2 Inventory-III [3], the Dementia Rating Scale [4], Mood Disorder Questionnaire [5], and the Adult Self-Report Inventory (ASRI) [6]. The scores revealed signiﬁcantly elevated scores for ADHD (combined type), moderate levels of depression, and severe generalized anxiety. There was no evidence of dementia, mania, or substance misuse. Extended release-mixed amphetamine salts, a ﬁrst-line stimulant treatment for ADHD, were added to duloxetine. In standard fashion, the mixed amphetamine salts were titrated up to 30 mg/day over the ﬁrst three weeks. Cognitive- behavioral therapy to address phobic avoidances was recom- mended but not pursued. MJ contacted the oﬃce within one week and reported improvement in her fatigue and mood. Two weeks later she returned and reported that, in addition to improvements in aﬀective symptoms, she reported greater productivity at work and at home. The medication combination was maintained, and she returned six weeks later. At that visit, MJ and her husband enthusiastically reported less fatigue, improved energy, diminished irritability, and restoration of her sleep-wake cycle. There was no evidence of mania. MJ returned one month later. Her improvement per- sisted, but she reported that 7 hours after her 8 am morning dose of mixed amphetamine salts her symptoms of fatigue and anxiety returned. A second dose of mixed amphetamine salts 20 mg was initiated at 2 PM. One month later, MJ’s husband contacted the clinic and reported that she had deteriorated. In the previous month, she suspected bed bugs in their condominium. In the past ten days, she complained of becoming infested with insects. Her husband denied that this was a possibility. Against his protestations, she began examining the hallways of her ceramic foyer and interpreted small specks on the ﬂoor as evidence of fecal remnants. On psychiatric examination, she veriﬁed this belief and reported that she had moved out of the apartment and contacted city oﬃcials to condemn her luxury condominium. She suspected a conspiracy among the building supervisors, building inspectors, and her husband to minimize the extent of the infestation. She reported her intention to divorce her husband. The onset of symptoms was temporally correlated with the increase of the stimulant dosage. For this reason, the mixed amphetamine salts were immediately discontin- ued. No other psychotropic agents were administered. MJ objected to this plan, fearful that the signiﬁcant progress she had made on her fatigue and cognitive symptoms would be reversed. Within two days of discontinuation, the concerns of delusional parasitosis diminished. One week later, MJ com- pletely stopped discussing the delusion. When asked by the physician, she minimized the extent of the delusional parasitosis and concluded that it fundamentally resulted from a vision problem and her husband’s exaggeration. On reevaluation one week later, the patient avoided the subject of delusional parasitosis inferring that she found the topic to be unpleasant. She reported that she missed the stimulant medication. Her fatigue and hopelessness had returned; she was unable to awake in the morning and noticed Case Reports in Psychiatry signiﬁcant productivity loss at work. One month later, after MJ’s strong persuasion and the absence of any delusional activity, the mixed amphetamine salts-XR was reintroduced at 20 mg/per day. MJ again derived immediate relief from her incapacitating fatigue. Unfortunately, at the lower dosage of mixed amphetamine salts-XR rechallenge, her symptoms of amotivation and poor concentration returned, although less severe. 3. Discussion Delusional parasitosis has been discussed in the literature, although there has not been a reported link between delusional parasitosis and mixed amphetamine salts. A recent article outlines other causal factors, yet the majority of recent publications are dedicated to the treatment of delusional parasitosis with antipsychotic medications. In a 2010 report, Flann et al. [7] discusses three separate cases of delusional parasitosis in patients treated for Parkin- son’s disease. All three patients were taking dopamine ago- nists. Two patients were taking ropinirole, while the third was taking cabergoline. All patients reported abnormal beliefs of being infested with parasites, while one patient reported that the bubbles in a glass of water were insect larvae. After examination, there was no evidence of infestation among any of the patients. Upon discontinuation of the medications, delusions of all three patients resolved completely. In a 2006 article, Nicolato et al. [8] report treatment of ten patients with delusional parasitosis. The ten cases (seven females and three males) presented with diﬀering dermatological signs of delusional parasitosis. All patients had a preexisting clinical comorbidity: four carrying a diabetes diagnosis, four with hypertension, and three with thyroid disease. None of the patients’ clinical illnesses were linked to the delusional parasitosis. Upon examination, ﬁve patients were diagnosed with a delusional disorder that could not be linked to another psychiatric condition, two with major depressive disorder with psychotic features, two with dementia, and one carried a diagnosis of schizophrenia. All patients were treated with an anti-psychotic medication, both typical and atypical. These medications included haloperidol, pimozide, olanzapine, quetiapine, or risperi- done. Six subjects achieved resolution of the delusional parasitosis completely, while three had partial improvement. In one case, no improvement was noted. Kenchaiah et al. [9] extend the discussion regarding the use of atypical antipsychotics in the treatment of twenty individuals with delusional parasitosis. All patients described an infestation of parasites either on or inside their skin, while some experienced tactile hallucinations and even auditory hallucinations. Treatment usually involved the atyp- ical antipsychotic risperidone or olanzapine. Haloperidol was used as were the antidepressants ﬂuoxetine, sertraline, and imipramine. Although the anti-psychotic pimozide is traditionally associated with the treatment of delu- sional parasitosis, it was not used in this series. Among the twenty subjects, four maintained complete resolu- tion of their delusional parasitosis. Eleven cases reported