Suicide following an infestation of bed bugs.

PATIENT: Male, 62. FINAL DIAGNOSIS: Bipolar disorder. SYMPTOMS: Bordeline personality disorder. MEDICATION: - CLINICAL PROCEDURE: Bed bug infestation. SPECIALTY: Psychiatry.
OBJECTIVE: Unusual clinical course.
BACKGROUND: In the past decade, bed bug infestations have been increasingly common in high income countries. Psychological consequences of these infestations are rarely examined in the scientific literature. CASE REPORT: We present a case, based on a coroner's investigation report, of a woman with previous psychiatric morbidity who jumped to her death following repeated bed bug infestations in her apartment. Our case report shows that the bed bug infestations were the likely trigger for the onset a negative psychological state that ultimately led to suicide.
CONCLUSIONS: Given the recent surge in infestations, rapid action needs to be taken not only in an attempt to control and eradicate the bed bugs but also to adequately care for those infested by bed bugs.

Background

Reports during the last decade have demonstrated a rising incidence of bed bug infestations in several high income countries where they had been almost eradicated [1-3]. Reasons for the resurgence are unclear but changes to pest control practices, insecticide resistance, international travel and immigration are likely contributors [2,4,5]. In Montréal, Canada, a survey conducted in 2011 estimated that 2.8% of households had a bed infestation in the year before the survey (unpublished data, Direction de santé publique de Montréal).

The common bed bug (Cimex lectularius) is a wingless, red-brown, blood-sucking insect with a lifespan from 4–12 months and can survive up to a year without feeding [2,5]. Attracted to warmth and blood, bed bugs emerge at night to feed on human hosts. During the day, they hide in cracks and crevices in beds, wooden furniture, floors, and walls; and can therefore be difficult to detect [2,5]. Eradication requires a comprehensive, and often costly, approach. Multiple extermination attempts over an extended period with treatment or replacement of clothing, furniture, and upholstered materials are sometimes necessary [4]. These factors can result in considerable uncertainty regarding the presence or persistence of bed bugs and fears of re-infestation.

Although a variety of medical sequelae of bed bug bites have been reported and reviewed [5], psychological consequences are rarely examined in the scientific literature. In one recent article, a review of online blogs and other internet sites showed that bed bug infestations can be responsible for considerable psychological distress with nightmares, flashbacks of the infestation, hypervigilance (to keep the bugs away), insomnia, anxiety, avoidance behaviors, and personal dysfunction [6]. Noting the absence of studies describing clinical examples or referring to peer-reviewed articles in their source material, another recent article reported a case series of psychiatric consequences of bed bug infestations [4]. It demonstrated a range of psychotic, affective, and anxiety disorders, some of which were new onset whereas others followed worsening pre-existing conditions. For some patients, depressive symptoms were sufficiently severe to merit inpatient hospitalization, loss of occupational and educational productivity, and even a suicide attempt. Social isolation, because of stigma and self-imposed withdrawal, and substance use were also noted.

Below we present the case, based on a coroner’s investigation report, of a woman who shared several of the characteristics mentioned above. In her case however, she jumped to her death following repeated bed bug infestations in her apartment, with her suicide note specifically mentioning her inability to cope with the bed bugs as the underlying reason for her decision.

Case Report

Ms. A was a 62 year old woman, diagnosed with bipolar disorder (treated with mood stabilizer), borderline personality, chronic alcoholism and an addiction to gambling. She had suicidal thoughts intermittently since age 25 years and had made three suicide attempts in the past. There had been long periods of abstinence from alcohol and gambling.

Ms. A lived in an apartment in a social housing complex. Six weeks before her death, Ms. A discovered bed bugs in her apartment. An exterminator was called, but four weeks later there was another infestation. During the second visit, the exterminator recommended that all her clothes be placed in plastic bags for three weeks, before a third fumigation of the apartment. Having developed a phobia of the bed bugs, Ms. A requested help to be relocated but could not be accommodated. Ms A resumed her gambling, losing a considerable sum of money. She also resumed her consumption of alcohol, which increased following her losses at the casino.

On the night of her death, she awoke at 3 am and found a drop of blood on her dressing gown. She was convinced the bed bugs had returned and wrote a note stating that she had been depressed since their arrival and would be going to a better world. She also wrote an email to a friend a few minutes before killing herself: “I am panicking now because I just saw a drop of blood on my dressing gown sleeve and I am sure that vampires are back and I cannot stand to live in fear of me being eaten alive… I cannot stand it and I chose to take my life... At the time of writing, I have swallowed a bottle of wine and two hundred pills and I feel nothing, I feel completely empty, it is unbearable…” [authors’ translation]. When she called to notify her employer that she would be absent from work, he picked up on her distress and immediately called 911. The police arrived and found Ms. A on her balcony on the 17th floor. Efforts to dissuade her from jumping were unsuccessful and she died instantly with multiple injuries to the brain, thorax and pelvis as a result of her fall.

Discussion

In line with two recent articles [4,6], our case report shows that bed bug infestations can have serious psychological consequences and, from her written notes, it seems likely that the trigger for the onset of Ms. A’s negative psychological state that ultimately led to her suicide, was the infestation by bed bugs. We know of no other reports in the literature of a suicide explicitly linked to a bed bug infestation.

Bed bugs are notoriously difficult to eradicate. The prolonged and invasive nature of the extermination procedure can place enormous stress on any individual, but effects may be even more profound for already vulnerable individuals. Ms. A was diagnosed with psychiatric illnesses and had a history of suicidal behaviour. The inability to control the infestation undermined her sense of coping and, as reported for other patients [4], she returned to alcohol abuse as a coping strategy.

In addition to a systematic approach to the control and eradication of bed bugs [5], management of the psychological consequences is also needed. Clinicians should be alert to psychological distress that often accompanies an infestation of bed bugs and should ask targeted questions to determine whether an anxiety-depressive pathology is present in order to respond appropriately. In addition, adequate social support to prevent isolation and cope with the psychological symptoms needs to be provided [4].

Conclusions

Our report of an isolated case history, together with the published case series [4] and review of blogs and other internet sites [6], provides evidence that bed bugs are a severe stressor and can result in serious and life-threatening psychiatric consequences for those that are vulnerable. Given the recent surge in infestations in many different cities, rapid action needs to be taken not only in an attempt to control and eradicate the bed bugs but also to adequately care for the individuals affected.