. Acta Psychiatr Neurol Scand. 1938;33:227–59 [reprinted as “The Pre-senile Delusion of Infestation,” Classic Text No. 54, History of Psychiatry 2003, 14:232–56].CrossRefGoogle Scholar
  2. 2.
    •• Freudenmann RW, Lepping PL. Delusional infestation. Clin Microbiol Rev. 2009;22:690–732. This extensive review covers ES diagnosis, characteristics, and treatment, with excellent discussions of the literature regarding all aspects of the condition. PubMedCrossRefGoogle Scholar
  3. 3.
    Aw DCW, Thong JY, Chan HL. Delusional parasitosis: case series of 8 patients and review of the literature. Ann Acad Med Singapore. 2004;33:89–94.PubMedGoogle Scholar
  4. 4.
    Murray WJ, Ash LR. Delusional parasitosis. Clin Microbiol Newsl. 2004;26:73–7.CrossRefGoogle Scholar
  5. 5.
    Huber M, Kirchler E, Karner M, Pycha R. Delusional parasitosis and the dopamine transporter. A new insight of etiology? Med Hypotheses. 2007;68:1351–8.PubMedCrossRefGoogle Scholar
  6. 6.
    Reichenberg JS, Magid M, Drage LA. A cure for delusions of parasitosis. J Eur Acad Dermatol Venereol. 2007;21:1423–4.PubMedCrossRefGoogle Scholar
  7. 7.
    Bak R, Tumu P, Hui C, et al. A review of delusions of parasitosis, part 1: presentation and diagnosis. Cutis. 2008;82:123–30.PubMedGoogle Scholar
  8. 8.
    Bury JE, Bostwick JM. Iatrogenic delusional parasitosis: a case of physician-patient folie a deux. Gen Hosp Psychiatry 2010, 32:210–212.Google Scholar
  9. 9.
    Dunn J, Murphy MB, Fox KM. Diffuse pruritic lesions in a 37-year-old man after sleeping in an abandoned building. Am J Psychiatry. 2007;164:1166–72.PubMedCrossRefGoogle Scholar
  10. 10.
    Robles DT, Romm S, Combs H, et al. Delusional disorders in dermatology: a brief review. Dermatol Online J. 2008;14:2.PubMedGoogle Scholar
  11. 11.
    Lyell A. Delusions of parasitosis: the Michelson Lecture. Br J Dermatol. 1983;108:485–99.PubMedCrossRefGoogle Scholar
  12. 12.
    Trabert W. 100 years of delusional parasitosis. Psychopathology. 1995;28:238–46.PubMedCrossRefGoogle Scholar
  13. 13.
    Monk BE, Rao YJ. Delusions of parasitosis with fatal outcome. Clin Exp Dermatol. 1994;19:341–2.PubMedCrossRefGoogle Scholar
  14. 14.
    Bourgeois ML, Duhamel P, Verdoux H. Delusional parasitosis: Folie à deux and attempted murder of a family doctor. Br J Psychiatry. 1992;161:709–11.PubMedCrossRefGoogle Scholar
  15. 15.
    • Boggild AK, Nicks BA, Yen L, et al. Delusional parasitosis: six-year experience with 23 consecutive cases at an academic medical center. Int J Infect Dis. 2010;14:e317–21. This study compared 23 ES cases presenting to a university medical center. PubMedCrossRefGoogle Scholar
  16. 16.
    • Healy R, Taylor R, Dhoat S, et al. Management of patients with delusional parasitosis in a joint dermatology/liaison psychiatry clinic. Brit J Dermatol. 2009;161:187–218. This paper illustrates the benefits of having dermatologists and psychiatrists treat ES patients in conjunction. CrossRefGoogle Scholar
  17. 17.
    Poorbaugh JH. Cryptic arthropod infestations: Separating fact from fiction. Bull Soc Vector Ecol. 1993;18:3–5.Google Scholar
  18. 18.
    Colombo G, Caimi M, Donà GP. Shared Ekbom’s syndrome. A case study. Eur Psychiatry. 2004;19:115–6.PubMedCrossRefGoogle Scholar
  19. 19.
    Ramirez-Bermudez J, Espinola-Nadurille M, Loza-Taylor N. Delusional parasitosis in neurological patients. Gen Hosp Psychiatry. 2010;32:294–9.PubMedCrossRefGoogle Scholar
  20. 20.
    Wenning MT, Leigh ED, Catalano MD, Catalano MC. Atypical antipsychotics in the treatment of delusional parasitosis. Ann Clin Psychiatry. 2003;15:233–9.PubMedGoogle Scholar
  21. 21.
    Fellner MJ, Majeed MH. Tales of bugs, delusions of parasitosis, and what to do. Clin Dermatol. 2009;27:135–8.PubMedCrossRefGoogle Scholar
  22. 22.
    Hinkle NC. Ekbom Syndrome: the challenge of invisible bugs. Ann Rev Entomol. 2010;55:77–94.CrossRefGoogle Scholar
  23. 23.
    Vila-Rodriguez F, MacEwan BG. Delusional parasitosis facilitated by web-based dissemination. Am J Psychiatry. 2008;165:12.CrossRefGoogle Scholar
  24. 24.
    Nel M, Schoeman JP, Lobetti RG. Delusions of parasitosis in clients presenting pets for veterinary care. J S Afr Vet Assoc. 2000;72:167–9.Google Scholar
  25. 25.
    Bellanger AP, Crouzet J, Boussard M, et al. Ectoparasites or Ekbom Syndrome? Can Fam Physician. 2009;55:1089–90.PubMedGoogle Scholar
  26. 26.
    Bewley AP, Lepping P, Freudenmann RW, Taylor R. Delusional parasitosis: time to call it delusional infestation. Br J Dermatol. 2010;163:1–2.PubMedCrossRefGoogle Scholar
  27. 27.
    Waldron WG. The role of the entomologist in delusory parasitosis. Bull Entomol Soc Amer. 1962;8:81–3.Google Scholar
  28. 28.
    Szepietowski JC, Salomon J, Hrehorow E, et al. Delusional parasitosis in dermatological practice. J Eur Acad Dermatol Venereol. 2007;21:462–5.PubMedGoogle Scholar
  29. 29.
    Traver JR. Unusual scalp dermatitis in humans caused by the mite, Dermatophagoides (Acarine, Epidermoptidae). Proc Entomol Soc Wash. 1951;53:1–25.Google Scholar
  30. 30.
    Donabedian H. Delusions of parasitosis. Clin Infect Dis. 2007;45:e131–4.CrossRefGoogle Scholar
  31. 31.
    Kim C, Kim J, Lee M, Kang M. Delusional parasitosis as ‘Folie à deux.’ J Korean Med Sci. 2003;18:462–5.PubMedCrossRefGoogle Scholar
  32. 32.
    Poli R, Agrimi E. Ekbom’s syndrome: two case reports treated with olanzapine. Clin Neuropsychiatry. 2009;6:124–7.Google Scholar
  33. 33.
    Bhandary SK, Peter R, Bhat S. Delusional parasitosis in ENT. Indian J Otolaryngol Head Neck Surg. 2008;60:387–9.CrossRefGoogle Scholar
  34. 34.
    Lee CS. Delusions of parasitosis. Dermatol Ther. 2008;21:2–7.PubMedCrossRefGoogle Scholar
  35. 35.
    Hillert A, Gieler U, Niemeier V, Brosig B. Delusional parasitosis. Dermatol Psychosom. 2004;5:33–5.CrossRefGoogle Scholar
  36. 36.
    Ahmad K, Ramsay B. Delusional parasitosis: lessons learnt. Acta Derm Venereol. 2009;89:165–8.PubMedGoogle Scholar
  37. 37.
    Räsänen P, Erkonen K, Isaksson U, et al. Delusional parasitosis in the elderly: a review and report of six cases from Northern Finland. Int Psychogeriatr. 1997;9:459–64.PubMedCrossRefGoogle Scholar
  38. 38.
    Duggal H, Singh I. Delusional parasitosis as a presenting feature of dementia. J Neuropsychiatry Clin Neurosci. 2010;22:1.Google Scholar
  39. 39.
    Daniel E, Srinivasan TN. Folie à Famille: delusional parasitosis affecting all the members of a family. Indian J Dermatol Venereol Leprol. 2004;70:296–7.PubMedGoogle Scholar
  40. 40.
    Friedmann AC, Ekeowa-Anderson A, Taylor R, Bewley A. Delusional parasitosis presenting as folie à trois: successful treatment with risperidone. Brit J Dermatol. 2006;155:841–65.CrossRefGoogle Scholar
  41. 41.
    Niemeier V, Kupfer J, Gieler U. Observations during an itch-inducing lecture. Dermatol Psychosom. 2000;1 Suppl 1:15–8.CrossRefGoogle Scholar
  42. 42.
    Koblenzer CS. The current management of delusional parasitosis and dermatitis artefacta. Skin Ther Lett. 2010;15:1–3.Google Scholar
  43. 43.
    Amato Neto V, Amato JGP, Amato VS, Ferreira CS. Ekbom Syndrome (delusory parasitosis): ponderations on two cases. Rev Inst Med Trop S Paulo. 2007;49:395–6.PubMedGoogle Scholar
  44. 44.
    Edlich RF, Cross CL, Wack CA, Long WB. Delusions of parasitosis. Amer J Emerg Med. 2009;27:997–9.CrossRefGoogle Scholar
  45. 45.
    Nicolato R, Correa H, Romano-Silva MA, Teixeira Jr AL. Delusional parasitosis or Ekbom syndrome: a case series. Gen Hosp Psychiatry. 2006;28:85–7.PubMedCrossRefGoogle Scholar
  46. 46.
    Koo J, Lee CS. Delusions of parasitosis: a dermatologist’s guide to diagnosis and treatment. Amer J Clin Dermatol. 2001;2:285–90.CrossRefGoogle Scholar
  47. 47.
    • Freudenmann RW, Lepping PL. Second-generation antipsychotics in primary and secondary delusional parasitosis: outcome and efficacy. J Clin Psychopharmacol. 2008;28:500–8. This paper analyzes 63 ES cases treated with second-generation antipsychotics and points to their preference over pimozide. PubMedCrossRefGoogle Scholar
  48. 48.
    • Lee CS, Accordino R, Howard J, Koo J. Psychopharmacology in dermatology. Dermatol Ther. 2008;21:69–82. These recommendations assist dermatologists in treating psychopathological disorders. PubMedCrossRefGoogle Scholar
  49. 49.
    • Bak R, Tumu P, Hui C, et al. A review of delusions of parasitosis, part 2: treatment options. Cutis. 2008;82:257–64. This review summarizes and compares treatment recommendations, including potential drug side effects. PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC (outside the USA) 2011

Authors and Affiliations

  1. 1.Department of EntomologyUniversity of GeorgiaAthensUSA

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