Understanding the Challenges in Management of Delusional Infestations

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Delusional infestation (DI) is a psychodermatologic disorder characterized by the presence of a fixed, false belief that one is infested with living or non-living organisms. Patients with DI also endorse associated abnormal cutaneous symptoms such as crawling, biting or itching. DI can be extremely debilitating, as patients seek treatment and resort to self-injurious behaviors to eliminate fictional pathogens. Thus, patients may present with skin changes secondary to skin picking and excoriations. Patients with DI most often seek the help of dermatologists, because they are unable to appreciate a psychiatric etiology for their disorder; dermatologists are key to establishing both treatment and psychiatric referral for these challenging encounters. Having an informed and optimized approach in handling DI patients is vital, as clinical interactions with these patients could otherwise be unproductive and unpleasant. With good therapeutic rapport and a strong doctor-patient relationship, dermatologists may implement effective treatment with newer, second-generation anti-psychotic medications or pimozide. In this chapter, the clinical presentation, diagnostic and interpersonal approach, as well as the treatment of DI, are reviewed.