Lesson 1: Clinical Disorders - Part A

Description

A distraught mother brought her six year-old son into a hospital emergency room because she was afraid that she could no longer prevent him from setting fires.

She was especially afraid that he would set their house on fire while she and her 10 year-old daughter slept. Since the boy was four, he had shown an unhealthy fascination with fire. He had set several fires in the past two years, all of which his mother had found and extinguished. She noted that her son was sneaky about setting the fires, making it increasingly difficult for her to monitor.

The boy told the doctor that he sets fires because a “man in his head” tells him to – and that he is afraid to disobey the man for fear of physical punishment. The mother does not take this reason seriously as he has given a variety of other reasons in the past, depending on to whom he was speaking. Both mother and son agreed that he started the fires in retaliation against his mom when he was angry with her.

The first fire the boy set involved burning holes in plastic bed sheets. When his mother found out, she hit him on the hands and told him about the dangers of fire. The second incident occurred after the mother painted a door frame. Her son tried to burn the door frame with a lighter. He was not hit, but he had his bicycle privileges revoked for one week. The third episode occurred when the mother was asleep. Her son had set the garbage on fire and then beat the fire out with a broom. She awoke to an odd smell and found her son running around the house in a peculiar manner. With the fourth fire, the boy burned a dishtowel and threw it in the garbage. When his mother found out, she sent him to bed. Afterwards she explained how dangerous fires were. The last fire involved a toy in a Styrofoam® box. The boy burned holes in the box where the toy’s feet and arms would be. The mother also found her son attempting to smoke in the bathroom. Once again, she talked about the dangers of fire. She explained that fires get bigger with alcohol and smaller with water. In these discussions, the boy became very excited but promised to stop playing with fire.

The mother remarked that her son missed his friends from their old neighbourhood and that he was unhappy in school. She believed that her son had no friends outside of school and that both her children often complained of being bored. Other than the fire-setting behaviour, no other aggressive behaviours were exhibited by the boy. He was occasionally difficult to discipline, but the mother said that was because he ignored her. The boy’s teacher was surprised to hear of the fires. The teacher described the six year-old as lovely, bright, and obedient – a student who worked and played well with others.

The 26 year-old mother admitted to becoming violently angry at times, so much so that she was not able to control herself. She even said that she had made her son put his hand in a gas flame to teach him that fire hurts. Later, however, she denied this fact despite the fact that her son confirmed her original story.

The boy, except for the burn, was physically healthy. Emotionally, however, he was guarded and distrustful when interviewed. This distrust was due, in part, to fear of his mother’s reaction. Eventually, he shared that he loves to talk about fires. Although he knew that he could get hurt or even killed by fire, he was fascinated by them. When speaking about fires, the boy’s affect was inappropriate. He laughed at the wrong times and/or have blunted emotion when he should have more passionate feelings. He also appeared genuinely frightened of the “man in his head.”

Diagnosis

The setting of fires can be symptomatic of conduct disorder. The six year-old, however, has no other antisocial problems and performed well at school – working well with both peers and his teacher. It is doubtful that he set fires as political statements or for insurance purposes, but evidently he derived much pleasure and excitement from fire and fire-setting. Although documenting such information in a young child is difficult, it can be inferred that there was tension before the boy set the fires. Therefore, the diagnosis is pyromania, an ICD. Because he had no other signs of psychotic behaviour apart from the “man in his head,” and because his reasons for setting the fires varied, an additional diagnosis of a psychotic disorder is not made.

His overall diagnosis in Axis I is pyromania.