Aniket Mukherjee1, Geethanjali2

PRESENTATION OF CASE Master T, 13-year-old male patient, low-socioeconomic status and rural background reported with his mother after being referred by Department of Dermatology with chief complaints of decreased academic performance with aggressive and argumentative behaviour since 8 months and multiple wounds over the body since 1 month. Insidious onset, gradually progressive, chronic and fluctuating course with precipitating factors of being admonished by school authorities. He had frequent quarrels and fights with his classmates and bullied them to do his homework and did not pay any heed to what the teachers instructed him to do. He would spend most of his time at home in pass-time activities like playing mobile games and watching TV. Thus, academic performance declined over this period and he has been scoring single digit marks in his exams. He would ask for new clothes every week and ask his choice of food to be prepared every day and be very stubborn about it and would not eat until done so. His mother then noticed the presence of 3-4 wounds on his forearm and when asked he did not give any credible answers as to how they appeared. Over the next few days, many more wounds were noticed by his mother and they were in the easily accessible areas of his body like the forearms, face, chest, abdomen and anterior aspects of his legs with no wounds on the back and posterior aspects of his legs. He also refused to go to school because of these and reported that the school authorities have asked him not to come until the wounds were healed. He denied inflicting those wounds upon himself or skin picking and they were of similar shapes and sizes. He also wanted to skip his annual exams on the pretext of his wounds. No associated itch, bleeding, pain or discharge. He expressed no guilt or concern. Also, history of him not being in touch with his father for many days in any given week as he is a driver by occupation and stays away from home for prolonged periods and thus he has been deprived of his affection. No history of any substance abuse. No significant past, family or developmental history. Weak bonding and attachment with father. Evolving personality traits-choleric temperament, hedonistic outlook, low conscientiousness, responsibility and sense of duty.
GPE - Multiple similar skin excoriations of 2 x 2 to 2 x 4 cm on the easily accessible areas of his body. Some lesions had crusting and others were healed or hyperpigmented. No systemic abnormality noted.
Mental Status Examination- Kept on meddling with his mother’s cell phone during interview and showed indifference to whatever questions were being asked, increased psychomotor activity, intermittent eye to eye contact, uncooperative, rapport established with difficulty, impulses of pleasure seeking behaviour, masked inferiority complex, defense mechanism- Denial. No delusions, obsessions, compulsions, suicidal ideations, depressive or anxious cognitions, dysphoric affect, ill-sustained concentration. Reduced social and occupational drive with increased recreational drive.
DIFFERENTIAL DIAGNOSES i) Dermatitis artefacta with oppositional defiant disorder. ii) Conduct disorder. iii) Obsessive compulsive disorder.