Dr. Jayesh Shah

Case of Difficult Twins

A boy, aged 14 was brought to me on 16.2.91 for complaints of white spots-leucoderma. The spots were spread all over around the eyes, upper limbs and both the knees. His attitude towards his disease was very peculiar. He was totally disinterested & unenthusiastic about taking any treatment. He sounded very cynical & indifferent to his mother who accompanied him for the consultation. He lamented that he was tried various treatment but nothing but helps. In his words," I used to feel bad, now I feel nothing. If it is a natural phenomena, let it be. If it doesn't go what to do ? " In reality he was extremely irresponsible and was never genuinely interested in getting himself treated. In a way his behavior was childish. In his words," Nothing used to work. Then I didn't want to go for treatment. They used to force me to go but the treatment never seemed to work. They asked me to take tablets and stand in the sun but it never helped. So I left the treatment I said," Forget it since 2 years everybody accepts these white spots. My friends don't even tell me, you look bad". His voice and tone reflected an unfriendly reluctance to cooperate. He was forcibly brought for consultation.

Somehow, I managed to enthuse him to talk about himself ! He described himself as very short tempered, like a person who cannot take a joke. " I don't like anybody teasing me". He expressed some exam tension which was interesting to prove into. It apparently looked as if his anxiety was related to success & failure. Initially, it felt as if he was anxious about the humiliation when asked about his results. one statement he strongly made was," I will have to listen to long lectures that these people (parents) will give". At this stage, I knew that child seems to be a very difficult person and it was interesting for me to get him to talk about his inner state. He expressed intense irritation to what he felt as over-parenting. He could not tolerate his mother asking him to have food on time, to come back on time or if his mother inquired about where he was going etc. In his words," I can take care of myself.

I hate people asking me, advising me - do this, do that". At this point I ask him if this was the main factor that makes him angry. The mother spontaneously says "Not angry but very very very. angry I our patient immediately, in a soft but stern voice and in Hindi whisper to his
mother to shut up, as if not wanting me to hear this. All through the interview, he would come down heavily on his mother if she tried to say anything. He was V. upset when I wanted to know who had filled the case book. So this, he started reproaching his mother and demanding to know what was written in the book. Then he turns to me and says, "What do they know about me? I will tell you about myself!"

In his state of anger he starts shouting abusing and violently venting his anger on other children in the house. He would stop the other children watching their film on the video and insist on seeing his film instead. He would also bang the door in anger, shut himself off in a room - all beside himself with anger. It takes him four or five hours before he cools down again.
The inner feelings of his state became clear to me after he narrated the following incidence :

The first incident was related to getting a bad remark in his conduct diary in school. Obviously getting such remark evokes a reprimand from the parents. In his words, "I gave them the calendar to sign and they scolded me. I got very angry, it is not my fault and I got this remark.
Two boys were talking and the whole class gets the remark. We were not talking and we got the remark. They scolded me in the morning and I was upset the whole day. I did not play football in the school, refused to talk to my friends. I sat on one side and I was upset the whole day. In
reality he and his brother are the most mischievous, notorious trouble-makers in the school. Following is the example of it. He spoke about enmity between his group of friends and another group. In his words, "Two friends had a fight and we all got involved in it. I got a punch on my face, I got very angry. I could not do anything on that day.

Next day, I took 10 of my friends from Chira Bazaar (almost roadside street boys) and we bashed up that boy. I hit him and made him to apologize. I wanted to take revenge against him. How dare he hit me when there is no fault of mine! I wanted to hit him back. Once I am very very angry, I don't know what I say, what I do. I don't know why I am hitting him but I cannot control.

I keep on hitting him. Only later on, I realize that I have hit him." This was very striking considering the kind of culture that was evident from the mothers nature and stance. They seemed to be coming from a good family. The other characteristic symptom he expressed was the compulsive need for company "I cannot stay alone in the room. I must listen to a radio or a cassette. I don't like it to be empty around, nobody only four walls around me. I feel mentally suffocated in a room alone especially when there is no noise around, everything is very quite".

He is extremely fond of having very loud music in his room even when he is studying. I could not elicit what his threat was about when he was alone.

He was very irritable about trifles and had frequent quarrels with his cousins especially about watching movies on Video. He was very obstinate and refused to give up what he had decided in his mind. For e.g. He has decided to play a certain game when coming back from school, he finds the cousin playing the same game, he would snatch it and insist on playing that game. Very often he plans his day's schedule and obstinately sticks to his decisions. It took a hard time for the mother to get him to change his decisions. It took a hard time for the mother to get him to change his decision and come for the consultation. Once he decided to buy something, he must go. He stubbornly and rigidly sticks to his decisions.

I could further understand his state after a long interview with the mother and his twin brother. His twin brother was in the same state as if in a much higher potency ! He was free from any physical ailments but was much more intense in his mental state. On trifles he would threaten
to use his Rambo knife and use very hard and abusive language.

He had an obsession of collecting Rambo knives. In his words, "Its like a hobby to collect knives. I have so many knives at my house. I have got tow 18 1/2 inches Rambo knives. I keep it but I don't use it! My father threw many of my knives away". When I asked him if he felt like using
his knife when angry, he strongly retorted, "My hands are enough. I don't need a knife!. He was equally quarrelsome and excitable. For e.g.

Once his tuition teacher was trying to counsel him he keep calm by citing an example from her own life. She tried to tell him how she kept calm in spite of all the trouble she had in her family. To this, he reacted very violently, "who is troubling you? I will take out my Rambo knife and see him ..... "when his brother warned him about my asking lot of `mental things', he started shouting" Before the doctor makes me mental, I will make the doctor mental" They frequently used Hindi like the language, they learn from Hindi Films. The mother was weeping in despair when she was describing to me the kind of cheap, vulgar and abusive language these boys used. The abuses would have vulgar sexual overtones and gestures. They would bring sexual films and order the other members of the family to get out of the room so that they could close the room and watch such movies. They were of the bullying type, always picking and teasing some child or the other. Both the brothers would quarrel with the mother and accuse the mother of being partial towards the other. These children had no problems about telling lies and wandering and loitering instead of going to school. They were highly active and very restless.

Click Here to read Ananlysis and Follow Up of Dr. Jayesh Shah's Case 1 - Difficult Twins.