A patient of mine came in several weeks ago with a complaint of “bugs under my skin.” During the course of the visit, it became clear to me that his symptoms did not match any known human bug infestation. Simply put, I thought he was having psychotic symptoms. As is so often the case with patients who have delusions, he does not believe that his mental health is playing any part in his symptoms. He is convinced that he has bugs burrowing under his teeth, into his eyeballs and under his nails. He saw them there in the exam room, but I didn’t. I tried to offer support in the best way I knew how (which, in the case of delusional parasitosis, is not much). When my reality testing and basic interventions did not appear to be sufficient, I encouraged him to go the the emergency room for an evaluation. Surely, I thought, someone there will call a psych consult when they listen to his story. Much to my dismay, no one has called a psych consult. The patient has been to several ER’s in the past month. He’s been treated for various skin conditions, without success. He told me he was seen by Dermatology and they did a skin biopsy. None of this has helped his symptoms. He’s currently convinced that he has an exotic parasitic illness that is not found in our state (or, in fact, our country). His symptoms are not consistent with this illness, nor has he recently traveled to any tropical locales, and yet still he hasn’t had a psych consult. WTF, emergency room staff? How does this not set off any red flags?
My fear is that he is going to harm himself trying to dig out the bugs. He has already made several statements about having to get them out. Of course I advised him not to try to remove the bugs himself, but he feels desperate, and desperate people do desperate things.
I’m so frustrated with this case. I can’t convince the patient that he doesn’t have a bug infestation, and he can’t entertain the idea that this might not be real. The ER–for whatever reason–has missed several opportunities to call in a consult, and the patient doesn’t want to go see psych as an outpatient. What are we supposed to do, wait until he seriously injures himself? Argh.
(And in case anyone is wondering “Maybe he really does have some kind of infestation?”…I’ve thoroughly entertained the idea and there just isn’t any singular infestation that would explain his symptoms. It is possible that he has some other underlying condition that is causing skin itching and he is interpreting that as bugs under the skin, but I am almost 100% positive that it’s not actually bugs)