Delusional Infestation Associated with Post-Herpetic Neuralgia and EEG Abnormalities RUTH HARPER and GILLIAN MOSS
An 80-year-old widow with delusional Infestation in association abnormalities
with post-herpetic neuralgia and EEG in the left anterior perietal lobe responded
to combined pimozideand carbamazepine. Aetiological factors are reviewed in relation to the literature. British Journal of Psychiatry (1992), 161, 411—412 Delusional infestation is the falseidea that something
is alive and moving in or under the skin, frequently complained of initially to dermatologists and, often lesswillingly, to psychiatrists (Tullett, 1965;Gould & Gragg, 1976). The nosological status of delusional
crawlingabout insideher, breeding,and that shewasafraid to eat and drink in caseshe fed them. They werepainfully biting her. She also subsequently described butterflies alighting on her back, where she was unable to see them,
but in the distribution of her previous episode of herpes zoster. She continuedto experiencepost-herpeticneuralgia,
but wasableto distinguishthisfrom theothersensations. There was no evidence of mood disturbance or cognitive dysfunction. She was again started carbamazepine, 200mg daily, and pimozide, 6 mg daily, on which her symptoms changed from infestation with spidersto “¿flat things― and then a “¿feeling of water―.
infestation has been debated since it was first described by Thibierge in 1894. Ekbom (1938)
Discussion
reported seven patients with delusional infestation, Our patient describedtwo discreteforms of infesta emphasising the aetiological heterogeneity of the tion on the secondreferral —¿ spiderscrawling under group. Subsequent reports have supported this the skin and butterflies alighting on her back —¿ the (Tullett, 1965;Gould & Gragg, 1976;Skott, 1978; latter following the dermatomal distribution of her Lyell, 1983). The precise phenomenological nature
previous herpes zoster, but readily distinguished
from
of thissymptomhasalsobeendebated- whetherit
the discomfort of post-herpeticneuralgia- although
is a tactile hallucination, illusion, or delusional misinterpretation of a real sensation (Skott, 1978; Berrios, 1982). We present a case of an 80-year-old widow with delusional infestation of two discrete natures in association with post-herpetic neuralgia and left anterior parietal lobe EEG abnormalities.
possiblyrelated to dysaesthesiaarisingin association.
Case report Mrs A was initially referred to the old-age psychiatry servicesby the geriatriciansin 1986, aged 76 years. She had had an episode of herpes zoster (‘shingles')infection 18 months previously and had persistent post-herpetic neuralgia.
For 15 months
she had believed
that tiny animals
were burrowingunder her skin and breeding. She had also experienced episodes of feeling dizzy and depersonalised, associated at times with loss of consciousness. For three to four months before referral she had felt low in mood, and tearful, with loss of appetite and early morning wakening. There was no evidenceof cognitive dysfunction. An EEG demonstrated left anterior parietal sharp waves. She was startedon carbamazepine,200mg daily (regular levels within therapeuticrange), with subsequent improve ment in her physical complaints and mood, but her beliefs regardinginfestation remainedunchanged. In view of this,
pirnozide,4mg dailywasstarted,withsubstantialresolution of her symptoms. She was again referredin 1988, no longer on medication and now widowed. She complained that after seeinga large spider in her flat three weeks previously she had spiders
Previous studies and case reports indicate the greater prevalence of delusional infestation in women,particularlyin middleor late life (Tullett, 1965; Frithz,
1979; Lyell,
1983), and often isolated
(Skott, 1978;Lyell, 1983). In contradistinctionto many case reports, there was no evidence in our patient of previous genuine infestation. The variationin clinicalpresentation of delusional infestation is evident from previous studies. It has been described in association with affective psychoses
(e.g. Skott, 1978); mental handicap (Skott, 1978); acute and chronic organic brain disease(Gould & Gragg, 1976; Skott, 1978); alcohol abuseand drugs, e.g. cocaine (Tullett, 1965); more rarely, schizo
phrenia(Hopkinson,1970);withunderlyingphysical disorders such as pellagra predisposing to pruritus or altered sensation(e.g. Lyell, 1983); vitamin B12 deficiency (Pope, 1970); diabetes mellitus (Munro, 1978);and, finally, as a unitary syndrome within
the monosymptomatic hypochondriacal
psychoses(Munro, 1978;Reilly, 1988).In our patient the role of dysaesthesia and discomfort from post herpetic neuralgia are significant;
however, the
significance of the left anterior parietal EEG abnormality is lessclear —¿ perhapsthis is involved in altered appreciation of somatosensory stimuli. Our patient responded to a combination of pimozide
411
412
HARPER & MOSS
and carbamazepine- the latter recognisedasof use Pops, F. M. (1970)Parasitophobiaas thepresentingsymptomof Vitamin B,2 deficiency. Practitioner, 204, 421—422. in post-herpetic neuralgia and the former well T. M. (1988) Delusional infestation. British Journal of establishedin the treatment of delusionalinfestation REILLY, Psychiatry, 153 (suppl. 2), 44-46. (Reilly et a!, 1978; Lyell, 1983). —¿,
JOPLINO,
W.
H.
&
BRAan,
A.
W.
(1978)
Successful
treatment with pimozide of delusional parasitosis. British Journal
of Dermatology,98, 457-459.
References BERRIOS, 0. E. (1982) Tactile hallucinations: conceptual historical aspects. Journal of Neurology, Neurosurgery
and and
Psychiatry, 45, 288-293. EKBOM, K. A. (1938) Der praesenile
Dermatozoenwahn.
Acta
Sicorr, A. (1978) Delusions of infestation. Reports from the Psychiatric Research Centre. St Jorgen Hospital, University of Gothenberg,
Sweden.
Tuuzrr, 0. L. (1965) Delusions of parasitosis. British Journal of Dermatology, 77, 448—455.
Psychiatrica Neurologica, 13, 227-259. FRITHZ, A.
(1979)
Delusions
of infestation:
treatment
injections of neuroleptics. Clinical and Erperimental
by depot
Dermatology,
4, 485—488.
Oouw, W. M. &GRA0G, 1. M. (1976)Delusionsof parasitosis - an approachto the problem.Archivesof Dermatology,112, 1745—1748. LYELL, A. (1983) Delusions
of parasitosis.
British
Journal
of
E. Moss, MSc, MRCPsych,Consultant Psychogeri
of
atrician, Prestwich Hospital, Bury New Road, Salford
Dermatology, 108, 485-499. MUNRO, A. (1978)
manifesting
Monosymptomatic
as delusions
hypochondriacal
of parasitosis.
British
psychosis
Journal
5Ruth Harper, BSc,MRCP, MRCPsych, Lecturer, University Department of Psychiatry, Clinical SciencesBuilding, LeicesterRoyal Infirmary; Gillian
Dermatology, 108, 485-499.
Correspondence
Severe Deprivation in Childhood: A Case Report from Thailand L. B. BARTLETand P. LIMSILA
A 3%-year-old girl was incarcerated in a bamboo cage after ft was feared she had contracted rabies. Six years later, when she was released, she had lost almost all motor control,
displayed
a number
of stereotyples,
was
incontinent of both faeces and urine, and was diagnosed as having grand mel epilepsy. After four years of treatment (aged 13) she had shown considerable improvement and her mental age was seven years. British Journal of Psychiatry (1992), 161, 412—414
In Western countries, gross prolonged deprivation in childhood is, fortunately, rare. Child-careservices, inadequateasthey often are, comeinto action before childrenendurelengthyperiodsof suffering. In recent yearsthere have beenfew reports about children in
Case report Mai, a 10-year-oldgirl, wasreferredto the Yuwaprasart Child PsychiatricHospital(Bangkok)in September1987 by a missionary sister of St Paul de Chart because of retardation
in speech and strange behaviour. The missionary
sister had brought Mai from her home village in hill-tribe country in a politically unsettled area near the Thai-Laos border north of Nong-Kai. She told a remarkable tale.
Mai was the third of four children, all of whom had developed normally; there were no unusual features about her own earlydevelopment.Her mothertold the missionary sister that at 3½years she had made the same progress as her older sister at that stage. She was fully toilet trained.
Shecoulddressherself.Shefedherself,handlingfoodssuch as stickyriceadequately.Shetalkedin sentences,described
this group in the medical and psychological literature.
her needs and asked questions. She sang several songs in
In theThird World, wheredeprivationandwantare
the Laotianlanguage.She walkedand ran. She followed
endemic, it is likely there are more children in these grave situations. As community services for children
in thesecountriesimprove and aschild mental health concepts are better understood, more of these catastrophiesmay come to light. This report describesa caseof gross deprivation that recently
her parents to work in the fields every day. While waiting, she played with her siblings and mixed happily with other children, with whom she communicated and interacted normally.
She
displayed
no
unusual
behaviour
and
her parents had no worries regarding her health and
development.
came to the attention of the child psychiatric services
At the age of 3½years she was bitten by a puppy which had been behaving strangely for some days. The villagers
in Thailand.
became alarmed as two other children in the same district
An 80-year-old widow with delusional Infestation in association abnormalities
with post-herpetic neuralgia and EEG in the left anterior perietal lobe responded
to combined pimozideand carbamazepine. Aetiological factors are reviewed in relation to the literature. British Journal of Psychiatry (1992), 161, 411—412 Delusional infestation is the falseidea that something
is alive and moving in or under the skin, frequently complained of initially to dermatologists and, often lesswillingly, to psychiatrists (Tullett, 1965;Gould & Gragg, 1976). The nosological status of delusional
crawlingabout insideher, breeding,and that shewasafraid to eat and drink in caseshe fed them. They werepainfully biting her. She also subsequently described butterflies alighting on her back, where she was unable to see them,
but in the distribution of her previous episode of herpes zoster. She continuedto experiencepost-herpeticneuralgia,
but wasableto distinguishthisfrom theothersensations. There was no evidence of mood disturbance or cognitive dysfunction. She was again started carbamazepine, 200mg daily, and pimozide, 6 mg daily, on which her symptoms changed from infestation with spidersto “¿flat things― and then a “¿feeling of water―.
infestation has been debated since it was first described by Thibierge in 1894. Ekbom (1938)
Discussion
reported seven patients with delusional infestation, Our patient describedtwo discreteforms of infesta emphasising the aetiological heterogeneity of the tion on the secondreferral —¿ spiderscrawling under group. Subsequent reports have supported this the skin and butterflies alighting on her back —¿ the (Tullett, 1965;Gould & Gragg, 1976;Skott, 1978; latter following the dermatomal distribution of her Lyell, 1983). The precise phenomenological nature
previous herpes zoster, but readily distinguished
from
of thissymptomhasalsobeendebated- whetherit
the discomfort of post-herpeticneuralgia- although
is a tactile hallucination, illusion, or delusional misinterpretation of a real sensation (Skott, 1978; Berrios, 1982). We present a case of an 80-year-old widow with delusional infestation of two discrete natures in association with post-herpetic neuralgia and left anterior parietal lobe EEG abnormalities.
possiblyrelated to dysaesthesiaarisingin association.
Case report Mrs A was initially referred to the old-age psychiatry servicesby the geriatriciansin 1986, aged 76 years. She had had an episode of herpes zoster (‘shingles')infection 18 months previously and had persistent post-herpetic neuralgia.
For 15 months
she had believed
that tiny animals
were burrowingunder her skin and breeding. She had also experienced episodes of feeling dizzy and depersonalised, associated at times with loss of consciousness. For three to four months before referral she had felt low in mood, and tearful, with loss of appetite and early morning wakening. There was no evidenceof cognitive dysfunction. An EEG demonstrated left anterior parietal sharp waves. She was startedon carbamazepine,200mg daily (regular levels within therapeuticrange), with subsequent improve ment in her physical complaints and mood, but her beliefs regardinginfestation remainedunchanged. In view of this,
pirnozide,4mg dailywasstarted,withsubstantialresolution of her symptoms. She was again referredin 1988, no longer on medication and now widowed. She complained that after seeinga large spider in her flat three weeks previously she had spiders
Previous studies and case reports indicate the greater prevalence of delusional infestation in women,particularlyin middleor late life (Tullett, 1965; Frithz,
1979; Lyell,
1983), and often isolated
(Skott, 1978;Lyell, 1983). In contradistinctionto many case reports, there was no evidence in our patient of previous genuine infestation. The variationin clinicalpresentation of delusional infestation is evident from previous studies. It has been described in association with affective psychoses
(e.g. Skott, 1978); mental handicap (Skott, 1978); acute and chronic organic brain disease(Gould & Gragg, 1976; Skott, 1978); alcohol abuseand drugs, e.g. cocaine (Tullett, 1965); more rarely, schizo
phrenia(Hopkinson,1970);withunderlyingphysical disorders such as pellagra predisposing to pruritus or altered sensation(e.g. Lyell, 1983); vitamin B12 deficiency (Pope, 1970); diabetes mellitus (Munro, 1978);and, finally, as a unitary syndrome within
the monosymptomatic hypochondriacal
psychoses(Munro, 1978;Reilly, 1988).In our patient the role of dysaesthesia and discomfort from post herpetic neuralgia are significant;
however, the
significance of the left anterior parietal EEG abnormality is lessclear —¿ perhapsthis is involved in altered appreciation of somatosensory stimuli. Our patient responded to a combination of pimozide
411
412
HARPER & MOSS
and carbamazepine- the latter recognisedasof use Pops, F. M. (1970)Parasitophobiaas thepresentingsymptomof Vitamin B,2 deficiency. Practitioner, 204, 421—422. in post-herpetic neuralgia and the former well T. M. (1988) Delusional infestation. British Journal of establishedin the treatment of delusionalinfestation REILLY, Psychiatry, 153 (suppl. 2), 44-46. (Reilly et a!, 1978; Lyell, 1983). —¿,
JOPLINO,
W.
H.
&
BRAan,
A.
W.
(1978)
Successful
treatment with pimozide of delusional parasitosis. British Journal
of Dermatology,98, 457-459.
References BERRIOS, 0. E. (1982) Tactile hallucinations: conceptual historical aspects. Journal of Neurology, Neurosurgery
and and
Psychiatry, 45, 288-293. EKBOM, K. A. (1938) Der praesenile
Dermatozoenwahn.
Acta
Sicorr, A. (1978) Delusions of infestation. Reports from the Psychiatric Research Centre. St Jorgen Hospital, University of Gothenberg,
Sweden.
Tuuzrr, 0. L. (1965) Delusions of parasitosis. British Journal of Dermatology, 77, 448—455.
Psychiatrica Neurologica, 13, 227-259. FRITHZ, A.
(1979)
Delusions
of infestation:
treatment
injections of neuroleptics. Clinical and Erperimental
by depot
Dermatology,
4, 485—488.
Oouw, W. M. &GRA0G, 1. M. (1976)Delusionsof parasitosis - an approachto the problem.Archivesof Dermatology,112, 1745—1748. LYELL, A. (1983) Delusions
of parasitosis.
British
Journal
of
E. Moss, MSc, MRCPsych,Consultant Psychogeri
of
atrician, Prestwich Hospital, Bury New Road, Salford
Dermatology, 108, 485-499. MUNRO, A. (1978)
manifesting
Monosymptomatic
as delusions
hypochondriacal
of parasitosis.
British
psychosis
Journal
5Ruth Harper, BSc,MRCP, MRCPsych, Lecturer, University Department of Psychiatry, Clinical SciencesBuilding, LeicesterRoyal Infirmary; Gillian
Dermatology, 108, 485-499.
Correspondence
Severe Deprivation in Childhood: A Case Report from Thailand L. B. BARTLETand P. LIMSILA
A 3%-year-old girl was incarcerated in a bamboo cage after ft was feared she had contracted rabies. Six years later, when she was released, she had lost almost all motor control,
displayed
a number
of stereotyples,
was
incontinent of both faeces and urine, and was diagnosed as having grand mel epilepsy. After four years of treatment (aged 13) she had shown considerable improvement and her mental age was seven years. British Journal of Psychiatry (1992), 161, 412—414
In Western countries, gross prolonged deprivation in childhood is, fortunately, rare. Child-careservices, inadequateasthey often are, comeinto action before childrenendurelengthyperiodsof suffering. In recent yearsthere have beenfew reports about children in
Case report Mai, a 10-year-oldgirl, wasreferredto the Yuwaprasart Child PsychiatricHospital(Bangkok)in September1987 by a missionary sister of St Paul de Chart because of retardation
in speech and strange behaviour. The missionary
sister had brought Mai from her home village in hill-tribe country in a politically unsettled area near the Thai-Laos border north of Nong-Kai. She told a remarkable tale.
Mai was the third of four children, all of whom had developed normally; there were no unusual features about her own earlydevelopment.Her mothertold the missionary sister that at 3½years she had made the same progress as her older sister at that stage. She was fully toilet trained.
Shecoulddressherself.Shefedherself,handlingfoodssuch as stickyriceadequately.Shetalkedin sentences,described
this group in the medical and psychological literature.
her needs and asked questions. She sang several songs in
In theThird World, wheredeprivationandwantare
the Laotianlanguage.She walkedand ran. She followed
endemic, it is likely there are more children in these grave situations. As community services for children
in thesecountriesimprove and aschild mental health concepts are better understood, more of these catastrophiesmay come to light. This report describesa caseof gross deprivation that recently
her parents to work in the fields every day. While waiting, she played with her siblings and mixed happily with other children, with whom she communicated and interacted normally.
She
displayed
no
unusual
behaviour
and
her parents had no worries regarding her health and
development.
came to the attention of the child psychiatric services
At the age of 3½years she was bitten by a puppy which had been behaving strangely for some days. The villagers
in Thailand.
became alarmed as two other children in the same district
