Insect bites or psychogenic lesions

56 y man, no significant PMH, presented to the office with diffuse skin lesions that he states started with some insect bites sustained a few days ago. He has been picking on the lesions and cleaning with alcohol, taking multiple showers everyday to get rid of the eggs and larvae that might be present in the lesions. His wife has been helping him with the entire “cleansing process”. He cannot say for sure if all these lesions started after insect bites or whether some were created in an attempt towards digging under the skin with nails and other sharp instruments to remove the suspect eggs and larvae. On exam, he has multiple superficial skin ulcers with excoriations on his chest and upper extremities.

Which of the following is the appropriate statement?

1. Patient is suffering from neurotic excoriations
2. He has delusions of parasitosis
3. It is too early to state if he has a psychological disorder- ANSWER
4. Factitious syndrome is a likely diagnosis.
5. Body dysmorphic disorder should be considered.