Delusional parasitosis
| Delusional parasitosis | |
|---|---|
| Other names | Ekbom's syndrome[1] |
| Specialty | Psychiatry, dermatology |
Delusional parasitosis (DP), also called delusional infestation,[2] is a mental health condition where a person falsely believes that that their body is infested with living or nonliving agents. Common examples of such agents include parasites, insects, or bacteria. This is a delusion due to the belief persisting despite evidence that no infestation is present.[3][1] People with this condition may have skin symptoms such as the urge to pick at one's skin (excoriation) or a sensation resembling insects crawling on or under the skin (formication). In Morgellons disease, a type of delusional parasitosis, people falsely believe harmful fibers are coming out of their skin and causing wounds.[1][4]
Delusional parasitosis is classified as a delusional disorder in the fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The precise cause is unknown. Current research suggests it may be linked to problems with dopamine in the brain, similar to psychotic disorders.[2] Diagnosis requires the delusion to be the only sign of psychosis, not caused by another medical condition, and present for at least a month. A defining characteristic of delusions is that the false belief cannot be corrected.[5] As a result, most affected individuals believe their delusion is true and do not accept treatment.[2] Antipsychotic medications can help with symptom remission.[6] Cognitive behavioral therapy and antidepressants can also decrease symptoms.[1][7]
The condition is rare and affects women twice as much as men.[1] The average age of individuals affected by the disorder is 57.[8] An alternative name, Ekbom's syndrome, honors the neurologist Karl-Axel Ekbom, who published seminal accounts of the disease in 1937 and 1938.[1]
Classification
[edit]Delusional parasitosis is classified as a delusional disorder of the somatic subtype in the Diagnostic and Statistical Manual of Mental Disorders (DSM5).[1][5] Since 2015, the most common name for the disorder is delusional parasitosis. The condition has also been called delusional infestation, delusory parasitosis, delusional ectoparasitosis, psychogenic parasitosis, Ekbom syndrome, dermatophobia, parasitophobia, formication and "cocaine bugs".[5]
Delusional parasitosis can occur in two different forms.[5] The first, primary delusional infestation, is a psychiatric disorder.[2] The second, secondary delusional infestation, is linked to other medical or psychiatric conditions.[2]
Morgellons is considered a form of delusional parasitosis. People with this condition have painful skin sensations that they believe are caused by fibers. This condition is similar to other delusional infestations. However, those self-diagnosed with Morgellons believe strings or fibers are present in their skin lesions.[1][5] Morgellons disease is not listed in the International Classification of Diseases (ICD-11).[4]
Delusory cleptoparasitosis is a type of delusion where the person believes the infestation is in their home, rather than on or in their body.[9]
Signs and symptoms
[edit]People with delusional parasitosis believe that "parasites, worms, mites, bacteria, fungus" or similar organisms have infected them. Reasoning or logic cannot change this fixed, false belief.[5] Symptoms can differ among those with the condition. It often involves a crawling or pin-pricking sensation. Many describe it as a sensation of parasites crawling upon or burrowing into the skin. Sometimes, this includes a physical sensation (known as formication).[1][5][8] People with this condition may injure themselves trying to remove the "parasites". This can lead to skin damage such as excoriation, bruises, and cuts. Moreover, using harsh chemicals or obsessive cleaning can cause further harm.[8]
People with this condition recall events like a bug bite, travel, sharing clothes, or contact with someone they think was infected.[1] These exposures may cause the individual to pay attention to bodily sensations they usually ignore. The individual may then believe these symptoms are due to an infestation.[1] Those affected may see any skin mark or small object on them or their clothing as proof of a parasitic infestation. Those with the condition often collect such "evidence" to present to medical professionals. Medical professionals call this the "matchbox sign", "Ziploc bag sign" or "specimen sign." The name stems from the fact that the evidence is typically stored in a small container, like a matchbox.[1][8] The matchbox sign is present in five to eight out of every ten people with DP.[1] Related is a "digital specimen sign", in which individuals bring collections of photographs to document their condition.[1]
Similar delusions may be present in close relatives. This is known as a folie à deux and it occurs in 5–15% of cases.[8] It is considered a shared psychotic disorder.[8] The internet has created a unique situation where many people can reinforce shared delusions. This has led to the term "folie à Internet" for delusional parasitosis. When those affected are isolated from each other, their symptoms usually improve, but most still need treatment.[8]
Approximately eight out of ten individuals with DP have co-occurring conditions, such as depression, substance use disorders, and anxiety. Their personal and professional lives are frequently disrupted due to extreme distress regarding their symptoms.[10]
A 2011 Mayo Clinic study of 108 patients failed to find evidence of skin infestation in skin biopsies and patient-provided specimens; the study concluded that the feeling of skin infestation was DP.[1][11]
Cause
[edit]The cause of delusional parasitosis is unknown. Primary delusional parasitosis may result from high dopamine in the brain's striatum. This happens from diminished dopamine transporter (DAT) function.[1][8] The dopamine transporter regulates dopamine reabsorption in the brain.[1][8] For example, substances that block dopamine reuptake, like cocaine and methylphenidate, can cause symptoms like formication. Additionally, several conditions linked to faulty dopamine transporters can also lead to secondary delusional parasitosis. Examples of such conditions include: "schizophrenia, depression, traumatic brain injury, alcoholism, Parkinson's and Huntington's diseases, human immunodeficiency virus infection, and iron deficiency".[8] Providing further support for the dopamine theory, antipsychotics improve DP symptoms. This may be because they affect dopamine transmission.[8][5]
Secondary delusional parasitosis is caused by another medical or psychiatric disorder. Medical conditions associated with secondary delusional parasitosis include: deficiencies in vitamins such as B12 or folate, thyroid dysfunction, diabetes, Parkinson's disease, dementia, encephalitis, meningitis, and multiple sclerosis.[8][5] Additionally, some infectious diseases such as HIV and syphilis have also been associated with delusional infestation.[5] Secondary delusional parasitosis is also associated with substance use disorders. The most commonly associated substances include chronic alcohol use, alcohol withdrawal, long-term cocaine use, long-term amphetamine use.[5] Finally, there also a number of prescription drugs that may cause DP as a side effect. These include "phenelzine, pargyline, ketoconazole, corticosteroids, amantadine, ciprofloxacin, pegylated interferon alpha, and topiramate."[5]
Diagnosis
[edit]Delusional parasitosis is diagnosed when: 1) the delusion is the only symptom of psychosis, 2) the delusion has lasted a month or longer, 3) the patient's behavior is otherwise not markedly odd or impaired, 4) mood disorders (if present at any time) have been comparatively brief, and 5) the delusion cannot be better explained by another medical condition, mental disorder, or the effects of a substance. For diagnosis, the individual must attribute abnormal skin sensations to the belief that they have an infestation, and be convinced that they have an infestation even when evidence shows they do not.[1]
The condition is recognized in two forms: primary and secondary. In primary delusional parasitosis, the delusions are the only manifestation of a psychiatric disorder. Secondary delusional parasitosis occurs when another psychiatric condition, medical illness or substance (prescription or recreational) use causes the symptoms. In secondary delusional infestation, the delusion is a symptom of another condition rather than the disorder itself.[5] Secondary forms of DP can be functional (due to psychiatric disorders) or organic (due to other medical illness or organic disease).[8] The secondary organic form may be related to vitamin B12 deficiency, hypothyroidism, anemia, hepatitis, diabetes, HIV/AIDS, syphilis, or use of stimulants like methamphetamine and cocaine.[8][12]
The first step in diagnosis is to conduct a comprehensive examination to rule out other causes of the patient's symptoms.[8] Testing to rule out other conditions fosters trust between the provider and patient.[10] To check for parasitic infestations, providers use skin examinations, skin biopsies, dermatologic tests and laboratory analyses. [1][10] A parasitic infection is more suspicious in patients with elevated eosinophil levels. If a patient's labs and clinical history are suspicious for a parasitic infection, specific testing can be done. It is important to consider sociocultural factors as well, such as patients who are houseless, refugees, or have traveled recently. [2] For example, depending on the patient's symptoms and the patient's clinical picture, testing for "schistosomiasis, paragonimiasis, filariasis, strongyloidiasis, and toxocariasis" may be indicated.[2]
A detailed lab analysis can rule out other causes. Examples of such analyses include complete blood count, comprehensive metabolic panel, erythrocyte sedimentation rate, C-reactive protein, urinalysis for toxicology and thyroid-stimulating hormone.[1][10] Tests may also be done for "human immunodeficiency virus, syphilis, viral hepatitis, B12 or folate deficiency", and allergies.[1] Additionally, the provider should review medications that may cause similar symptoms.[8]
Differential
[edit]Healthcare professionals must distinguish delusional parasitosis from actual infections like scabies or mites.[13] Agricultural products (grocer's itch), pet-induced dermatitis, caterpillar/moth dermatitis, and exposure to fiberglass can cause itchy skin/ the feeling of bugs crawling on the skin.[10] After ruling out infestations and exposures, providers should check for other causes of these symptoms.
There are a variety of other psychiatric conditions that may be related to the patient's symptoms. These include schizophrenia, anxiety disorders, obsessive–compulsive disorder, dementia, delirium, affective or substance-induced psychoses, and medical conditions that cause psychosis.[10] Additionally, several drugs may also cause such symptoms, such as amphetamines, dopamine agonists, opioids, and cocaine.[10] Medical conditions that must be considered differential diagnosis include hypothyroidism, and kidney or liver disease.[10]
Many of these physiological and environmental factors are capable of inducing a "crawling" sensation. The diagnosis of delusion develops when some people become fixated on the sensation and its possible meaning, as this fixation may develop into DP.[14]
Treatment
[edit]A key component of the disorder is that patients with delusional parasitosis are not comforted by the lack of evidence for infestation.[10] Additionally, many patients will reject the diagnosis of delusional parasitosis. As a result, these patients may also reject treatment for the condition.[1][5][15] This makes treating the issue extremely difficult. Directly confronting individuals about delusions is unhelpful because by definition, the delusions are not likely to change.[8] However, patients with delusional infestation require appropriate treatment for their symptoms in order to improve their wellbeing.[2] Therefore, it is crucial to that the provider does not disagree nor agree with the delusion and rather emphasizes symptom reduction. [1]
Multidisciplinary care is crucial to the treatment of delusional infestation.[2] Individuals with delusional infestation often see many providers in different specialties. It is crucial to gain the patient's trust and collaborate with other providers to foster a therapeutic partnership.[8] Integration of care between both psychiatrists and dermatologists have been effective.[2] Further, fostering trust is the first step in achieving remission of symptoms. Dermatologists may have more success introducing the use of a medication as a way to alleviate the distress of itching.[8]
As of 2019, there have not been any studies that compare available treatments to placebo.[16] The only treatment that provides a cure is low doses of antipsychotic medication. Risperidone is the treatment of choice.[1] This is due to both efficacy of the drug and a more favorable side effect profile. [1]Previously, the treatment of choice was pimozide, but it has a higher side effect profile than the newer antipsychotics.[10] Aripiprazole and ziprasidone are likely to be effective but have not been well studied for delusional parasitosis. Olanzapine is also effective. All are used at the lowest possible dosage, and increased gradually until symptoms remit.[1] For patients who are hesitant to start medication, cognitive behavioral therapy (CBT) can be useful.[10][8] Despite no clear evidence supporting their use, some providers use topical steroids and anti-itch agents for symptom relief. These medications have minimal side effects and can serve as adjunctive therapy.[2]
Patients may see results in as little as two weeks on an antipsychotic. However, it is advised to wait 6-10 weeks for maximum results.[1] Although patients may experience symptom resolution, it is recommended to continue the antipsychotic for at least 3 months before discontinuing. [1]
Prognosis
[edit]Patients will often have symptoms for months before being diagnosed.[1] The average duration of the condition is about three years.[1] If not treated, symptoms will typically worsen. Patients may develop chronic scarring as a result. [9] Patients may also develop skin infections as a result of their scratching and obsessive cleaning efforts.[2] Cure may be achieved with antipsychotics or by treating underlying psychiatric or medical conditions.[1] Relapse occurs in 25% of patients treated. [1]
Delusional parasitosis drastically impacts the lives of those affected. The condition leads to social isolation which can worsen depressive symptoms. [1] Additionally, the condition often affects patients self esteem. [9] It is crucial to monitor for both depression and suicide risk in patients affected by delusional parasitosis.[2] The condition can also impact the individuals ability to function in their daily life, which can negatively impact employment.[1]
Epidemiology
[edit]While a rare disorder, delusional parasitosis is the most common of the hypochondriacal psychoses.[5] It is more common than other types of delusions, like those associated with body odor or halitosis.[5] DP is often undetected because those who have the condition do not consider their symptoms to be a delusion and may not consult a psychiatrist.[5] This makes it extremely difficult to estimate the number of people who suffer from delusional parasitosis. A population-based study in Olmsted County, Minnesota, found a prevalence of 27 per 100,000 person-years and an incidence of almost 2 cases per 100,000 person-years.[5] Other studies have found annual incidence rates to be anywhere from 2-17 cases per 1 million people per year.[9] Of note, the majority of dermatologists will see at least one person with DP during their career.[8]
The condition is observed twice as often in women than men. The highest incidence occurs in people in their 60s, but there is also a higher occurrence in people in their 30s, associated with substance use.[1] It occurs most often in "socially isolated" women with an average age of 57.[8] There is a high co-occurence with substance use disorders and psychiatric disorders.[1] Individuals with DP may be considered to be high functioning.[9]
Similar to delusional infestation, Morgellons is most common in women with an average age of 55. It is also associated with recreational substance use as well as psychiatric disorders.[1] Since the early 2000s, a strong internet presence has led to increasing awareness of Morgellons.[1] As a result, this strong internet presence has increased self diagnosis of Morgellons.[1]
History
[edit]Karl-Axel Ekbom, a Swedish neurologist, first described delusional parasitosis as "pre-senile delusion of infestation" in 1937.[1] The common name has changed many times since then. Ekbom originally used the German word dermatozoenwahn, but other countries used the term Ekbom's syndrome. That term fell out of favor because it also referred to restless legs syndrome (more specifically termed Willis–Ekbom disease (WED) or Wittmaack-Ekbom syndrome).[17][18] Other names that referenced "phobia" were rejected because anxiety disorder was not typical of the symptoms.[18] The eponymous Ekbom's disease was changed to "delusions of parasitosis" in 1946 in the English literature, when researchers J Wilson and H Miller described a series of cases, and to "delusional infestation" in 2009.[1][19] The most common name since 2015 has been "delusional parasitosis".[5]
Ekbom's original was translated to English in 2003; the authors hypothesized that James Harrington (1611–1677) may have been the "first recorded person to suffer from such delusions when he 'began to imagine that his sweat turned to flies, and sometimes to bees and other insects'."[20]
Morgellons
[edit]Mary Leitao, the founder of the Morgellons Research Foundation, [21] coined the name Morgellons in 2002, reviving it from a letter written by a physician in the mid-1600s.[22][23] Leitao and others involved in her foundation (who self-identified as having Morgellons) successfully lobbied members of the U.S. Congress and the U.S. Centers for Disease Control and Prevention (CDC) to investigate the condition in 2006.[24][25] The CDC published the results of its multi-year study in January 2012. The study found no underlying infectious condition and few disease organisms were present in people self- diagnosed with Morgellons. The fibers found were likely cotton, and the condition was "similar to more commonly recognized conditions such as delusional infestation".[26]
An active online community has supported the notion that Morgellons is an infectious disease, and propose an association with Lyme disease. Publications "largely from a single group of investigators" describe findings of spirochetes, keratin and collagen in skin samples of a small number of individuals; these findings are contradicted by the much larger studies conducted by the CDC.[5]
Society and culture
[edit]Jay Traver (1894–1974), a University of Massachusetts entomologist, has been characterized after her death as having made "one of the most remarkable mistakes ever published in a scientific entomological journal",[27] after publishing a 1951 account of what she called a mite infestation.[28] Her detailed description of her own experience with mites was later shown to be incorrect,[27] and has been described by others as a classic case of delusional parasitosis.[29][17][30][31] Matan Shelomi says the paper has done "permanent and lasting damage" to people with delusional parasitosis, "who widely circulate and cite articles such as Traver's and other pseudoscientific or false reports" via the internet, making treatment and cure more difficult.[30] He argues that the historical paper should be retracted because it has misled people about their delusion and that papers "written by or enabling deluded patients", along with internet-fed conspiracies and the related delusion of Morgellons, may increase.[30]
Shelomi published another study in 2013 of what he called scientific misconduct when a 2004 article in the Journal of the New York Entomological Society included what he says is photo manipulation of a matchbox specimen to support the claim that individuals with DP are infested with collembola.[32]
See also
[edit]References
[edit]- ^ a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac ad ae af ag ah ai aj ak al am an ao Moriarty N, Alam M, Kalus A, O'Connor K (December 2019). "Current understanding and approach to delusional infestation". Am. J. Med. (Review). 132 (12): 1401–1409. doi:10.1016/j.amjmed.2019.06.017. PMID 31295443. S2CID 195893551.
- ^ a b c d e f g h i j k l m Mendelsohn A, Sato T, Subedi A, Wurcel AG (July 2024). "State-of-the-Art Review: Evaluation and Management of Delusional Infestation". Clin Infect Dis. 79 (2): e1–e10. doi:10.1093/cid/ciae250. PMID 39039925.
- ^ Waykar V, Wourms K, Tang M, Verghese J (22 October 2020). "Delusional infestation: an interface with psychiatry". BJPsych Advances. 27 (5): 343–348. doi:10.1192/bja.2020.69. ISSN 2056-4678.
- ^ a b Kemperman PM, Vulink NC, Smit C, Hovius JW, de Rie MA (July 2024). "Review of literature and clinical practice experience for the therapeutic management of Morgellons disease". J Eur Acad Dermatol Venereol. 38 (7): 1300–1304. doi:10.1111/jdv.19831. PMID 38308572.
- ^ a b c d e f g h i j k l m n o p q r s t Suh KN (June 7, 2018). "Delusional infestation: Epidemiology, clinical presentation, assessment and diagnosis". UpToDate. Wolters Kluwer. Retrieved March 8, 2020.
- ^ McPhie ML, Kirchhof MG (March 2022). "A systematic review of antipsychotic agents for primary delusional infestation". J Dermatolog Treat. 33 (2): 709–721. doi:10.1080/09546634.2020.1795061. PMID 32658556.
- ^ Ahmed A, Affleck AG, Angus J, et al. (October 2022). "British Association of Dermatologists guidelines for the management of adults with delusional infestation 2022". Br J Dermatol. 187 (4): 472–480. doi:10.1111/bjd.21668. PMID 35582951.
- ^ a b c d e f g h i j k l m n o p q r s t u v Reich A, Kwiatkowska D, Pacan P (December 2019). "Delusions of parasitosis: an update". Dermatology and Therapy (Review). 9 (4): 631–638. doi:10.1007/s13555-019-00324-3. PMC 6828902. PMID 31520344.
- ^ a b c d e Lutfi Al-Imam AM (January 2016). "A systematic literature review on delusional parasitosis". Journal of Dermatology & Dermatologic Surgery (Review). 20 (1): 5–14. doi:10.1016/j.jdds.2015.11.003.
- ^ a b c d e f g h i j k Campbell EH, Elston DM, Hawthorne JD, Beckert DR (May 2019). "Diagnosis and management of delusional parasitosis". Journal of the American Academy of Dermatology (Review). 80 (5): 1428–1434. doi:10.1016/j.jaad.2018.12.012. PMID 30543832. S2CID 56483906.
- ^ Hylwa SA, Bury JE, Davis MD, Pittelkow M, Bostwick JM (September 2011). "Delusional infestation, including delusions of parasitosis: results of histologic examination of skin biopsy and patient-provided skin specimens". Archives of Dermatology. 147 (9): 1041–1045. doi:10.1001/archdermatol.2011.114. PMID 21576554.
- ^ Fisher, Alec H.; Stanciu, Cornel N. (December 2017). "Amphetamine-Induced Delusional Infestation". American Journal of Psychiatry Residents' Journal. 12 (12): 12–13. doi:10.1176/appi.ajp-rj.2017.121204.
- ^ Lepping, P.; Freudenmann, R. W. (March 2008). "Delusional parasitosis: a new pathway for diagnosis and treatment". Clinical and Experimental Dermatology. 33 (2): 113–117. doi:10.1111/j.1365-2230.2007.02635.x. ISSN 0307-6938. PMID 18205853 – via Oxford Academic.
- ^ Hinkle NC (2000). "Delusory parasitosis" (PDF). American Entomologist. 46 (1): 17–25. doi:10.1093/ae/46.1.17. Archived from the original (PDF) on 2012-10-21.
- ^ Harth W, Hermes B, Freudenmann RW (April 2010). "Morgellons in dermatology". Journal der Deutschen Dermatologischen Gesellschaft (Case report and review). 8 (4): 234–242. doi:10.1111/j.1610-0387.2009.07219.x. PMID 19878403. S2CID 205857564.
- ^ Assalman I, Ahmed A, Alhajjar R, Bewley AP, Taylor R (December 2019). "Treatments for primary delusional infestation". The Cochrane Database of Systematic Reviews. 12 (12): CD011326. doi:10.1002/14651858.CD011326.pub2. PMC 6903768. PMID 31821546.
- ^ a b Hinkle NC (June 2011). "Ekbom syndrome: a delusional condition of "bugs in the skin"". Current Psychiatry Reports. 13 (3): 178–186. doi:10.1007/s11920-011-0188-0. PMID 21344286. S2CID 524974.
- ^ a b Freudenmann RW, Lepping P (October 2009). "Delusional infestation". Clinical Microbiology Reviews (Review). 22 (4): 690–732. doi:10.1128/cmr.00018-09. PMC 2772366. PMID 19822895.
- ^ Slaughter JR, Zanol K, Rezvani H, Flax J (December 1998). "Psychogenic parasitosis. A case series and literature review". Psychosomatics (Historical review and case report). 39 (6): 491–500. doi:10.1016/S0033-3182(98)71281-2. PMID 9819949.
- ^ Ekbom KA, Yorston G, Miesch M, Pleasance S, Rubbert S (June 2003). "The pre-senile delusion of infestation". History of Psychiatry (Historical biography). 14 (54 Pt 2): 229–256. doi:10.1177/0957154X030142007. PMID 14521159. S2CID 444986.
- ^ a b Cutlip, Hunter A.; Mogallapu, Raja; Ang-Rabanes, Michael (May 2022). "Morgellons Disease Treated as a Psychosomatic Condition". Cureus. 14 (5): e25236. doi:10.7759/cureus.25236. ISSN 2168-8184. PMC 9217663. PMID 35755571.
{{cite journal}}: CS1 maint: unflagged free DOI (link) - ^ DeVita-Raeburn E (March–April 2007). "The Morgellons mystery". Psychology Today. Retrieved May 8, 2015.
- ^ Browne T (1690). "A Letter to a Friend". James Eason, University of Chicago.
- ^ Schulte B (January 20, 2008). "Figments of the Imagination?". Washington Post Magazine. p. W10. Retrieved June 9, 2008.
- ^ "Unexplained dermopathy (aka "Morgellons"), CDC Investigation". Centers For Disease Control. November 1, 2007. Archived from the original on June 3, 2016. Retrieved May 9, 2011.
- ^ Pearson ML, Selby JV, Katz KA, et al. (2012). "Clinical, epidemiologic, histopathologic and molecular features of an unexplained dermopathy". PLOS ONE. 7 (1): e29908. Bibcode:2012PLoSO...729908P. doi:10.1371/journal.pone.0029908. PMC 3266263. PMID 22295070.
- ^ a b Lockwood, Jeffrey (2013). The Infested Mind: Why Humans Fear, Loathe, and Love Insects. Oxford University Press. pp. 101–2. ISBN 978-0199930197.
- ^ Traver J (February 1951). "Unusual scalp dermatitis in humans caused by the mite, Dermatophagoides (Acarina, epidermoptidae)" (PDF). Proceedings of the Entomological Society of Washington. 53 (1).
- ^ Hinkle NC (2000). "Delusory parasitosis". American Entomologist. 46 (1): 17–25. doi:10.1093/ae/46.1.17.
- ^ a b c Shelomi M (June 2013). "Mad scientist: the unique case of a published delusion". Science and Engineering Ethics. 19 (2): 381–388. doi:10.1007/s11948-011-9339-2. PMID 22173734. S2CID 26369401 – via Academia.edu.
- ^ Poorbaugh JH (June 1993). "Cryptic arthropod infestations: separating fact from fiction" (PDF). Bulletin of the Society for Vector Ecology. 18 (1): 3–5. ISSN 0146-6429. Archived from the original (PDF) on 2017-12-15. Retrieved 2020-08-04.
- ^ Shelomi M (June 2013). "Evidence of photo manipulation in a delusional parasitosis paper". The Journal of Parasitology. 99 (3): 583–585. doi:10.1645/12-12.1. PMID 23198757. S2CID 6473251.