[Public Health Issue] Invisible Bugs

Delusory parasitosis (DP) is a false, unshakable belief that tiny organisms, such as mites, fleas, or worms, live in or on the skin, or within the body (Hinkle 2000). People with DP describe sensations of something crawling on or in the skin or biting them, identify bits of debris such as dirt and dust as “bugs,” and usually have mislabeled skin irritation such as red bumps or sores as “bites.” Sufferers will seek help from entomologists and physicians, but the first phone call is typically to the pest control technician (Lyell 1983).
Symptoms of DP include itching, stinging and crawling sensations on the skin. People with DP have been known to throw out personal belongings, burn mattresses and bathe in bleach or pesticides. Generally, sufferers are either retired or disabled, female and 40 to 80 years old. Although DP is a psychological condition, sufferers most frequently seek relief from pest control companies (Koblenzer 1987).
Pest control technicians are not psychologists, so they rarely feel equipped to deal with these situations. DP is becoming more frequently reported (Webb 1993) and the pest management industry faces financial and legal implications because of this condition. A recent survey of pest control technicians in Georgia reports nearly 40 percent had not received information regarding DP, 15 percent had received information and remembered it, but 45 percent had received information — and forgotten it. Additionally, the survey found pest control technicians spend an average of five hours a month with people suffering from symptoms of this condition. A company of eight technicians, each earning $12 an hour, would lose $5,760 a year. Technicians capable of identifying and managing customers with DP symptoms can save a company thousands of dollars a year.

WHAT TO LOOK FOR. Three key characteristics to identify customers with delusory parasitosis include:
1) Speaking style: Speaking in a frantic, manic way; talking for hours; expressing desperation, saying things like, “You are my last hope.”
2) Experience: Describing bugs turning into inanimate objects, changing colors, disappearing or exhibiting other paranormal behaviors.
3) Management: Applying dangerous amounts of pesticides to their homes or their bodies, extreme cleaning activities, having called several other pest control companies with no relief.
A customer displaying these behaviors should be a “heads-up” to the pest management professional that something out of the ordinary is occurring. Navigating a situation with such a customer can be delicate and should be handled with the utmost consideration and care.

WHAT TO DO. The house must first be checked for an infestation by the pest management professional. Perform a conscientious inspection, put out traps and investigate for any signs of a valid pest problem. If the customer provides samples, have them identified by an entomologist. If your office is not equipped to do so, submit specimens to the National Pest Management Association or your state extension entomology office. Question the client about when they first noticed the problem and ask for a description of the insects and how they might have gotten into the home. Make notes of any contradictions (such as the bugs being too small to see but later described as red). Ensure courteous service because customers with this condition often feel frustrated, thinking “no one will help.” By being thorough and informing the customer of what you are doing in the inspection, you will assure that this attitude is not validated.
Never spray anyway, “just in case.” Ask what kinds of pesticides have been used in the home, either professionally or over the counter. Be kind, firmly assuring them that their safety is your priority and that you cannot apply pesticides in their home in the absence of a pest. 
Document the inspection in the customer’s file, noting that no infestation was found in the home. Alert the pest management firm’s manager to the situation and include a dated note to this effect in the file too. This will alert receptionists and co-workers to the situation. Customers with delusory parasitosis may call the company repeatedly to complain that they are still experiencing itching and biting sensations. By making a note in the file and talking to a manager right away, you have reported the situation and can refer to an authority should the customer have a complaint. The customer may ask for further investigation, in which case a referral to their county extension agent or local health department is appropriate.

FINAL THOUGHTS. People with delusory parasitosis are not “crazy” but are acting logically in regard to their experience — when the person feels bugs and when they see red bumps — it is not unreasonable for them to assume they have bugs. When someone falsely concludes that they are experiencing a skin parasite they can feel frustrated, emphasizing the necessity of treating these customers exceptionally kindly and compassionately. In addition to frustration, DP sufferers often experience loss of sleep, anxiety, depression, or have suicidal thoughts because of the constant itching and biting sensations. They feel abandoned by entomologists, physicians and pest control technicians. If a client gives an indication of suicidal thinking, technicians should talk to their manager and then it may be decided that you should call the police for a welfare check to ensure the customer’s safety.
DP research requires new interdisciplinary cooperation of psychologists, pest control technicians, entomologists and most importantly sufferers. Pest control technicians can not only reduce the amounts of pesticides applied in homes by being able to identify DP, but can save businesses thousands of dollars a year. Identification and management of the condition through networks of pest control technicians, entomologists and psychologists will lead to better treatment and advocacy of delusory parasitosis.

Sarah Bione has a degree in psychology and works in the entomology department at the University of Georgia performing interdisciplinary research on delusory parasitosis and unidentified skin parasites. Dr. Nancy Hinkle is a professor in the Department of Entomology at the University of Georgia, Athens. They can be reached at sbione@giemedia.com and nhinkle@giemedia.com respectively.

References
Hinkle, N.C. 2000. Delusory parasitosis. American Entomologist 46: 17-25.
Koblenzer, C.S. 1987. Delusions and hallucinations as they relate to the skin. Pp. 103-130 in Psychocutaneous Disease. Orlando, Fla., Grune and Stratton, Inc.
Lyell, A. 1983. Delusions of parasitosis. Seminars in Dermatology 2(3): 189-195.
Webb, J.P. 1993. Delusions of Parasitosis; A symposium; Coordination Among Entomologists, Dermatologists and Psychiatrists. Bulletin of the Society for Vector Ecology 18(1):1-3.