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Reprinted as a book chapter in Child Health and Human Development Yearbook 2014. Joav Merrick, (Ed.). p. 121-128.

This article is available at UKnowledge: https://uknowledge.uky.edu/pediatrics_facpub/176 Int J Child Adolesc Health 2014;7(2):109-115 ISSN: 1939-5930 © Nova Science Publishers, Inc.

Firesetting behavior and associated comorbid psychiatric disorders

Stephanie J Stockburger, MD, FAAP Abstract and Hatim A Omar, MD, FAAP Department of Pediatrics, Division of Adolescent Firesetting behavior results in serious damage to lives and Medicine, University of Kentucky, Lexington, KY, USA property every year. Firesetting has been linked to a number of comorbid psychiatric disorders including depression, , conduct disorder, antisocial personality disorder, obsessive compulsive disorder, psychotic disorder, schizoid personality disorder, and . Psychiatric disorders differ by gender. In addition, juvenile firesetters have history of a separate set of psychiatric comorbidities. The strong correlation between psychiatric comorbidities and firesetting behavior illustrates the need for service and collaboration.

Keywords: Firesetting, pyromania, , impulse control disorder, comorbid psychiatric disorders, conduct disorder, antisocial personality disorder, schizophrenia, gender

Introduction

Firesetting is an often overlooked problem that is completed by youth as well as adults and results in serious damage to lives as well as property. Firesetting has been linked to a number of comorbid psychiatric disorders. Evaluating comorbid psychiatric disorders has important implications in the prevention, diagnosis and treatment of firesetting behavior.Firesetting behavior has been a subject of interest for a number of years in scientific literature. The term pyromania was first used by Marc in 1833 (1). Kraepelin defined pyromania as an “impulsive insanity” (1,2). Sigmond Freud believed pyromania was the result of aberrant psychosexual development Correspondence: Professor Hatim A Omar, MD, FAAP, (1,2). Director of Adolescent Medicine and Young Parent The result of firesetting may involve both the programs, J422 Kentucky Clinic, Department of legal and mental health systems. The problem is more Pediatrics, Kentucky Children’s Hospital, University of Kentucky College of Medicine, Lexington, KY 40536 common than is often realized and results in extensive United States. E-mail: [email protected] damage.There are more than 62,000 per year in 110 Stephanie J Stockburger and Hatim A Omar the United States (1). This number is particularly criminal activity, to express anger or vengeance, to startling considering that only 3% of suspected arson improve one’s living circumstances, in response to a led to conviction (3). The National Fire or hallucination, or as a result of impaired Protection Association estimated 316,610 intentional judgment. Finally, the firesetting is not explained by fires each year during the period from 2003-2006 (3). conduct disorder, a manic episode, or antisocial Intentional fires during the same time period were personality disorder (1). associated with 437 civilian fire deaths, and 1404 There are numerous psychiatric comorbidities civilian fire injuries (3). It is estimated that the United among those diagnosed with pyromania, those States suffers a loss of $2 billion dollars annually due convicted of arson, and those with intentional to intentional firesetting. It has been presumed that firesetting behavior. This article will evaluate the this behavior is so common, and the losses so great, current literature regarding various associated because firesetting is relatively “easy” to complete psychiatric comorbidities associated with the different (1). Firesetting does not require weapons or types of firesetting behavior. Gender differences, as interpersonal interaction (1). well as juvenile offenders, are associated with A distinction must be made between the terms differing psychiatric comorbidities among those with firesetting behavior, intentional firesetting, firesetting behavior. pyromania, and arson. Firesetting is a behavior that includes setting fires both accidentally and intentionally (1). The term “intentional firesetting” is Methods not necessarily synonymous with “pyromania” as the latter is a psychiatric diagnosis defined by the DSM. Literature search was conducted using PubMed and Intentional firesetting does not always imply a included terms such as “pyromania”, “firesetting”, psychiatric disorder (1). Arson, on the other hand, is a “arson”, and “psychiatric disorders”. This review legal term. Arson is a criminal act “in which one investigates the current literature related to firesetting willfully and maliciously sets fire to or aids in setting behaviors and comorbid psychiatric disorders. fire to a structure, dwelling, or property of another” (1,4). In the United States, the law presumes all burning to be accidental. In order to be convicted of Discussion arson, the prosecution must overcome this presumption and prove that the fire was set by There are high rates of psychiatric comorbidities criminal design (1). among those who set intentional fires, those who are In order to thoroughly understand the term diagnosed with pyromania, and those who are “pyromania” the DSM-IV diagnostic criteria must be convicted of arson. Multiple studies have evaluated reviewed. The updated version of the DSM (DSM-5) the comorbidities among those with firesetting is unchanged from the DSM-IV criteria (5). behavior, and those convicted of arson, and those Pyromania is listed along with pathological gambling, diagnosed with pyromania. In addition, several , intermittent explosive disorder, and studies have identified gender differences among as separate categories within the those who set fires. Psychiatric comorbidities have Impulse Control Disorders (6). Pyromania is defined also been identified in juveniles with firesetting as “Deliberate and purposeful firesetting on more than behavior. one occasion”(1). There is tension or affective arousal A high rate of comorbid Axis I mood disorders before the act. The person must have a fascination and impulse control disorders exist among those who with, interest in, curiosity about, or attraction to fire meet criteria for pyromania. A study of twenty-one and its situational contexts. In addition, there must be adult and adolescent subjects were recruited from pleasure, gratification, or relief when setting fires or inpatient and outpatient studies of impulse-control when witnessing or participating in their aftermath. disorders who met DSM-IV criteria for lifetime The firesetting cannot be done for monetary gain, as pyromania were administered a semi-structured an expression of sociopolitical ideology, to conceal interview to evaluate for psychiatric comorbidity.

Associated comorbid psychiatric disorders 111

Thirteen of the subjects (61.9%) had a comorbid Axis criteria for pyromania (12.5% vs. 0%) (9).A separate I and 10 (47.6%) met criteria for a study of 234 psychiatric inpatients evaluated the current impulse control disorder (7). prevalence of impulse control disorders using a The same study also evaluated the subject’s structured interview. The lifetime rate of impulse feelings surrounding the firesetting behavior. All control disorders was found to be 23.5% with a subjects reported a “rush” when watching or setting current rate of 18.8%. The most common impulse fires. None of the subjects reported a sexual feeling control disorders were pathologic skin picking, associated with firesetting. Sixteen subjects (76.2%) compulsive buying, and intermittent explosive reported that the frequency and intensity of the disorder (6). firesetting increased over time. Eighteen subjects There are high rates of antisocial behavior in (85.7%) reported feelings of relief when setting fires those with a lifetime history of firesetting (10). A and 19 (90.5%) reported feeling severe distress after large study titled the National Epidemiologic Survey firesetting. Eight subjects had thought of suicide in on Alcohol and Related Conditions (NESARC) order to control their firesetting behavior. Subjects provided data about 407 subjects with a lifetime with current substance use disorder and major history of firesetting. Face-to-face interviews were depressive disorder reported that the symptoms of conducted of all 43,000 adults in the study. Lifetime pyromania preceded the substance use disorder and prevalence of firesetting in addition to mood, anxiety, depressive symptoms. They also felt the substance use substance use, and personality disorders in DSM-IV and depressive disorder were a result of distress over were assessed. The lifetime prevalence of firesetting setting fires (7). in the United States was 1.0% (10). Firesetting was Although the above study consists of a small associated with a broad array of antisocial behaviors. sample size, it demonstrates the features that place There were strong associations between lifetime pyromania as a category under Impulse Control alcohol and marijuana use disorders, conduct Disorders in the DSM-IV (6). Specifically, the disorder, antisocial, and obsessive-compulsive subjects felt a sense of tension or excitement before personality disorders, and family history of antisocial acting out. They also experienced relief, pleasure or behavior (10). The most prevalent antisocial gratification while acting out or shortly thereafter. behaviors were staying out late without permission, They reported feeling remorse afterwards. In addition, cutting class and leaving without permission, and the frequency and intensity of firesetting increased shoplifting. The least prevalent was forcing someone over time (7).An impulse control disorder is described to have sex. The strongest associations between as “(1) repetitive or compulsive engagement in the antisocial behaviors and firesetting behavior were behavior despite adverse consequences, (2) found for robbing or mugging someone or snatching a diminished control over the problematic behavior, (3) purse, destroying others’ property, and forcing an appetitive urge or craving state prior to someone to have sex (10). engagement in the problematic behavior, and (4) a While a number of psychiatric comorbidities have hedonic quality during the performance of the been linked to firesetting behavior, bipolar I disorder problematic behavior” (7,8). Thus, pyromania is does not appear to be a common comorbidity. A study categorized in the DSM-IV and DSM 5 as a type of of 124 bipolar I patients recruited from the outpatient impulse control disorder. clinic of a unit did find a high Impulse control disorders may be underdiagnosed prevalence rate of comorbid impulse control disorders among those with a current psychiatric diagnosis. A (27.4%). The impulse control disorders included study involving 102 adolescents who were admitted to pathologic skin picking, compulsive buying, an inpatient psychiatric service were screened for intermittent explosive disorder, and trichotillomania. impulse control disorders. Forty percent met criteria Interestingly, there were no instances of pyromania or for impulse control disorder. Those with an impulse compulsive sexual behavior (11). However, due to the control disorder were more likely to report previous fact that patients with bipolar I disorder appear to be psychiatric hospitalization and internalizing disorders. at high rate of having a comorbid impulse control, one A statistically greater percentage of females met cannot rule out firesetting behavior in these patients.

112 Stephanie J Stockburger and Hatim A Omar

Individuals with schizophrenia and other and antisocial personality disorder as well as a appear to be at increased rate of arson diagnosis of schizoid personality disorder (3). conviction. There is evidence in the literature that When female arsonists are compared to male psychosis is associated with serious crimes such as arsonists, female arsonists are more likely to have homicide. A case-control study investigated the higher levels of depression and psychosis (13). In association of being diagnosed with schizophrenia or addition, the most common comorbid psychiatric other psychoses and committing arson. Data was used diagnosis in female arsonists appears to be borderline from Swedish national registers for criminal personality disorder and antisocial personality convictions, hospital discharge diagnoses, and disorder (13,14). A study which reviewed records of sociodemographic factors. The study included the 167 arsonists (129 male and 38 female) found fewer years 1988-2000. All convicted arson offenders of women had childhood history of stealing, and they both sexes in Sweden were included (1689) and were were more likely than men to have been sexually compared to a random sample of control subjects abused. More than half of all women sampled from the general population. The study found that suffered from a diagnosable psychiatric illness, arson offenders were more likely to be diagnosed with mainly affective disorder. Women were less likely schizophrenia or other psychosis. The rates of than men to have an alcohol problem or to be comorbidity of the psychotic disorder with a intoxicated at the time of fire setting. Women were personality disorder were 30.6% (N=60) in men and also more likely to have element of attention-seeking 42.6% (N=40) in women. There were 48.5% (N=95) or parasuicide (15). Interestingly, women were more men with a psychotic disorder as well as comorbid likely to be presumed to be suffering from a mental substance use disorder while 38.5% (N=36) women illness in order to avoid prosecution which may be had same comorbidity. The study concluded that part of the reason that females tend to be diagnosed individuals with schizophrenia or other psychosis with a psychiatric illness (16,15). have increased risk of arson convictions. Thus, arson One of the most disturbing statistics regarding is in the same category as homicide as both being firesetting is how common the behavior is in our crimes that are strongly associated with psychotic youth. Firesetting occurs in 13.6-17% of youth (3,17). disorders (12) It is associated with high rates of family dysfunction, Gender differences exist among those with history of sexual abuse, school difficulties, substance firesetting behavior. Data from the NESARC study use disorders, and personality treats including was also used to evaluate gender differences and impulsivity and hostility (3,17). Children firesetters psychiatric correlates in those with lifetime history of have been found to be more likely to engage in future firesetting (3). The study found that firesetting is delinquent behavior (3,18). associated with a wide range of antisocial behaviors In children, firesetting has been found to be that differed by gender. Men with a lifetime history of related to the number of depressive, conduct disorder, firesetting were more likely than men without oppositional defiant disorder, and attention deficit firesetting to a have a lifetime generalized anxiety hyperactivity disorder symptoms (18,22). In girls, disorder, conduct disorder, antisocial personality firesetting is associated with problems with , alcohol or cannabis use disorder, or and depression (19,22). Other characteristics of obsessive compulsive disorder (3). When women with juvenile firesetters include poor social judgment, poor a lifetime history of firesetting were compared to planning, weak social anticipation and feelings of women without a lifetime history they were found to loneliness, isolation and inadequacy in peer relations have a lifetime diagnosis of alcohol abuse and (20,22) as well as peer rejection (21,22). Those with a cannabis use disorder, conduct disorder, antisocial history of repetitive firesetting scored higher on personality disorder, oppositional defiant disorder, measures of depression, interpersonal problems, psychotic disorder, bipolar disorder, or schizoid alienation, and deviation than those individuals who personality disorder (3). Women with firesetting had only one episode of fire setting (22). Severe behavior were more likely than men with firesetting firesetters were found to lack empathy with others and behavior to have lifetime diagnosis of alcohol abuse

Associated comorbid psychiatric disorders 113 were significantly less likely to express remorse for Another study sought to evaluate juvenile the consequences of their behavior (22). firesetting in Italy and the relationship to aggression Anger and hostility appear to play a role in and . Surveys were administered to juvenile firesetting behavior. Both firesetters and 567 youth ages 11-18 years in Italy as well as to -players have been found to display more parents, teachers, and peers. Twenty-nine percent of aggression and hostility, and participate in more youth were found to have engaged in fire setting. fighting and arguing (22,23). A past history of Firesetters had higher rates of delinquent acts than physical violence, cruelty to children or animals, aggressive youth without firesetting behavior. power struggles with adults were all more Firesetters had higher levels of withdrawn behavior characteristic of severe firesetters or match-players and social problems than aggressive youth (without compared to non-firesetters (20,22). firesetting behavior). Youth who were both aggressive As noted above, fire setting behaviors in children and firesetters had more anxiety and depressive are related to psychopathology and family stressors. difficulties than aggressive youth. At follow-up, youth One study notes that fire behaviors can be identified who were aggressive and firesetters were more likely in young children using a brief screening measure. A than controls to report covert antisocial behavior such study of 1359 4- to 9-year olds in Australia, were as physical assault and gang violence (25). evaluated using parent report surveys. Five percent Firesetting behavior is often chronic and were reported to engage in any match or fire play. longitudinal. Without appropriate treatment, Firesetting in boys was found to be associated with controlled fires may turn into arson (7). Factors increasing age, parental stress, antisocial behavior, associated with arson recidivism include personality hyperactivity, cruelty to animals, and thrill-seeking disorders, psychosis, and mental retardation (26). temperament. In girls, higher levels of parental stress, Individuals with repeat arson offenses also often have both positive and negative parenting, antisocial comorbid alcoholism (26). The nature of firesetting behavior, and problems with anxiety and depression behavior requires collaboration between mental health were correlated with firesetting behavior (19). and fire service workers. One example of a program A study completed in Canada helps identify the that has been successful is the TAPP-C program (The mental health and substance use correlates of Arson Prevention Program for Children). This firesetting behaviors in adolescents. A total of 3,965 program collaboratively provides education and students in grades 7-12 were surveyed about their mental health care for children. Evaluation of the firesetting behavior. A total of 13.7% reported one or program showed significant benefits to both intra- two episodes during the past year while 13.5% disciplinary and interdisciplinary knowledge (27). reported three or more episodes during the last year Collaborative relationships among community (24). Youth with firesetting beginning before age 10 organizations such as insurance companies, schools, were more likely to report frequent firesetting during children’s protective service agencies, and juvenile the past year. Compared to nonfiresetters, desisters court systems are important for the prevention, (lifetime but not in the last year) and low frequency identification, and treatment of firesetting behavior (1-2 times/last 12 months) firesetters were more likely (28). to report psychological distress, binge drinking, In conclusion, firesetting is a complex behavior frequent cannabis use, and sensation seeking. Higher arising from multiple factors that shape a person’s rates of delinquent behavior, suicidal intent, and low behavior. Firesetting has severe consequences to parental monitoring were reported in low frequency individuals, property and communities. Psychiatric firesetters compared to nonfiresetters. Individuals comorbidities that are associated with firesetting who were high frequency firesetters were found to include depression, substance abuse, conduct have elevated risk ratios for all risk monitors plus disorder, antisocial personality disorder, obsessive “other illicit drug use.” Interestingly, but as may be compulsive disorder, psychotic disorder, schizoid expected, the cumulative number of risk indicators personality disorder, and schizophrenia. Further was positively correlated with firesetting severity (24) collaborative effort between mental health providers, primary care health providers, fire service workers,

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Submitted: August 05, 2013. Revised: September 07, 2013. Accepted: September 10, 2013.