A 13-year-old boy is brought to the office by his parents due to concerns about his behavior. His mother says, "A few weeks ago, he got into trouble for forging my signature so he could go on a school trip. He has been talking back and arguing with us more than he used to. I also found a cigarette lighter in his pocket, although he swears that he doesn't smoke and just likes to play with it when he's stressed." The patient maintains a B average in school and spends most of his afternoons playing video games with a new group of friends. Three months ago, he was accused of being involved in a suspicious fire at the local park. His father says, "He has always wanted to be a firefighter. At age 9, he was playing with matches in the backyard and started a fire just to see how long it would take the firefighters to arrive." The patient says, "I don't know why my parents are so upset. I do well in school, and I do all my chores. Why can't they just leave me alone?" He has no significant medical history. On mental status examination, the patient is cooperative but sullen. He has no delusions, hallucinations, or suicidal ideation. Which of the following is the most likely diagnosis?

Question

A 13-year-old boy is brought to the office by his parents due to concerns about his behavior.  His mother says, "A few weeks ago, he got into trouble for forging my signature so he could go on a school trip.  He has been talking back and arguing with us more than he used to.  I also found a cigarette lighter in his pocket, although he swears that he doesn't smoke and just likes to play with it when he's stressed."  The patient maintains a B average in school and spends most of his afternoons playing video games with a new group of friends.  Three months ago, he was accused of being involved in a suspicious fire at the local park.  His father says, "He has always wanted to be a firefighter.  At age 9, he was playing with matches in the backyard and started a fire just to see how long it would take the firefighters to arrive."  The patient says, "I don't know why my parents are so upset.  I do well in school, and I do all my chores.  Why can't they just leave me alone?"  He has no significant medical history.  On mental status examination, the patient is cooperative but sullen.  He has no delusions, hallucinations, or suicidal ideation.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d785_5863_bc81_11902ea56711_MD0003_00 This adolescent's fascination with fire and history suggestive of intentional fire setting are consistent with a diagnosis of pyromania, a rare impulse-control disorder more commonly found in male patients. Pyromania involves deliberate fire setting with no obvious motive (eg, financial gain, revenge, political statement, recognition) to relieve internal tension. Individuals with this condition tend to be fascinated by fire and anything related to it (eg, fire stations, firefighters, cigarette lighters). They deliberately start fires to reduce tension and afterward feel pleasure or relief. Pyromania must be differentiated from fire setting associated with a manic episode, psychosis, conduct disorder, or substance intoxication. (Choice A) Antisocial personality disorder is diagnosed in individuals age ≥18. It involves a pattern of violation of basic societal rules and the rights of others and requires a history with some symptoms of conduct disorder before age 15. (Choice B) Fire setting can also be a symptom of conduct disorder. However, in conduct disorder, fire setting is done to cause damage and is not accompanied by a fascination with fire or the need to relieve tension. In addition, a diagnosis of conduct disorder requires a pervasive pattern of violating rules and the rights of others that includes additional problem behaviors (eg, aggression/cruelty toward people and animals, theft), which this patient does not exhibit. (Choice C) Although normal adolescence is characterized by a desire for privacy and independence that may manifest as sullen behavior (eg, arguing with parents) and testing limits (eg, forging a parent's signature), it would not explain this patient's fascination with fire and involvement in fire setting. (Choice D) Oppositional defiant disorder is characterized by a pattern of angry or irritable mood and defiant behavior toward authority figures. Although this patient is more argumentative with his parents, this is typical of adolescence, and he has no pervasive pattern of defiance. Individuals with oppositional defiant disorder do not typically engage in fire setting. Educational objective: Pyromania is characterized by intentional and repeated fire setting with no obvious motive. Patients have a fascination with fire and deliberately start fires to reduce tension and feel pleasure or relief. References: Juvenile firesetting. (http://www.ncbi.nlm.nih.gov/pubmed/26593122) Prevalence and correlates of fire-setting in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). (http://www.ncbi.nlm.nih.gov/pubmed/20361899)

A 13-Year-Old Boy Is Brought to the Office by His