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CRITICAL COMMENT . . .
J. Parasitol., 99(3), 2013, pp. 583–585
ÓAmerican Society of Parasitologists 2013
Evidence of Photo Manipulation in a Delusional Parasitosis Paper
Matan Shelomi, Department of Entomology, University of California–Davis, 1 Shields Ave, Davis, California 95616. Correspondence should be sent to:
mshelomi@ucdavis.edu
ABSTRACT: In 2004, an article in the Journal of the New York Entomological
Society claimed that individuals with delusory parasitosis actually suffer
from collembola infestations. The article has been critiqued for poor
methodology and results that contradict all knowledge about
collembolans. Less easily accounted for has been a figure in the article
purporting to show a collembolan in a skin scraping. The image appears
to have been altered using photo manipulation software to an
unacceptable degree, and this paper demonstrates that to be the case.
The altered figure represents creation of nonexistent data, a form of
scientific misconduct. Whether the deception is deliberate or a product of
an otherwise well-meaning author ignorant of the limits of acceptable
image manipulation is unknown, but the result is peer-reviewed support
for a conclusion that complicates patient treatment. In the current era of
computers, even regional entomology journals must have detailed
standards for what kind of images and image manipulations are
acceptable for publication.
Delusional parasitosis (DP), also known as Ekbom Syndrome (von
Ekbom, 1938), is a psychiatric disorder more familiar to entomologists
and dermatologists than to most psychiatrists (Driscoll et al., 1993;
Hinkle, 2010). Sufferers have a delusion, or an unshakable yet false belief,
that insects of some sort are infesting their home and body. They often
pick at their skin in efforts to remove the ‘‘parasites’’ and present them to
an entomologist or doctor as evidence (Hinkle, 2000). This ‘‘matchbox
sign,’’ named after the most-common sample container (Lyell, 1983), is
indicative of the disorder: While some patients are legitimately infested
with common body or head lice, this is rare (Lyell, 1983), and the empty
box and ruling out of all other causes of the skin irritation leaves DP as the
only remaining diagnosis. Unfortunately, the nature of DP and other
delusory disorders is that no amount of evidence will ever convince the
sufferer that they are not infested (Lynch, 1993). While DP is treatable,
with some reports of complete remission (Trabert, 1995; Meehan et al.,
2006; Lepping et al., 2007), most patients will aggressively deny needing
psychiatric help, sometimes resorting to violence (Bourgeois et al., 1992),
but usually just stop contact with those unwilling to corroborate their false
beliefs (Lee, 2008) preferring to ‘‘Doctor-hop’’ until they get the answer
they want to hear (Aw et al., 2004).
One such answer is the paper in the Journal of the New York
Entomological Society (JNYES), now called Entomologica Americana,
entitled ‘‘Collembolla (Springtails) (Arthropoda: Hexapoda: Entognatha)
Found in Scrapings from Individuals Diagnosed with Delusory Parasit-
osis’’ (Altschuler et al., 2004). In the paper, skin scrapings from 20 DP
patients and 20 control patients were sampled under a microscope for
incongruities. Over 300 photographs were taken of suspicious-looking
frames from the DP group only. ‘‘The images were reviewed by
entomologists and the presence of Collembola verified and identified as
representative of the families Isotomidae and Entomobryidae.’’ The article
appears frequently on websites catering to patients of DP and the related
delusional disorder, Morgellons disease (Pearson et al., 2012), and is
provided for free and defended by the first author on the website for her
organization, the National Pediculosis Association, Inc.t(http://www.
headlice.org/).
The methodology of the paper is flawed. The authors admit that ‘‘initial
microscopy was non-blinded; i.e., the clinicians examining and photo-
graphing the slides knew that they were from either the study participant
or control group.’’ Non-blinded studies allow for observer bias, to which
the paper also admits: ‘‘Microscopic examination of scrapings of control
subjects appeared to be consistent with normal skin and therefore no
photographic images were taken.’’ In other words, the slides from control
patients were not analyzed the same way as those from DP patients nor
does any evidence remain that a control group ever existed. As for the
‘‘entomologists’’ [plural] who purportedly verified the presence of
collembolla, none are identified, and the sole author with an entomology
background is an arachnid and cimicid specialist. Lastly, those performing
the image analysis had been told to make collembola ‘‘the focus’’ of their
search only after failing to find a ‘‘common factor’’ among the 300 photos,
which had been originally selected because they contained ‘‘Pollen, conidia
or spores, hyphae, mycelium or fibers.’’ This means the analyzers were
unable to find collembola until they were expressly told to do so.
Collembola experts Christiansen and Bernard (2008) published a
thorough refutation of the paper’s entomological aspects in Entomological
News. Their most concrete refutation dealt with the figures: ‘‘None of the
images presented in Altschuler et al. (2004), except possibly the ‘enhanced’
version of figure 2 (p. 91), bear the slightest resemblance to any springtail
or springtail body parts.’’ The items in the images are half the size of the
world’s smallest known springtails, the Neelidae. While 3 figures are given
in Altschuler et al., their figure 2 (provided herein as Fig. 1) was the most
controversial. A zoomed-in section of the photo is suggested to contain a
collembolan.
Berenbaum (2005) attributes the image of ‘‘collembolans’’ as a case of
pareidolia: when a vague or random pattern is seen as significant, such as
the face on Mars or Bigfoot sightings. While labeling is usually enough to
suggest pareidolic interpretations of an image to a viewer, the authors
went one step further by presenting an image edited with ‘‘contrast tools’’
to show more detail. This is the ‘‘‘enhanced’ version’’ Christiansen refers
to and the basis of this argument for unethical image manipulation and
data fabrication, a form of scientific misconduct (Christiansen and
Barnard, 2008).
Journals vary in their definitions of when image processing counts as
tampering with scientific evidence. The advent of digital imaging and
photo manipulation software like Adobe Photoshopthas provided
techniques unavailable in the past that can be employed by almost
anyone (Cutrone and Grimalt, 2001). While there have been several high-
profile cases of intentional falsifications, usually involving gel electropho-
resis bands (Rossner and Yamada, 2004), most cases where photos have
been inappropriately touched-up prior to publication have been uninten-
tional situations where the scientists simply did not know the limits and
guidelines (Cromey, 2010). This is most likely the case with the Altschuler
et al. paper because the authors show a commendable level of disclosure,
revealing the minutiae of their methodology and admitting to problems
such as the high levels of observer bias. Even the unaltered images
corresponding with the figures in the journal are freely available on the
first author’s website (http://www.headlice.org/news/collembolosis/
microimages.htm). The possibility exists that the authors would not have
used inappropriate photo manipulation had they known it was
inappropriate.
Nonetheless, the enhanced image is suspicious and its descriptions are
noticeably sparse compared to the high levels of disclosure elsewhere.
Besides the caption of ‘‘contrast tools,’’ no other mention of photo
DOI: 10.1645/12-12.1
583
manipulation software or techniques is mentioned. According to most
literature on the subject, including the American Academy of Dermatol-
ogy’s ‘‘Position Statement on Photographic Enhancement’’ (2007), using
tools such as contrast and color balance manipulation to enhance an
image are acceptable as long as they are ‘‘simple adjustments to the entire
image. . . Manipulations that are specific to one area of an image and are
not performed on other areas are questionable’’ (Cromey, 2010). Figure 2
(of this paper) shows the unaltered (A) and altered (B) image from the
Altschuler et al. paper as well as the same unaltered figure with contrast
applied to the entire image equally (C) (Adobe Photoshop, brightness 70,
contrast þ100, then contrast þ100 again). When contrast is applied evenly,
the putative collembolan is not clearly visible. Indeed, if one was not
ordered to specifically look for an insect, one might easily detect
alternative explanations. The level of detail present in the Altschuler et
al. enhanced image, particularly in the areas of the legs and a very odd pair
of stripes along the abdomen, does not appear when contrast is applied
equally. Such detail, however, can easily be created using functions such as
burn, dodge, and colorize in Photoshop when applied to select portions of
the image manually as if via paintbrush. Even before the advent of
Photoshop, burning and dodging of physical photographs was considered
to be unethical manipulation and alteration of scientific data. Selectively
enhancing contrast or levels on only part of an image is also considered
scientific misconduct, and the brightness and low detail on the areas of the
bottom left and top right of the altered image suggest that no contrast was
applied to those sections.
Some may argue that illegal enhancements do not change the ‘‘fact’’
that an insect is present in the unaltered image. However, the presence of
collembola in the picture has been thoroughly disproved, along with the
role of collembolans in human dermatitis overall (Lim et al., 2009). Thus,
the appearance of a detailed, collembola-like figure in the altered image
must be pareidolic. The poor methodology employed throughout the
study led to a situation where pareidolic sightings and interpretations were
encouraged and promoted.
The article is not likely to be retracted despite meriting such a response,
with the demise of JHYES being the most prominent obstacle. It has been
suggested that the editors of its descendant, Entomologica Americana,
should publish a ‘‘Letter of Concern’’ to indicate that the results in the
paper may not be reliable (Sox and Rennie, 2006) and its online version on
the JNYES website altered to indicate same. It is likely that the authors
themselves will never be investigated. The first author’s National
Pediculosis Association is a non-profit organization outside the jurisdic-
tion of the U.S. Office of Research Integrity (ORI) (Krueger, 2009).
Furthermore, ORI only investigates work funded by Public Health Service
Agencies and has a six-year limitation on the time between publication
and investigation (Public Health Service, 2005).
Confirming the delusions of DP sufferers makes them more unwilling to
accept psychiatric treatment (Driscoll et al., 1993; Lee, 2008) or to seek
internal medical care to search for alternative causes of their sensations,
such as neurological damage or diabetes. A retraction is unlikely to undo
the damage that has been done (Budd et al., 1998, 1999; Neale et al.,
2010), and DP patients themselves will probably not accept a retraction
because of the paranoia and stubbornness typical of their condition.
Precedence exists for retraction on scientific misconduct and public health
FIGURE 1. From page 91 of Altschuler et al. (2004). ‘‘Fig. 2. Collembola
in debris in lower right.’’ Image courtesy of Entomologica Americana
(formerly Journal of the New York Entomological Society). Labels in the
left inset read, clockwise from the top: tail, furcula, head, eye, mouthparts,
leg, collophore. Label on right insert reads: ‘‘Contrast tools show more
detail.’’
FIGURE 2. The unaltered (A) and altered (B) images from Altschuler et
al. (2004) Fig 2, courtesy of Entomologica Americana. When contrast is
applied evenly to (A), the result (C) does not resemble Altschuler’s altered
image, suggesting that inappropriate image manipulation is needed to
achieve such results.
584 THE JOURNAL OF PARASITOLOGY, VOL. 99, NO. 3, JUNE 2013
risk grounds (Editors of the Lancet, 2010). Altschuler et al. is also not the
first DP-denying paper to warrant a ‘‘better-late-than-never’’ retraction
(Shelomi, 2011).
This case shows the importance for journals, including regional ones, to
publish strict guidelines on what kind of image manipulation is allowed
(Entomologica Americana’s style guide still has none). Requiring authors
to send to the journal original, high-resolution copies of any figures used is
important, as is mandating that all manipulations be noted in the
Materials and Methods or photo legend (Rossner and Yamada, 2004).
Such guidelines will not only protect the journals from publishing
materials that do not conform to scientific procedure or are tainted by
fraud but will also serve as a guide for authors who may not know what is
unacceptable. The shift from physical to digital media has made scientific
misconduct much easier but has also eliminated some of the permanence
from historical literature and makes correcting past errors much easier.
The author thanks Dr. Lynn Kimsey and the Bohart Museum of
Entomology, University of California–Davis, and Dr. Ernest Bernard of
the University of Tennessee. This material is based upon work supported
by the National Science Foundation Graduate Research Fellowship under
Grant No. 1148897. Images courtesy of Entomologica Americana
(formerly the Journal of the New York Entomological Society).
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