Right. That was fun.
I’ll post the case I was working on, because it’s both simple and complicated and it’s just easier to do ye olde copy and paste. Look for it at the end. I spent days working this case. I had to assess, diagnose, and treat the kid. His symptoms didn’t match up well with any of the DSM-5 diagnoses, so it was a bitch. None of us in class are happy with our conclusions; we just did the best we could. My copy of the DSM, which I’ve only had for a couple of months, is on its way to being bound by duct tape. Before I was done with the case, I’d taken calling 6 yr. old Bruce “Damien,” as in The Omen. I referred to him as Damien so many times while discussing him with classmates that I almost called him that when I did my write-up! But it’s done. I’ve turned it in. I can move on.
Now I have to deal with fleas. The cats are going to the vet on Friday to be treated, and the house will be flea bombed at the same time. We went through this last year around this time, too. I hate fleas.
I don’t have class again until Thursday night, so I can do whatever I want tonight. In between squashing fleas of course.
Bruce is an attractive 6 year old boy whose mother brought him to the emergency room because she was frightened that she could prevent the child from setting fires, which he had done several times in the last year and a half. Although he had so far managed to put out all the fires he set himself, his mother was afraid that he would set the house afire while she and his sister were asleep. She complained that he was sneaky about setting the fires, making it impossible for her to control him or to know how many fires he had actually set.
Bruce says that he has set fires because a “man in my head tells me to.” This “man” stays in his room when he is awake and “goes away when he is asleep. The man makes a noise (“brr”), which Bruce interprets as a command to “set fires.” He is afraid to talk to anyone about the man or not to obey his commands, “because he might beat me up.” His mother apparently does not take the voice seriously, stating that Bruce has offered a variety of different reasons for setting fires, depending on to whom he was talking. Both agree that he sets fires in retaliation against his mother when he is angry with her.
Bruce has been fascinated with setting fires for the last 2 years. His mother remembers that he and a friend set the first fire by burning holes in the plastic sheets on his and his sister’s beds. His mother found out about the incident later and reacted by hitting him on his hands and telling him how dangerous fires were. During the next fire-setting incident, Bruce used a lighter to try to burn a door frame that his mother had just painted. This time he was not hit, but was forbidden to ride his bicycle for a week. His mother was sleeping during a third episode, in which he set the garbage on fire with a table lighter. He then took a broom and beat out the fire. His mother awoke to a funny smell and remembers that he was running allover the house in a peculiar manner. She related this incident with amusement at the child’s antics.
The last two fires had taken place 3 weeks previously, when Bruce first tried to burn a dishtowel on a gas flame. After he burned the fringe, he rolled up the towel and threw it in the garbage. His mother, who was just outside the apartment at the time, sent him to bed and later explained to him again about the dangers of fire setting. During the last incident, he took a stretch monster toy that was kept in a styrofoam box and burned holes with a lighter on the sides of the box that corresponded to the monster’s arms and feet.
Apart from these incidents, his mother remembers that Bruce would often find matches or go into the bathroom with a lighter and try to smoke. His mother has talked to him at length about fires, how they get bigger with alcohol, and can be put out with water. He becomes excited during these discussions, but then promises never again to play with fire.
At the present time, his mother reports, Bruce is unhappy in school and misses his former friends from the neighborhood the family moved from 3 months before this evaluation. She says that he has made no new friends outside school, and that he and his sister complain frequently of boredom.
Aside from the fire setting, there is no history of any other aggressive or antisocial behavior. His mother reports that Bruce has been difficult to discipline, but mainly because he ignores her. Bruce’s schoolteacher was surprised to hear of his fire setting. She described him as a lovely, bright, obedient child who played and worked well with both the teacher and his peers. Upon further inquiry, she could say only that at times he was a little “wild” in his play.
Bruce lives with his l0-year-old sister and 26-year-old mother, who herself was hospitalized as an adolescent after she had been truant from school for 7 months in retaliation for her mother’s remarriage. In an initial discussion with the interviewer, she acknowledged that at times she becomes violently angry, to the point where she is unable to control herself.
The findings of Bruce’s physical examination were within normal limits except for the second-degree burn on his hand, which his mother initially said came from her attempts to “teach him that fire hurts” by insisting that he put his hand in a gas flame. (She later denied this, but Bruce insisted that she had done it.)
When interviewed, Bruce was somewhat guarded and distrustful at first. This seemed to be a manifestation of shyness and fear of what his mother would do or say. Over the course of several evaluation sessions, Bruce’s play revolved around themes of fires getting bigger and out of control. He knows that he can get burned and that a big fire could burn his house and that “ I woulddie.” When talking about fires, his affect was either inappropriate (laughter) or blunted. When discussing the “man” and his command hallucinations, Bruce seemed to be genuinely frightened, as if he regarded the man as real and threatening. He denied suicidal ideation, although his mother reported that he had recently said that he wished to die.