They feel bugs inside them. Doctors don’t know why—ME/CFS mentioned.

The ME/CFS mention:
In the United States, the average doctor’s appointment lasts around 18 minutes, and the average primary care doctor sees about 20 patients a day. That can be enough time if a patient has, say, a clear case of shingles. But the encounter becomes far more challenging when a patient arrives complaining of symptoms with no obvious cause.

Doctors have roughly 17,000 diagnostic disease categories to choose from, most of which share some of the same 150 to 200 common signs and symptoms. A headache could be a symptom for some 300 diseases and chest pain could be a symptom of 25. A symptom like fatigue could have countless possible causes. “There are several sources of frustration for a doctor when a patient walks in and says, ‘I just have not had my usual energy, and I’m not able to function at home or at work the way I used to,’” said Dr. Anthony Komaroff, a leading expert in myalgic encephalomyelitis/chronic fatigue syndrome, or M.E./C.F.S., at Harvard.
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‘I just have not had my usual energy, and I’m not able to function at home or at work the way I used to,’
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Patients don't just have fatigue though, even if they don't recognise PEM (and many don't in the beginning) they also have sleep disturbance, cognitive dysfunction, probably GI issues and pain points. In combination its quite a discrete condition its not common for all this to come along together as random separate conditions. But then in my experience the doctor is already not listening at symptom 3 so they likely don't even hear the 4-6 primary symptoms (depending on criteria) before they have made up their mind its all health anxiety.
 
Not really great to have ME/CFS mentioned in an article about delusions.

I imagine the idea of infestation is what a rational person experiencing these symptoms might land on in the absence of an actual explanation from medicine. Some people may then go to extremes. Persistent itch is a very unpleasant symptom.

Perhaps it's a form of small fibre neuropathy. I see there's a chapter in The Physician's Guide to Delusional Infestation (2024, SpringerLink, Paywall): Neurological Aspects of Delusional Infestation

Dr. Oaklander is associate professor of neurology at the Massachusetts General Hospital and Harvard Medical School in Boston and assistant in neuropathology at the Massachusetts General Hospital, where she directs the Nerve Unit. She is internationally recognized for her research on the small fiber peripheral neurons that mediate itch, pain, and many internal functions. Here, she reviews the neurological itch pathways and conditions that cause persistent itching and scratching. Specific neurological disorders lead patients with odd sensations to suspect insect infestations.
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