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GRAEME YORSTON ET AL.

Peth, B. and Szilgyi, A.(1970) Von der nosologischen Lage des Ekboms-Syndroms. Psychiatria
Clinica, 3, 296319.
Schwarz, H. (1929) Circumscripte Hypochondrien. Monatsschrift Psychiatrie und Neurologie, 72,
15064.
Sigmond, G. (1848) On hallucinations. Journal of Psychology, Medicine & Mental Pathology, 1,
568608
Thiebirge, G. (1894) Les acaraphobes. Annales de Dermatologie et de Syphiligraphie, 3, 730-6.
Trabert, W. (1995) 100 years of delusional parasitosis meta-analysis of 1223 case reports.
Psychopathology, 28, 238-46.
Trenkwalder, C., Walters, A. S. and Hening, W. (1996) Periodic limb movements and restless legs
syndrome. Neurologic Clinics, 14, 62950
Von Bahr, G. (1977) Medicinska fakulteten i Uppsala. (Stockholm: Almqvist & Wiksell International),
147.
Witttmaack, T. (1861) Pathologie und Therapie der Sensibilitts-Neurosen (Leipzig: Schfer), 459.
Willis, T. (1672) De animae brutorum (London: Wells & Scott), 339.
Wilson, J. W. and Miller, H. E. (1946) Delusions of parasitosis (acarophobia). Archives of Dermatology
and Syphilology, 54, 3956.

Classic Text No. 54

From the Beckomberga Hospital, Angby, Stockholm.
Physician Superintendent Dr F. Weisel

The Pre-senile Delusion of Infestation*

K. A. EKBOM

t is quite common for mentally ill people to believe they have creatures in
(or on) the body. French writers, in particular, have been interested in such
syndromes and proposed names like parasitifrisme, zoopathie and anthropathie, etc. Mostly patients complain of larger animals (e.g. snakes, cats) or

*
Translation of: Ekbom, K. A. (1938) Der praesenile Dermatozoenwahn. Acta Psychiatrica et
Neurologica Scandinavica, 13, 22759. The translators thank Karl Ekbom (junior) for granting us
permission to publish this translation of his fathers paper.

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even human beings, but it is not uncommon for them to describe smaller
animals (e.g. lice, scabies, maggots). Such presentations can occur in
different forms of mental illness, perhaps even in most of them, but they
usually represent only one of many symptoms. It is the underlying illness that
determines the overall presentation of the beliefs. As an example, I would
like to report very briefly a woman who was for a while a patient in the
Beckomberga Hospital.
Anna P. (Admission No. 315/1933) 64 years old. Unmarried. Maidservant.
Ill for 8 years. Untidy, stubborn. Hearing difficulties. Grotesque,
grandiose and persecutory delusions and hypochondriacal ideas. Persecutors
had injected maggots, which had been taken out of a coffin, into her flesh.
Someone had also stuffed a snake through her mouth and cut pieces of
flesh out of her and eaten them as beefsteak. In her place the skin of a
corpse had been stuck up and a beard stuck to her chin, she was stabbed
by spears and other similar things. She is a princess and demands a
million Kronen daily as compensation.

Such cases are very simple and I shall not linger over them in the following.
However, there are patients in whom the presentation of delusions of little
animals or bugs is an isolated phenomenon and appears less elaborate or
fanciful in content. These patients go to a dermatologist, and the psychiatrist
rarely gets to see them. In the dermatology literature these cases are
described as parasitophobias.1 They are infrequently and generally described
as being rare, though sometimes it is said that they are not especially
unusual. For the dermatologist the cases are mainly of curiosity interest, and
he is satisfied to establish that he is not dealing with a skin disease but a
psychological illness, without entering into the nature of it. This is a logical
error. If a patient goes to a doctor because of itching of the scalp and states
that the itchiness is caused by lice, it can be easy to prove that the lice do not
exist but the itching does not need to be in the imagination as well, even if
one cannot find an anatomical basis. It is perhaps too simple that the
parasitophobias should be considered as mental illness and nothing more.
From the psychiatric point of view the parasitophobias do offer much of
interest. Several good descriptions have been given, but they seem to have
passed by almost without trace. This is because they are published under
different, not immediately transparent titles. It is generally quite difficult to
find them in the corpus of the literature. It is therefore most likely that the
following historical overview is incomplete.
In 1896 L. Perrin described three cases of nvrodermies parasitophobiques

1
In psychiatric opinion, the term parasitophobia is not thought of as a uniform or clearly defined
condition. When I make use of the expression in the following, I mean a condition with an isolated
sincerely held delusion, without bizarre and ornamented elaboration; the contents: insects on or in
the skin.

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[parasitophobic neurodermatosis]. Although he uses the term phobie, he

regards his patients as des vritables alins [genuine psychiatric cases] and he
rightly emphasizes the lack of insight.
Raecke, in 1902, describes two cases of hypochondriasis which he regarded
as a distinct form of illness in its own right. One of Raeckes patients believed
he had insects (scabies), but in contrast to my cases he presented with a
tendency to bizarre elaborations of the delusional ideas.
The Scandinavian dermatologists Grn and Strandberg each published
cases of parasitophobia in 1925. Strandberg regards the illness as psychogenic. In his cases opium treatment achieved a good outcome.
E. D. Macnamara [sic] in 1928 gave a short description of five cases. Of
interest is the long duration of illness in four of the cases: in one case at least
six years, but probably much longer, in three other cases five, four and three
years, respectively. Unique in the literature are two unmarried sisters with a
folie deux. The illness begins with an unremarkable itch. As happens in
other hypochondriacal conditions the sensations come to be thought of in a
psychological way. All kinds of irritations become parasites, which become
endowed with special qualities. Macnamara has the view, that the illness
begins with cutaneous hallucinations and then visual hallucinations develop
secondarily; an interpretation that, to me, seems difficult to reconcile with
the above.
Hanns Schwarz described, in 1929, five cases under the heading
Zirkumskripte Hypochondrien [circumscribed hypochondriases]. In an initial
period of depression the hypochondriacal ideas arise through delusional
interpretation of skin sensations. In the ensuing shift into hypomania the
hypochondriacal ideas become isolated, and the parasites form the object of
the hypomanic pressure of activity. Schwarz therefore considers his cases as
manic-depressive insanity. They remind one of the querulous hypomanics,
but differ from the typical presenile psychotics because of the lack of sensory
misperceptions and impaired reality testing with ideas of reference, as well as
the restriction to a single organ system: the skin.
J. J. Eller (1929) divides the dermatophobias into a series of subdivisions,
of which in this context acaraphobia and parasitophobia are of interest. He
very briefly describes a case of parasitophobia.
R. Mallet and P. Male (1930) describe a case of dlire cnesthsique
[delusion of coenesthesia]. They report a systme dlirant [delusional system]
that is constructed upon troubles cnesthsiques [coenesthetic disturbance],
which they believe is based on hallucinations. The lack of judgement and
absence of anxiety represents a difference from obsessive compulsive neurosis
which this state otherwise calls to mind.
J. Klauder (1936) stated that he cured acaraphobia with an analytic
discussion in a patient with an anxiety neurosis. The description is too short
to give an opinion of this case.
I turn now to the description of my own cases. I was able to collect seven

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cases within six months: the illness may therefore not be altogether uncommon.
Two cases (1 and 7) were admitted to Beckomberga Hospital. For granting
permission to investigate and publish the remaining cases, I would herewith
like to cordially express my gratitude to Doctors T. Frey (Psychiatric
Outpatient Clinic of Serafimer Hospital, Stockholm: cases 2, 3 and 5) and V.
H. Sjgren (Advice Centre for Mental Illness, Stockholm: cases 4 and 6). To
avoid unnecessary repetition in the case histories, I stress from the beginning,
that the following symptoms were absent in all cases: sensory misperceptions
of the visual, auditory, olfactory, taste and touch senses (except of the
insects), as well as delusions of reference, grandiosity, impairment and
having sinned, and all schizophrenic symptoms. Substance abuse (tobacco,
alcohol, soporifics, morphine, cocaine and so on) was not present in any of
the cases.
Case 1: Ada K. (Admission no 51/1937) 54 years of age, cleaner, divorced
(husband joiner), two children.
Born in Finland, father farmer. No nervous or mental illness within the
family. She never went to school but instead learned to read and write by
her own efforts (in the hospital she did not write letters by herself, instead
she let herself be helped by a fellow patient).
At the age of 40 she developed syphilis (rash over her whole body) and
received treatment for two years. At 42 run over by a car, unconscious for
3 hours. Dislocation of the right knee, fracture of the right collar bone.
Over the ensuing days severe headaches and, presumably, vomiting as
well. Since then no headaches worth mentioning. Menstruation stopped
at 46.
One year ago there was sudden swelling of the face and an itching and
burning rash all over the body consisting of Pfennig-sized, red, round
raised knots. These knots disappeared after half to one day, but new
ones came up, and it took several months for the rash to disappear. At the
same time as the disappearance of the rash (or a bit later), the patient
developed itching in the upper part of her back, at the neck, around the
ears and at the hairline. The itching is at its worst during the day time,
but does occur sometimes at night too. Ada is of the opinion that the
itching sensation is caused by the bites of little animals which run around
on her skin. To alleviate the itching and kill the bugs, she has burned her
skin with matches, a method that she used in the past for gnat bites. After
the burning the itching disappears for a while. In this way she has got
through dozens of boxes of matches. She cannot see the animals before
they are burned, but after she can see them as black and colourful
objects of various shapes. When she puts the match against her skin it
crackles and there is an unpleasant smell, which she sees as clear evidence
of the existence of the insects. She combs her hair several times daily with
a fine comb. After rinsing the comb she can see the animals swimming
around like fish in water. She worried that the little animals might fall
into food during cooking. More recently, it became obvious she could

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neither do her work nor keep her household in order because her time
was mainly taken up with burning and combing.
She was alert and lively, but at the same time sensitive and she cried
easily. Over the past year, dejected now and then, due mainly to money
difficulties. No anxiety or thoughts of suicide. Sleep good. Memory poor,
especially the past two years. She often mislays things.
First of all she went to the skin clinic and was referred from there to
the Advice Centre for Mental Illness. The records show she attended
there on 26.10.36. She did not mention bugs at that time, rather, small,
itchy granules encapsulated in the skin and in her hair and crawling on
her body.
Admitted on 1.2.37 at her own request to Beckomberga Hospital and
stayed until 24.4.37 in the sector ward for neurosis.
During the examination her manner is calm and orderly. She is lively
and larks about but not excessively. Her affect is lively but changeable.
Orientation in all respects is present. Repeats five numbers, not six. After
three minutes distraction she can still remember five previously shown
objects. No paralytic dysphasia. She appears somewhat naive and
countrified, but gross intellectual deficits are not present, at the most a
mild impairment. She calculates very badly, but one must remember she
never went to school. She is open-hearted and approachable and she talks
willingly, and in detail, about her little bugs. Her account is very clear,
but sometimes she contradicts herself. For example, she says on the one
hand that the bugs are not visible before they are burned, on the other
hand, that one can see them on the water, swimming around like fish. To
show the animals she takes out her fine comb and starts to comb her hair.
After that she shows a couple of small hairs, and it is completely
impossible to convince her that they are hairs and not insects. Thinking
about and indignant at this, she rejects all objections, without being able
to explain her reasons. She does not state with absolute certainty the kind
of animals (You, Doctor, will know that), but ordinary vermin they are
not. They are probably nerve waste by which the patient means an
illness that comes from nerves (in the past Ada consulted several
doctors, who told her that her symptoms were coming from the nerves).
Her body build is pyknic. She has red cheeks and is rather corpulent.
She looks healthy, apart from a slight cyanosis of the lips. When you look
at her, the skin lesions are striking, she inflicted them on herself by
burning with matches. They are, as one can see, at the forehead, temples,
neck and shoulders as well as in the left antecubital fossa.a The wounds
are hemp-seed to pea sized, irregularly contoured, superficial and covered
with black brown crusts. The skin between the wounds is scarred and
reddened in places. No excoriations or scabies tracks. Her hair is very
short along the hairline and looks like it has been cut by a machine. There
are tufts of short hair (21020 cm [sic]) at the centre of these shorn areas
with numerous burns visible.
Internal organs NAD [no abnormality detected] apart from moderately
severe emphysema. Blood pressure 150/90 mm Hg. Pupils of medium

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width, equal size, slightly irregular. Prompt reaction to light. Good acuity.
Hearing slightly reduced (right whisper at 0.5 metre, left 12 metres).
Right eardrum scarred. Patellar and Achilles reflexes NAD. Babinski:
negative. Skin sensation NAD. No other neurological abnormality.
Haemoglobin 100%. Red blood corpuscles 5.1 million. ESR: 14mm/hr.
Lumbar puncture: normal pressure. Pandy (+),b Nonne (+).c Weichbrodt
negative. Bisgaard 20-25. 3 cells per cm. Mastix reaction: no flocculation.
Wassermann, Mllersche Concentration Reaction and Meinicke Clearing
Reaction II in the blood and serum negative.d
To begin with, her behaviour in hospital was excellent. She was lively
and sociable and quick and able at work. But as she settled in she started
to become noisy and her behaviour disinhibited. Scolded sometimes by
her fellow patients. She was contrary and uncooperative. She quickly
began to dissimulate because she was clearly afraid of being seen as
mentally ill. She avoids doctors and, if one addresses her, she blushes,
turns away and giggles like a young girl in a silly manner. She gave
approximate answers and asserted that she had never believed in the
insects. From comments she made to the nurses, however, it is clear that
she has never changed her opinions. She refused to co-operate with the
intelligence test, saying she would not answer stupid questions. She
prefers to have a political discussion (she is a committed communist). She
was obstinate and stubborn, and if she got something into her head it was
not worth the trouble to try and talk her out of it. The wounds soon
healed. She received menthol spirits to rub into the skin to stop the
itching which she used diligently, but she told her carers she was missing
the matches. She often scratches with her fingers but of late, in hospital,
this is less frequent. She was treated with bromide, luminal and ovarian
preparations without any obvious benefit. On 24.4.37 she was discharged
to outpatient care (after a hospital stay of almost three months). In her
last days she openly showed her defiance against the hospital: she walked
on a freshly washed floor in a provocative way, despite a reminder not to
do so, she did not say goodbye to her carer and so on.
After fourteen days she disappeared from the care of her family. I have
not seen her again but now and then she presents herself to the Advice
Centre for Mental Illness, the last time being in August, 4 months after
discharge from Beckomberga. She still believed in her bugs and was
wanting a salve for the itching.
Addendum: in September 1937 the 21-year-old daughter of the patient
was admitted to the Beckomberga Hospital with acute schizophrenia.
Case 2: Hilma J. 55 years old. Waitress. Divorced (husband: engineer).
One child. No hereditary propensity. Infected with syphilis in 1915.
Treated with Lege artis. Cerebrospinal fluid normal in 1936. At the age
of 48 she had an operation for oophoritis and again at 50 because of an
abdominal hernia resulting from the first operation. Menopause at 48.
At the age of 50 a rash developed on one hand and under her breasts; the
rash was very itchy, especially at night time. After treatment she had no

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itching for several years. At 53 she developed an itchy rash on the dorsum
of the left hand and on her back. This time she did not visit a doctor;
instead she bought ammonia with which she scrubbed herself. After 810
days the rash disappeared. One night, a few months later she developed a
terrible itch over the whole of her head and since then the itch has
continued, sometimes a little better, sometimes worse. The itch is
particularly noticeable at night, but to some extent is present during the
day as well. It has disturbed her sleep. She became nervous and anxious,
which she was not before. She has the feeling that something is crawling
in her hair (both on her head and on the mons pubis, but not in the
axillae). Sometimes when she was hot and sweaty, she had uncomfortable
sensations on her back like thistles on my body. She believes that the
itch is caused by scabies which she forced up to her head when she
scrubbed herself with ammonia. At night time she feels the animals
running down from her hair to her face and breasts. She has seen the
scabies mites as well. They are pinhead-sized, quite long and browny
black. She catches them by pulling her hair through her fingers. It feels
the same as when you touch a louse she says with a look of disgust. She
seems to imagine that the animals stay mainly in her left ear, where she
had one or two abrasions, and that they crawl from there into her hair. At
her workplace she hangs up her coat some distance from those of her
work colleagues so as not to infect them. She fears losing her post,
because of her frequent scratching and the possibility of it coming out
that she has scabies. She took drastic measures against the insects. She
washes and combs her hair all the time. She spent considerable sums of
money on hair tonics and lotions. She always has ointment in the left ear
and in her pubic area. The hair tonic eases the itch. She got the
prescription from the dermatology out-patient clinic, from which she also
demanded several other scabies cures. The doctors often told her that she
didnt have scabies but she did not give in. If my head itches simply
bathing my body cannot help. She was also told that scabies doesnt
affect the head, but she didnt believe it. Finally the dermatologists got
fed up with her, refused to write further prescriptions and sent her to the
psychiatric clinic.
At examination she is open-hearted, approachable, good-natured, friendly
and grateful. Overall she gives the impression of being happy but she cries
easily about the bugs which are disturbing and annoying her very much.
She talks extremely willingly and very long windedly about her little
animals. One has to interrupt her sometimes to obtain a clear history. No
paralytic dysphasia. No impairment of memory. Her intelligence appears
normal. She is not obsessed and one can get her to admit that she just
believes she has scabies and that she is not completely sure she has.
I dont know but it drives me to despair. Despite this apparent giving in
she is just as convinced as before that she does have scabies. She will not
listen to reason, but keeps coming back to this diagnosis. She is of pyknic
build and rather corpulent. Looks healthy and youthful. Below the navel
there is a major hernia of the abdominal wall. Skin, inner organs and

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nervous system no abnormal findings. Blood pressure 130/80mm Hg.

Wasserman negative.
During a period of observation of several months her condition
remained more or less unchanged. Now and then she presents herself,
often bringing along a sample of the bugs in a piece of paper. The
samples contain grains of sand, particles of dirt, etc. On 24.8.37 (five
months after I saw her for the first time) she complained bitterly about
the itch which had become rather worse. In contrast she no longer feels
nervous. She is obviously as convinced of the insects as before but she
now shows a considerable inclination to dissimulation.
Case 3: Elin N. 52 years old. Widow for 5 years (husband: butler). Has
seven children, of whom one son was slow in development, most likely
after birth trauma. Otherwise no nervous or mental illness in the family.
She has a small pension and rents out a room. Between the ages of 29
and 32 measles, diphtheria and mumps. Menopause at 47. For 1015
years she has been nervous (restlessness, insomnia, tearfulness), especially
in the last six months. For some years mild headaches especially in the
mornings. Her memory is said to have deteriorated in recent years. In the
last six months short of breath. Cannot walk up more than two steps
without resting.
Two years ago Elin developed a stabbing sensation in the genitals (no
discharge). She believed she had got the infestation that you get when
you hang about at night with menfolk. She had heard talk of such
infestations, but did not know what they were called. She believed, she
had been infected by a loose woman who rented a room from her. One
day as she was making the bed for the lodger she saw an animal on the
sheet which looked like a white flea. It didnt move. Elin didnt dare go to
the doctor, for fear of being thought a wanton old woman. Instead she
washed her genitals with paraffin, alcohol and Sabadill vinegar. It burned
terribly but after one week the complaint disappeared. Two to three
months later she developed a stabbing sensation on her trunk, limbs and
on her face. There is a momentary prick, a feeling like a needle stick or
the bite of a small animal. Then she feels nothing but after a while it stabs
again somewhere else. The stabbing is felt during the day as well as at
night and it wakes her out of her sleep. She has also had other sensations:
heat on her face and a feeling that something is running under the skin of
her forehead. She has had no itching at all, but on her face, arms and
breasts pinhead sized papules developed. She kept scratching these
papules, because she believed they were caused by the louse which had
attached itself firmly into her skin. When she feels a bite, she quickly
grabs at the place shes been bitten to catch the little animal. One day
she caught two in one go. She saw them clearly. They are white in colour
and they do not move. The smallest are like a grain of sand, the biggest
like a small flea. They are not ordinary bugs. These, the patient frequently
had in her flat and she knows what they look like. She showed the little
animals to her daughter, who on one occasion thought she saw a

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proboscis at one end of the animal. The daughter is now of the opinion
however, that everything was imagined, and she will not acknowledge her
remark about the proboscis. The patient rubs her body with brandy which
helps for a day or two. She was worried she might pass it on to her
children or the tenants and therefore took great pains to shake out the
sheets. At first she kept the illness a secret, but when she started to
scratch her face her daughter found out and advised her to go to a doctor.
The doctor said there were no bugs, but Elin was not satisfied with this
and went to other doctors instead to be absolutely certain. On 5.3.37 she
came to the psychiatric clinic having been sent from the dermatology
clinic at which nothing objective had been found. She was given
medication (Digitalis, Kalzium-Diuretin, Luminal) and after she had
taken these for a few days the stabbing and the headaches disappeared.
She now feels (on 30.3) fresh and alert, she does not think about the
small animals and does not bother with the sheets anymore. She is not
exactly sure what she should think about the bugs. Earlier she had
believed it was an infestation that one gets through an immoral lifestyle.
The stabbing started in the genital region after all, but she happily admits
that she does not know much about such things. Ignorance is bliss. I
dont have time to read medical books. She has two female friends, who
also developed stabbing and itching of the skin around the age of fifty, but
they didnt think it was bugs, they thought it was a skin disease and went
to a dermatologist. All the doctors and all the others that she spoke to
told her there were no bugs. All this obviously made an impression on
her, but she is still not completely convinced. Currently she has no
complaints and this question is not relevant at the moment. Its all the
same to me now, whether I believe it or not.
Elin is clear-thinking and orderly and gives the impression of aboveaverage intelligence. Memory normal. She talks willingly and in detail but
without unnecessary circumstantiality of everything one wants to know.
She is happy, good-natured, approachable and friendly and she impresses
one with her honesty and affability. She is sensible, but as previously
mentioned has a lack of insight into her illness.
She is rather corpulent and is of pyknic body build. Appears healthy.
Heart: systolic murmur. On x-ray left sided hypertrophy. Blood pressure
210/110mm Hg. Haemoglobin 85%. ESR: 13mm. Otherwise NAD.
Five months later (on 20.8) the patient told me the following: she has
not been disturbed by little animals over this whole period. She feels well
in herself, but is still a bit nervous. She has not changed her ideas, but
they seem to have lost all relevance to the patient.

This patient is of special interest, because the symptoms seem to have

disappeared, which did not occur in my other cases. I believe the skin
complaints in this case were never as troublesome as in the others. Elin
had no unremitting, tormenting itching, just a sharp pain now and again
instead. But not even in this case were all her delusions put straight. They
only lost their immediacy. The course corresponds to Friedmanns mild

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paranoia where the delusions diminish after some years without being fully
corrected.
Case 4. Anna J. 56 years old. Spouse manager. No children. Heredity
nothing of interest.
47 years at menopause. At 36 infected with syphilis. Treated for five
years. At 50 rheumatism in the joints. For at least five years nervous:
sleeplessness, restlessness, feelings of anxiety, crying, dizziness,
headaches. For six or seven years itching over the whole body. For two
years itching of the scalp is the worst. At night time it is more intense. She
has been observed for a year and a half in the Advice Centre for Mental
Illness. Believed she had little animals on her head. Finally on 15.4.37 she
brought in a sample of little hairs wrapped up in cotton-wool and
declared that they were small animals which moved, especially when put
in alcohol. On her trunk and extremities she always has a number of
superficial wounds. According to the dermatology clinic notes these
wounds looked as if they were caused artificially by scratching. Other than
a slight inequality of pupil size the physical examination did not reveal
anything positive. Blood pressure 140/80mm Hg. The lumbar puncture
(1935) gave a normal result. Wassermann blood test negative. ESR
12mm.
When I saw her on 16.5.37 the value of the examination was lessened
because firstly she was obviously exaggerating numerous complaints in
order to obtain a report for a pension claim, and secondly she was trying
to explain away her previous comments about the animals apparently
because she feared to be seen as mentally ill. She is talkative, long-winded
and does not keep to the point. Vivacious behaviour. It is easy to get in
touch with her. Snivelling, cries easily, but is soon comforted again. She
still has itching over her body. Scratches herself and washes herself with
alcohol. Besides the abundant scabs on her back, arms and legs there are
also isolated, fresh, irregularly shaped Pfennig-sized excoriations. As well
as the itching she has a sensation of crawling and biting on her head. This
has improved over the last month, however. She washes her head several
times weekly. She denies that she believed she had bugs, but she finally
had to admit that she did believe there was a kind of bacillus crawling on
her head. She looked at them with a magnifying glass and believed she
could see them moving but said she might have made a mistake. One has
the impression that the patient dissimulates rather than having real insight
into her illness.
I have not seen her again.

These patients tend to dissimulation. They do not like to be the object of

psychiatric interest and they are very worried about being viewed as being
mentally ill. In this patient there is an additional interesting fact which was
observed in passing in some of the other cases: although she does her utmost
to deny that she ever believed in any little animals, she describes her

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complaints (itching, tingling) exactly as before, without trying to hide

anything. This shows that we are dealing with real sensory sensations and not
hallucinations. This question will be discussed in more detail later.
Case 5. Olga H. 58 years old. Housewife. Husband: painter. One child.
No family history of nervous or mental illness. Had difficulties in school.
Since the age of two or three blind in the right eye. States she had a
tapeworm in her youth. Goitre for five or six years. Menstruation stopped
when the patient was 54 and since then she has occasionally suffered hot
flushes in the head, sweating and feelings of anxiety in the stomach
region. Her sleep has not been good.
Itching for the past year, especially on her chin, between her toes and
around the anus, but also in other places such as her back and scalp. The
itching is at its worst in the evening. She is of the opinion that the itching
is caused by little worms which lie well concealed in the skin. She points
to a little naevus on her upper lip and says it is a worm which sits hidden
in the skin. Between her toes she noticed little white worms and she saw
them moving. Little white worms come away from the skin while
brushing herself in the bath. Little white granules come out of the corners
of her eyes. Very thin pink worms, 23 cm long are discharged, moving,
in her faeces. After they have come out they are sometimes able to attach
themselves firmly onto the skin. She has another worm in her stomach
and she can feel it sucking. Once she vomited up a small worm. She
read a book about roundworm and threadworm diseases and recognized
her own symptoms. However, she is not completely sure whether the
hidden worms in her skin are skin worms or threadworms. She visited
first the dermatology clinic and was given a strong liquid to apply but
has the impression that it didnt help very much. Later she went to the
medical clinic as well, but no worms were found.
The patient is most likely a bit feeble minded but clear-thinking and
orderly. She talks willingly and openly as well as sometimes dryly and
unemotively about her worms. She seems calm and collected and not
especially concerned or bothered about her symptoms. She has no
warmth but also no hostility or irritability. She is not stubborn or
unshakeable in her beliefs and concedes occasional points, but all the
same she cannot be convinced that the worms exist in fantasy only. She
still clearly feels that something in her skin is not as it should be. And
what could they possibly be, if not worms? They are not lice, and whats
more she saw clearly herself that they are worms. Where they came from,
she does not know.
Indeterminate body type. Slim. Quite pale. Soft nodular goitre of
moderate size. No signs of toxicity. Right eye: atrophy of eyeball. The left
cornea is clouded, she can however read fine print at a distance of 10cm.
The pupil reacts to light. Blood pressure 190/110mm. Otherwise no
findings.
Five months later her condition is unchanged. The patients husband
obviously shares her belief in the existence of the worms. He informed us

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by letter that the flat is damp and unhealthy (a fact which seemingly in his
opinion contributed to the appearance of the worms). They are going to
move house soon, however.

This is the only case in which the parasites are also said to have caused
complaints relating to the inner organs.
Case 6. Johanna M. 73 years old. Married (husband sewerworker).
Menstruation stopped about the age of 50. Twenty years ago cancer of
the vulva. Cured with radium treatment. Itching in the area of the right
scapula (and nowhere else) for 1520 years. She believes, that the itching
is caused by little animals. One has the impression that she started
believing in the animals only in recent years, but her statements in this
respect are uncertain. It nibbles and itches inside the flesh, not in the
skin itself. The itching disturbs her sleep but it can be felt at any time of
the day. She sometimes scratches herself with a wooden cooking spoon
making it bleed, which helps for a while. She has never had a rash or
wound (apart from the excoriations) at the site of the itch. She believes,
that there are little animals, which sit inside the flesh and bite. When they
have eaten enough the itching stops for a while. She has heard of louse
disease, which manifests itself in this way with lice coming out of the
body. She does not believe however, that she has lice herself, because she
bathes frequently and examines her shirt, and she has never seen animals.
And one should be able to see lice. Actually it sounds stupid to talk of
animals, bacilli would perhaps be a better term. It is maybe something
new to medical science. She explains the development of the illness by
describing how, 20 years before, in a marital argument with her husband,
she got a punch in the back. After the punch a blue spot developed.
Because of this bad blood developed and then the animals came. The
patient is not sure, that this explanation is correct, but she wants
nonetheless in all simplicity to express her opinion. She is able to look
after her house and the itching does not torment her more than she is able
to tolerate. She did not rub anything into her skin because if the doctors
are unable to do anything for it, then it is certainly not worth trying off
ones own bat. Often she was tempted to open the skin with a knife and
have a look beneath. But one doesnt do such a crazy thing. However,
she would like a blood sample taken from her back to be able to
demonstrate the animals. She suffers pain in her neck and a buzzing in
the head, but otherwise feels completely healthy. Her memory is not
especially bad. She states, she has a quick temper and has always been
stubborn.
On examination in the Mental Illness Advice Centre on 21.6.37 she
appears hale and hearty for her age. She is completely oriented in time
and place. Memory quite good. She is pleasant, friendly and appreciative.
Lively and talkative and eager to talk about the little animals as well as
everything else she can think of. Her description is clear and detailed,
with graphic and jocular expressions peppered with simplistic philosophical

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thoughts. She is not stubborn and when assured she has no bugs she
suggests, as an alternative explanation, that the itching could be her
nerves. But it is likely that she does not give up her beliefs in the bugs.
Healthy looking. Moderate sub-cutaneous fat. Skin no findings. No
abnormalities of sensation. Blood pressure 150/90mm Hg.
She visited the Advice Centre a year and a half earlier because of her
little animals and presented at that time, according to the medical notes,
the same picture as now.
The patient lives in the most northerly part of Sweden and was only
visiting Stockholm by chance which is why I have not seen her again. Two
months later (on 29.8) she informed me by letter, that the medicine
(Opium and Luminal) was excellent. The itching has almost stopped
and the animals have become much calmer, but not entirely disappeared.
Case 7. Emma P. (Admission No 32/1937) 58 years old. Unmarried.
Former cashier. No hereditary propensity. Menopause at 48. Two years
ago gastric ulcer, since then lived on a special diet. Denies venereal
infections. Minimal consumption of alcohol. She was born an illegitimate
child and gave birth to an illegitimate son at the age of 37. She has had
many jobs as a servant, waitress or cashier at different restaurants. She
has been unemployed in recent years and lived on benefits for the poor.
She is very upset by the fact that she is so old and no longer able to get a
job.
Since October 1936 she has noticed little animals in her flat. During the
day they sit behind the tiled stove, and she takes no notice of them, but as
soon as she goes to bed and the light is extinguished, they crawl into her
bed to warm themselves. She feels them crawling about on her body and
boring into her. They crawl into her armpits but not into the genital
region. They do not bite. They are so fast that as soon as she puts the
light on they disappear without trace. Emma has no doubt about the kind
of animals they are: they have to be foreign clothes mice. They have to
be mice, because they gnaw round holes in the sheets and covers, and no
animals, other than mice, gnaw round holes. They have to be foreign
mice, because they are much, much smaller than ordinary Swedish mice.
She can feel this, when they are crawling over her. They have to be
clothes mice, because they do not touch food that has been put down. (As
a child the patient heard her grandmother talking of clothes mice, which
enter wardrobes and eat clothes and are very difficult to destroy. In later
life she never heard talk of such clothes mice.) Only on two occasions did
she see the animals. One was 34cm long, black as coal and looked
somewhat like a beetle. The other one was also black but the size of a fly.
But in the middle of winter there are no flies. She admits that the little
animals do not have tails and do not look like mice, but like a beetle and a
fly. But they really gnaw round holes, she replies, certain of victory.
The suggestion that they could be moth holes she snubs with the
argument but they have four legs. She is very clear on this. If the little
animals had just two legs, they would jump, if they had six, then their

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bodies would be much longer and they are so small. Several times she
heard them jumping in the radio set, sounding like chords on a zither.
The little animals came into the flat in a clothes basket full of household
utensils, which Emma inherited from her mother. Emma packed the
basket herself in Malm, but it remained at the station for several
months, and it was obviously then that the foreign mice gnawed into the
basket. When it arrived in Stockholm, the patient noticed some round
holes in the cover. At the time she did not attach any importance to this,
but later she understood the connection. The animals then multiplied
rapidly. It would make no sense to move house because they would
without doubt come along too. Emma, however, has taken firm counter
measures. She sprayed the bed sheets with insecticides and has had the
flat repeatedly fumigated with hydrogen cyanide. She tried to make the
bed in such a way that the mice could not get in. But they ate their way
through the covers. She put down poisoned food for them, but they did
not touch it. She slept very badly, and for several nights she sat on a chair
fully dressed in the front room, to have peace. She felt tired and dejected
and cried a lot. Emmas landlady lay in the bed to convince her there
were no animals. But Emma saw the holes they had gnawed quite clearly
so they could not just be in her imagination. She is not bothered by the
neighbours and does not believe the little animals were put onto her by
some malicious person.
Through the intervention of the landlady a doctor was called, and
Emma was admitted on 20.1.37 to the Beckomberga Hospital, where she
stayed until 6.3.37, first in a quiet locked ward, later in the so-called ward
for neuroses (with open doors). Her behaviour was quiet and orderly the
whole time. She was hard working and helpful and appreciated by her
fellow patients because of her humour. Rapport was formed easily, and
she discussed clearly and openly but not in too much detail the history of
her illness. Her memory was good. She was unshakeable in her belief in
the reality of the little animals and she did not allow herself to be budged
one inch from her conviction. Her arguments were few, simple and always
the same (she had felt the animals clearly, and seen the round holes with
her own eyes, it was therefore not possible that they were just in her
imagination). She argues clearly and logically and without contradiction.
She liked it in the hospital very much, but she thought she was completely
well and wanted to go home. She was somewhat mistrustful of the
doctors and if one contradicted her, she became quite irritated. For the
most part, however, she was friendly and grateful. She related her
difficulties with bitterness and moroseness and she cried freely, but in
between she could be happy and make jokes without overdoing it.
The physical examination revealed nothing of great interest.
Indeterminate body type. Moderate adiposity. Looks rather pale and
tired. Internal organs and reflexes NAD. Blood pressure 130/80mmHg.
Good visual acuity. Meinickes Clearing Reaction II serum negative.
ESR 16mm. The blood indices were a bit low: haemoglobin 70%, red
blood corpuscles 3.7 million, but this improved with prescription of

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Ferrum reductum to haemoglobin 80% and red blood corpuscles 4.4

million.
In the hospital she initially complained of tiredness but this slowly
disappeared completely. She did not observe any little animals during her
six week long stay. At the time of discharge on 6th March she believed the
animals would be gone from her flat after it had been fumigated once
again during her stay in hospital. She refused with the utmost obstinacy
to move to another flat.
On 16th March Emma visited bringing a cake, with which she
tormented the doctors and other patients. She is happy and alert but cries
easily: the little animals are completely gone, because it is probably too
cold for them in the flat. On 3rd April she visits again: a few days after her
previous visit the little animals came back. At first it was one, then two,
then several, but there are not yet very many. They must have been in one
of her drawers. She can hear them scratching in this drawer at night.
Every night they crawl into her bed and disturb her sleep. She set up
saucers with ammonia to stop them but without success. She is going to
vacuum the flat now. She has not seen the little animals. She talks of
them in exactly the same manner as before.
On 26.4 morose and despondent. She tidies up and uses the vacuum
cleaner and puts ammonia soaked sponges into the bed, but it does not
help. Lays until late into the night in the lit room. Cannot fall asleep
before 23 oclock in the morning. Not the slightest insight into her
illness. Refuses stubbornly to move house or go back into hospital.
On 1.9: bothered by the little animals over the whole summer. Turned
to the Public Health Department requesting the fumigation of her flat. At
that time in a convalescent home where the little animals have not
moved in.

Despite many of the similarities, this case differs in some aspects from the
others. The skin sensations were not described. Thus the patient does not say
for example, that it is tickling in the skin and so on; no she feels the little
animals with their four legs. The systematization is also poorly developed,
but at least more elaborate than in the other cases. It is noticeable that the
animals are present only in the flat of the patient and they do not accompany
her to the hospital or into the convalescent home. Unlike the other cases
which involve parasites, the little animals live their own lives outside the body
of the patient. One could almost say that it was a malicious gang
tormenting the patient.
I have put my own cases in table form together with the earlier published
cases which match them clinically. A few cases were excluded: primarily
because they were too briefly described. Another case with delusions of
reference and another with an elaborate delusional system (both men) were
also excluded. The remaining 22 cases are all women. In 3 cases the illness
started between 30 and 40, in 15 cases between 50 and 60, in 3 cases
between 60 and 70 and one case was even over 70. In none of the cases did

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the illness appear in conjunction with the menopause, usually coming on

several years later. Physical examination reveals nothing of major interest. The
female patients look healthy and do not have the appearance of premature
ageing. Of my patients, 3 had a typical pyknic body build the others showed
less typical features (however, there was not one pure leptosomatic build).
The skin looks completely normal, apart from those cases in which the
patients caused lesions themselves. No abnormality of sensation can be
established. The blood pressure is raised in some cases but not in all. It is
noteworthy that 3 of my patients previously had syphilis (which is quite rare
in Sweden). They received anti-luetic treatment at the time, and the blood
and serum reactions are now negative. In the literature, however, there are no
references of an association between syphilis and parasitophobia, which is
why I do not venture any conclusions from my cases (I should mention that
Vi in 8 cases of Anthropopathie interne found 6 cases with syphilis).
The skin sensations consist mostly of itching. The feeling that something is
crawling about on, in, or under the skin occurs frequently. In the remaining
cases the patients report stabbing, biting, irritation, etc. Often the symptoms
are felt over the whole body but certain skin areas appear to be especially
favoured: first and foremost the scalp, then the face, the ears, the neck, the
upper parts of the back and chest, the hands and the genital area. In only one
case were the little animals accused of causing internal problems as well
(worms causing a sucking sensation in the stomach). The imagery of the type
of animals changes with the level of education, knowledge and previous
experience. If, for example, a patient has previously had a genuine case of
scabies, then it is the most natural thing for them to assume that the scabies
has recurred. On the other hand previous experiences can protect from all
too imaginative ideas. My patient Elin N. said, for example, it could not be
her usual bugs because she knew them well. However, it is remarkable that
parasites which are sadly so common in reality cannot be found in a single
case. Sometimes patients recognize there is something unusual about the
animals and resort to the explanation that they are foreign or something
new to medical science. Some of the patients are less speculatively minded
and talk of little insects or little animals. Often samples of the little
animals in cans or paper are brought in with them: little hairs, little threads,
grains of sand, skin scales and such like (in none of my patients could these
errors be excused by impaired visual acuity or inadequate correction of
presbyopia). Not uncommonly the patients neglect their daily work and
spend most of the time scratching, combing with fine-toothed combs,
squeezing or poking the animals out of their skin, they study them with
magnifying glasses, apply ointments, alcohol and paraffin washes, etc.,
change their clothes and air their bedding and so on. It is these energetic
women who run from doctor to doctor. Probably there are also many with a
meeker disposition who never muster the energy to visit the doctor.
Although the patients talk of their little animals tirelessly, the

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systematization (if one can talk of such) is pitiful and extremely rudimentary.
The patients seem more inclined to practical things than to theorizing. They
usually have a name for the little animals, they know where they came from
and know where they hold out, but often nothing more. The details remain
largely unchanged, even over long observation periods, and no new ones are
added. In one of Macnamaras patients some details were modified after 6
years, but the overall picture of the illness remained unchanged. The systematization is logically constructed, at least in the non-feeble-minded patients.
The ideas are quite conceivable, and bizarre and fantastic features completely
missing (except in Raeckes case, which therefore has not been included in
the table). The descriptions of the patients are so concrete and clear and are
carried with such conviction that they appear most believable, and it is no
wonder, that neighbours are occasionally fooled. A folie deux is described
just once however (by Macnamara). The patients behaviour concurs fully
with their ideas and they do not allow themselves to be swayed by reasoning.
Some steadfastly reject all objections: they have quite clearly seen and felt the
animals. Others can be talked to, and though sometimes admitting that they
might be mistaken, they still do not give up their delusional imaginings. In
not one single case has insight into the illness occurred. The ideas can
diminish and move into the background and be maintained with less
stubbornness but they are never corrected (case 3). With this we have arrived
at the question of the course and outcome of the illness. Here, further
observation is necessary. What can be said, however, is that the symptoms
can exist for years without any decrease of intensity and without the addition
of other psychotic symptoms. In the cases which have been observed only for
a short time, one must reckon that, for example, auditory misperceptions
could probably be added, even if no case of this kind has been described.
Temporary remissions occur.
Apart from the delusional ideas, no consistent mental symptoms are
present. The patients are clear-thinking and level-headed. They have normal
or sometimes slightly impaired intelligence. Remote and recent memory can
be slightly impaired but are generally intact. Hallucinations, ideas of
reference and interference and all schizophrenic symptoms are completely
absent. It is especially remarkable that the thought that the animals have
been sent by malicious people never occurs (compare the case of the
paranoid dement cited at the beginning of the essay). The affect is animated
and well controlled. Mild depression can occur, but is never accompanied by
retardation, anxiety or preoccupations of having sinned. I have never
observed clear elevation of mood. A certain long-windedness and talkativeness
can occur, but is not constant. Many of my patients had a syntonic
personality. I did not find definite schizoid character traits in a single case.
All my patients had an unobtrusive manner, apart from perhaps Ada K.
(Case 1), who, through her lack of inhibition and silly nature, sorely tested
the nurses patience (whether she always was like this, or whether it

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developed at the same time as the illness, or whether a change of personality

occurred after the earlier head injury, I do not know). Some patients
complain of difficulty sleeping and poor appetite, as well as general nervous
symptoms.
Are we dealing with hallucinations or false interpretations of real perceptions?
At the risk of being accused of splitting hairs, I am of the opinion that this
question is of major theoretical importance. However, in practice it is often
not possible to make this distinction, even in well understood conditions. For
example, a patient who is annoyed by electrical currents, can attribute
symptoms of an established physical illness, even damage to furniture, holes
in the wallpaper and so on, as being due to the effects of the current. The
same patient can also make these currents responsible for many other
sensations, for which no such concrete and obvious explanations can be
found, these complaints are then called hallucinations.2 It is difficult to draw
the boundary, however, and one can never be absolutely sure that one is
dealing with hallucinations. Is it possible now to answer that question? The
following details seem to suggest that in my cases we are dealing with real
perceptions: (1) The symptoms are concrete, detailed and convincingly
described. If we pursue the comparison with the victims of electrical currents
further, it can be seen that these patients often have a lot to say about the
people and appliances which send out the current, from which side it is
coming and where they feel it and so on, but they seldom give a good
description of what they are feeling. (2) The symptoms are not infrequently
limited to certain areas of the body, and the localization remains unchanged
for a long time. (3) Some patients do not make use of all their skin
sensations, describing them quite simply instead (without blaming the
animals). (4) Many patients scratch themselves, after which they have a short
rest. Admittedly signs of scratching are absent, but they are also absent in
ordinary pruritis senilis. (5) In certain cases the sensations remain unchanged
for long periods while the interpretations change slightly (for example at first
grains, then living animals). This suggests that paraesthesia is the primary
phenomenon. Perhaps in some cases a pre-stage occurs with paraesthesia
alone before the patient understands animals are involved. (6) A proportion
of the patients can discuss things and conclude: You say I have no little
animals, doctor, the itching must have another explanation then. Moreover,
dissimulating patients try to deny that they had ever talked about animals;
but they describe the itching itself exactly as before. One therefore gets the
impression that the patients themselves are able to distinguish between their
complaints as such and their interpretations. (7) Hallucinations of touch
existing alone, without other mental symptoms of any kind do not happen

2
On the other hand it is a common phenomenon that a patient with gross tactile hallucinations
interprets symptoms of an intercurrent physical illness absolutely correctly.

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very often. That symptoms can disappear by changing the surroundings,

certainly argues against hallucinations. The same situation sometimes
happens with patients with physical delusions of persecution. However, this
happened just once in my cases (Case 7). Emmas cloth mice disappeared
when she came into hospital, but re-appeared shortly after she went home.
However, Emma is, to a certain extent, different from the remaining cases:
among other things, she tends to make more interpretations, like the
paranoid patients, than descriptions.
After having weighed up the arguments for and against hallucinations, I
must admit that conclusive evidence exists for neither one nor the other. I am
inclined, however, to accept that we are dealing with real sensory perceptions
and not hallucinations (with Case 7, Emma P., however I must keep the
question open. Despite major similarities this case is perhaps not of the same
type as the others). We are probably dealing with skin sensations which are
not the same in all cases since the descriptions of the different patients do not
correspond exactly. Sometimes it is itching, sometimes paraesthesiae,
sometimes both. If the symptoms as in Case 6 are localized for years in a
constant well-circumscribed skin area, then a neurological origin is conceivable,
analogous to, for example, a post-herpes zoster persistent paraesthesia. If the
distribution is more diffuse, as in the majority of the cases, there is no reason
to conclude that the sensations are not arising from the periphery. Because
the symptoms start mostly in the presenium, it is conceivable that they play a
role in the ageing process of, for example, the endocrine system. It is to be
expected therefore that similar skin sensations occur in women in this age
group who are not mentally ill. It is not impossible that this really is the case,
but I certainly know nothing about it. In the dermatology literature,
climacteric and senile pruritis are differentiated, and a whole range of
sensations like itching and stabbing occurs in normal skin. These
physiological sensations can perhaps provide sufficient explanation in isolated
cases (Case 3), if the patient gives them a lot of attention and attaches to
them an abnormal meaning. But in the majority of the cases the complaints
seem to be much too extensive to be explained in this manner.
Apart from the skin sensations, however, a further factor is necessary for
the appearance of the illness: that is a fertile ground for the development of
delusional ideas as, for example, querulous delusions which require a particular
personality structure along with a real or imagined injustice. A person with a
normal disposition and healthy brain can certainly imagine having animals in
the skin3 but he does not hold on to these imaginings for years, against the
reassurances of doctors and relatives. In the later stages of life there is
a physiological tendency to hold on to ideas stubbornly and a reduced

3
Such cases are described, for example, in epidemics of imagined scabies among medical
students and nurses. It is here, perhaps, that the term parasitophobia is appropriate.

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susceptibility to criticism. There are certain very rare illnesses that start in
the presenium in which it is not really necessary to consider a particular
illness process (apart from age-related changes which in these cases do not
really reach higher degrees than normal). This contrasts with the querulants
and my patients where an external factor is added. I am thinking especially
about the persecutory delusions of the hearing impaired and Rdins
presenile delusions of being pardoned. They occur almost exclusively in deaf
women according to Kraepelin, who have been deaf for many years, but the
persecutory delusion emerges for the first time in the 5th or 6th decade, just
as Rdins prisoners were deprived of their liberty for decades before the
delusional ideas appeared in the presenium. Therefore one does have the
impression that the presenium creates favourable conditions for the
development of delusional ideas. Obviously, the possibility of a specific
disease process cannot be excluded with certainty, either in these cases, or in
my own. What my cases and the majority of the elderly mentally ill patients
do have in common is the uniform and rather poor character of the
delusional ideas.
I would not attempt to decide whether there is a particular personality type
which the parasitophobia patients display before the illness, as Kleists
patients have shown a hypoparanoid predisposition before the onset of
involutional paranoia. Weakness of intellect and a lack of education can be
suspected as possible contributory factors, but are certainly not necessary, as
in the case in one of Schwarzs patients, for example, the wife of a school
headmaster whom she managed to fool. It certainly gives the impression of a
serious weakness of judgement, when a person with normal visual acuity
states that an ordinary little hair is an animal and stubbornly holds on to this
view despite all reasoning. In general however the actions of the patients,
which are not influenced by this complex, cannot be distinguished by this
striking lack of judgement. The circumstances here are analogous to
paranoia, and the emotions which ordinarily play a major role in the
development of delusional ideas have probably been of less crucial influence
in my cases. The anxious, pessimistic mood, which is so favourable for the
development of hypochondriacal ideas, is almost completely absent. None of
the patients regarded their life and health as seriously threatened, and several
of them did not consider themselves ill at all.
The clinical picture of the illness described is difficult to fit into the
psychiatric diagnostic schema. The term phobia is used in the dermatological
literature, but these patients are not afraid of having animals in the skin, they
are certain they actually have them. They act in accordance with their ideas,
without being troubled by doubt and without any trace of the partial insight
of the absurdity of their ideas that regularly occurs in compulsive neurosis.
Anankastic character traits are not present. If they take action to protect their
surroundings from infestation, the actions are (apparently) rational and not
pursued ad absurdum regardless of caution.

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In practice it can occasionally be difficult clearly to distinguish delusional

ideas from purely obsessional thoughts (they can of course co-exist in one
and the same patient). In the cases described here, however, there can be no
doubt: we are not dealing with phobias. Obsessional neurosis begins much
earlier in life. Schwarz assigns his cases to the manic-depressive illness
category. To support this he points out among other things (besides the
overall clinical picture) that suicide can occur in the family, and that several
of the female patients had previously had periods of depression. In my
patients, hereditary predisposition and previous illness episodes are absent in
all cases. This does not necessarily exclude the diagnosis, but I consider it
unsatisfactory for my cases, but I do admit that some of the patients show a
pyknic body build and syntonic personality and are talkative, circumstantial
and hyperactive. Compared with ordinary presenile psychosis of the paranoid
type, the difference is clear. Auditory hallucinations, grandiose, selfreferential and depressive delusions, among other things, are absent. At the
most, one could describe a certain analogy with the delusions of alien
interference. However, to describe them as monosymptomatic partial forms
of paranoid schizophrenia or paraphrenia, seems rather unsatisfactory. There
are similarities with paranoia: absence of hallucinations, the insidious
development of an enduring, unshakeable delusional system combined with
complete preservation of clarity and order in thinking, volition and
behaviour (Kraepelin). On the other hand the disturbance of the viewpoint
in relating to the world (what is important) is absent and the development
hardly happens out of inner motives. Kraepelin did not want to propose a
hypochondriacal sub-division of paranoia as he had not seen an unequivocal
case. Similarly my cases are not to be categorized as paranoia as the
differences are far too large (neither do they remind one of Kleists cases of
involutional paranoia). In passing I should mention that the more active of
my patients resemble the querulant to a certain degree. In cocainism a similar
clinical picture can of course be found, though this is of theoretical interest,
and it need hardly cause difficulties in differential diagnosis, at least not in
Sweden, where cocaine addiction is rare.
We are therefore dealing with a very characteristic syndrome, which
cannot be placed in one of the generally accepted diagnostic rubrics without
forcing it. There are analogies with certain delusional forms of
hypochondriasis, which are also difficult to categorize, though few people
tend to view hypochondriasis as a separate illness nowadays. From the
current psychiatric viewpoint it is hardly worth discussing whether the
syndrome of parasitophobia needs to be viewed as a separate illness. This
illness should also include certain similar cases, in which the delusional
object does not concern animals: for example, Janets case number 185 of an
obsession des pingles (an approximately 50-year-old woman who believed
she had swallowed two pins). Of course, it is very important to follow up
these cases for decades, so that one can learn what finally becomes of them.

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Regarding the name, one finds parasitophobia in general usage in the

dermatological literature, as the psychiatrists couldnt agree on a single term.
If one does not wish to accept the misleading name parasitophobia, then one
could talk perhaps of the syndrome of presenile delusion of infestation
(corresponding to the presenile delusion of being pardoned).
Regarding therapy, there is not a lot to say. Strandberg and Schwarz,
independently of each other, have had some success with the use of opium.
In the single case in which I tried opium, the medicine seemed to have a
certain symptomatic effect (the animals became much calmer). In the only
one of my cases in which there were genuine tangible improvements (no. 3),
these occurred occasionally after treatment for hypertension which caused
heart failure, which may or may not have been coincidental. Luminal and
bromide are of some use. I have not seen any benefit with ovarian
preparations. Externally, itch soothing medicaments seem able to bring
temporary relief. In cases where the itching is very circumscribed (number 6,
for example), a trial of x-ray therapy could perhaps be justified. A change of
environment can occasionally be of use (case no.7), but one can do without
the more well intentioned than effective suggestions such as a scabies cure or
fumigation of the flat and so on.
SUMMARY
Overview of the literature and description of seven cases of my own of a
clinical picture which is termed parasitophobia in the dermatological
literature. The patients are mainly women. Age usually 50-60 years. The
patients complain of itching and paraesthesia and are stubbornly and fixedly
convinced that the complaints are caused by little animals (scabies mites, felt
lice, worms and so on). Much time is spent searching for and trying to
exterminate the animals. Poor but logically consistent, stable and
unchangeable delusional ideas without bizarre elaborations. Other psychotic
symptoms are completely absent. The course is chronic with lengthy remissions
in some cases. In one case the ideas lost their intensity and relevance without
having been corrected. It does not result in dementia (however, the final
outcome of the patients is unknown). The author is of the opinion that it is
not a matter of hallucinations of touch but of real sensory perceptions
(presenile paraesthesiae) which provide the material for the delusions. One
must distinguish both factors (1) the paraesthesiae and (2) the delusional
interpretations of the same. Both factors can have a common cause: probably
ageing and the associated degenerative changes in the brain and major
disturbances in the endocrine system and so on. A specific illness process
may possibly be necessary for the development of the delusions, however.
The syndrome is most characteristic and cannot be without difficulty placed
in one of the generally accepted groups of illnesses. The name parasitophobia
is useless, first of all because it is not a phobia, and secondly from a

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K. A. EKBOM

psychiatric viewpoint this name was used for heterogeneous clinical

presentations. The name presenile delusion of infestation is proposed.
REFERENCES
[Those marked * are listed in the original paper, although they are not cited in the text.]
*Adam (1928) Dominierende Vorstellung, berwertige Idee, Zwangsvorstellung, Wahnidee.
Allgemeine Zeitschrift fr Psychiatrie, 89, 383.
*Albrecht (1914) Die funktionellen Psychosen des Rckbildungsalters. Zeitschrift fr die gesamte
Neurologie und Psychiatrie, 22, 306.
*Bohnen, P. (192021) Zur Kenntnis der Involutionsparanoia. Allgemeine Zeitschrift fr Psychiatrie,
76, 451.
Eller, J. J. (1929) Neurogenic and psychogenic disorders of the skin. Medical Journal and Record,
CXXIX, 481, 544, 616, 675.
*Ewald, G. (193031) Zwangskrankheit und Paranoia. Zeitschrift fr die gesamte Neurologie und
Psychiatrie, 131, 33.
Friedmann, M. (1905) Milde Paranoiaformen. Monatsschrift fr Psychiatrie und Neurologie, 17, 467,
532.
Grn, K (1925) Les dermatophobies. Frhandlingar vid Nordisk Dermatologisk Frenings 6. mte,
Helsingfors 2628 Aug. 1924, p. 80.
Jahrreiss, W. (1930) Das hypochondrische Denken, Archiv fr Psychiatrie, 92, 686.
Janet, P. (190811) Les obsessions et la psychasthnie. Paris.
Klauder, J. (1936) Psychogenic Aspects of Skin Diseases. Journal of Nervous and Mental Disease, 84,
249.
Kleist (1912) Chronische wahnbildende Psychosen des Rckbildungsalters. Allgemeine Zeitschrift fr
Psychiatrie, 69, 705.
Kleist (1913) Die Involutionsparanoia. Allgemeine Zeitschrift fr Psychiatrie, 70, 1.
Kraepelin, E. (1915) Psychiatrie IV, 8th Edition.
*Kronfeld (1925) Psychotherapie bei dermatologischen Fllen. Dermatologische Zeitschrift, 45, 200.
*Laignel-Lavastine & Khan, P (1925): Interprtations cnesthopathiques absurdes. Journal de
Psychologie, 22.
*Laignel-Lavastine, Papillaut, Bonnard, R. (1928) Dlire de gyncopathie interne, Revue
neurologique, p. 938.
*Leroy, E. B. (1905) Les dlires du parasitifrisme. Revue neurologique, 13, 871.
MacNamara, E. D. (1928) Cutaneous and visual hallucinations. Lancet, (i), 8078.
Mallet, R. and Male, P. (1930) Dlire cnesthesique. Annales Mdico Psychologique, 88, 198201.
*Mayr, J.K. (1927) ber Psychogenese von Hautrankheiten. Zentralblatt fr Haut und
Geschlechtskrankheiten, 23, 1.
Perrin, L. (1896) Des nvrodermies parasitophobiques. Annales de Dermatologie et de Syphiligraphie,
7, 12938.
*Pettit, G. and Martrille, D. (1929) Dlire de zoopathie interne. Encphale 24, 292.
Raecke (1902) ber Hypochondrie. Allgemeine Zeitschrift fr Psychiatrie, 59, 390.
*Repond, A (1915) Beziehungen zwischen Parsthesien und Halluzinationen. Monatsschrift fr
Psychiatrie und Neurologie, 38, 216.
*Rmer, C. (1924) Behandlung der Psychoneurosen. Klinische Wochenschrift, 3:1, 354.
*Rothman, S.T. (1930) Jucken und juckende Hautkrankheiten. Handbuch der Haut- und
Geschlechtskrankheiten (Berlin, J. Jadassohn) 664.
*Sack, W. Th. (1933) Psyche und Haut. Handbuch der Haut- und Geschlechtskrankheiten
herausgegeben (Berlin, J. Jadassohn) 1302.
*Schilder, P. (1924) Zur Lehre von der Hypochondrie. Monatsschrift fr Psychiatrie und Neurologie,
56, 142.
Schwarz , H. (1929) Circumscripte Hypochondrien. Monatsschrift Psychiatrie und Neurologie, 72,
15064.
*Seelert (191415) Paranoide Psychosen im hheren Lebensalter. Archiv fr Psychiatrie, 55, 1.
*Serko, A. (1919) Die Involutionsparaphrenie, Monatsschrift fr Psychiatrie und Neurologie, 45, 245,
334.

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THE PRE-SENILE DELUSION OF INFESTATION

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Strandberg, J. (1925) Psyche und Hautkrankheiten in Psychogenese und Psychotherapie krperlicher

Symptome. (Vienna, Oswald Schwarz), 258.
Vi, J. (1935) Lide dlirante danthropathie interne. Congrs des mdecins alinistes et neurologistes de
France. XXXIXth Session, Bruxelles (2228 July), 470.

TRANSLATORS NOTES
(a) Two photographs illustrate the text at this point.
(b) Non-specific test for globulin in cerebro-spinal fluid, after Klmn Pandy (b. 1868), a
Budapest psychiatrist.
(c) The Nonne-Apelt reaction was another non-specific test for globulin in the cerebro-spinal
fluid, after Max Nonne (b. 1861) a Hamburg neurologist and Friedrich Apelt (b. 1877) a
Hamburg phyisician.
(d) Meinickes Klrungsreaktion (MKR) was a non-specific serological test for syphilis developed
by Ernst Meinicke 18781945.

(The Table is on p. 256)

Strandberg
Macnamara

Schwarz

Mallet & Male

Klauder
Ekbom

1
1
2
3
4
5
1
2
3
4
5
1

1
1
2
3
4

5
6
7

58
73
58

1
2 (20?)
three months

six months
2
2
1 (7?)

>6
3
4 months
5
4
one month
some time
one month
1

2
1

54
50
43

46
48
47
47

43
43

several weeks

48

W, especially hands
W
W, especially nose and G
first S, then B, hands
and axillae

itching
prickling sensation
itching
stabbing, itching

chin, S, B, A, toes
right scapula area
W

S, upper B, throat, ears

S, mons pubis
W, G
W, especially S

W
hands, feet

irritation, stings
misperception

itching
itching
itching
stabbing
itching, bites, prickling
sensation
itching
itching in the flesh
prickling sensation on top
of the skin

microbes,
S, upper body
face

W, esp A, under nails

firstly s, then W, esp N,
B, Ch

Localization

itching
movements
walking under the skin
prickling sensation

itching, stabbing
itching

Kind of perceptions

worms
bacillus
cloth mice

kitchen louse
little animals
scabies
crab louse
little animals

parasites
little insects
little insects
dog lice
little black things
little insects
insects
lice
various little animals
little animals, bacteria
little insects
crab louse

foreign fleas
dove fleas

Type of animal

256

50
54
55
52
56

55
60
61
64
44
42
57
53
59
69
30
56

52
65

Duration (years) Menopause

10:30 am

f
f

Age

12/6/03

Abbreviations: W = whole body, S = scalp, N = neck, B = back, Ch = chest, A = anus, G = genital area
Note: The table does not include the following: Perrins case 2: a 47-year-old feeble-minded woman (psychogenic factors) and case 3: a 46-year-old
man (?schizophrenia). Grns case 3: a 50-year-old woman (brief description). Raeckes case 4: a 36-year-old man (?schizophrenia). Ellers case: a 32year-old man (too brief a description).

Perrin
Grn

Gender

1
2

No. Author

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