Living with Pyromania

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Living with Pyromania Autism

• Dr. Leah Akinlonu SpR LD Psychiatry
• Dr. Kaysi Thinn SpR Forensic Psychiatry
• UCLAN 7th LD Offenders Conference March 2008

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Pyromania an insane propensity to set things
on fire
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Aims

• Background
• Case report
• Evidence base
• Issues for clinicians service providers

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Outline of Presentation

• Autistic Spectrum Disorders
• Pyromania
• Case report
• The Literature
• Management rehabilitation risk quality of
  life
• Service / resource issues
• Conclusions

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Autism 1

• Disorders of psychological development Pervasive
  developmental disorders
• Abnormal/ impaired development manifest before
  age 3 years
• ICD10 F84 childhood autism but can be diagnosed
  in all age groups

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Autism 2 Triad of Impairments
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Autism 2 Additional impairments

• May be present to varying degrees
• sensory disturbances
• sleep disturbances
• limited food preferences
• high tolerance to pain while being sensitised to
  light touch
• impaired theory of mind mindblindness
  (Baron-Cohen, 2001)

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Links with Offending Behaviour

• Features of ASD predispose to antisocial and
  offending behaviour. These include frustration at
  social limitations and at disruption to routines,
  misinterpretation of intentions of others, poor
  comprehension of social rules, compulsive
  fantasies or interests, and co-morbid psychiatric
  disorder (Crocombe, 2007)

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Pyromania 1

• ICD-10 Classification
• F60 DISORDERS OF ADULT PERSONALITY BEHAVIOUR.
• F63 HABIT IMPULSE DISORDERS
• F63.1 PATHOLOGICAL FIRE SETTING

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Pyromania 2

• The essential features are
• repeated fire setting without any obvious motive
  such as monetary gain, revenge, or political
  extremism
• an intense interest in watching things burn and
• reported feelings of increasing tension before
  the act, and intense excitement immediately after
  it has been carried out.

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Pyromania 3

• Differential diagnosis dissocial personality
  disorder, mood disorders, conduct disorders,
  temporal lobe epilepsy, substance abuse, learning
  disability and psychosis.
• Co-morbidity substance abuse disorders,
  obsessive-compulsive disorder, anxiety disorders,
  and mood disorders
• Incidence lt1, MgtF

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Pyromania 4

• Associated with depression, suicidal ideation,
  relationship difficulties, and difficulty coping
  with stress.
• Freudian psychoanalysis regression to a
  primitive desire to demonstrate power over
  nature, fire has a special symbolic relationship
  to the male sexual urge.
• "ego triad" of fire-setting, enuresis cruelty
  to animals (Hellmans triad)

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Pyromania 5

• Psychosocial hypotheses form of communication
  from those with few social skills, or an
  ungratified sexuality for which setting fires is
  a symbolic solution.
• Cremniter (1999) with reactive hypoglycemia or a
  ? concentration of 3-methoxy-4-hydroxyphenylglycol
  and 5-HIAA in the CSF. In general, ? 5-HIAA is
  also associated with impulsivity.

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Case Report

• AUTISM PYROMANIA
• In a young male resident in the community

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Background 1

• Demographic details 36yrs, single, unemployed,
  residing in low secure LD home on guardianship
  order
• Family History eldest son of 5, has 3 sisters
  and 1 brother. Turbulent relationship with
  parents, particularly father. No family history
  of LD, ASD or mental illness

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Background 2

• Developmental History normal birth, normal motor
  development, delayed speech, had Speech Therapy
• Attended special needs school, was bullied pins,
  ?aggression from father, violence absconding at
  school, expelled at age 19.
• interest in fire from age 16, would cook fried
  food late at night, no concept of safety

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Psychiatric history

• Moderate LD WAIS-III Full Scale IQ49 (P-57,
  V-50)
• Autism difficulty tolerating change, insistence
  upon routine, repetitive questioning, excessive
  attachment to certain objects
• No evidence of psychotic or affective illness
• 2002 (Age 33) -Admitted under Sec 2 MHA after
  damaging car of manager of residential home.
• 2007 (Age 36) -Admitted under Sec 2 MHA after he
  poured cooking oil on the floor of his
  residential home and set it on fire
• Medication Risperidone 0.5mg, currently nil

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Placements

• Has lived in 5 residential homes over the last 8
  years, as well as 3 extended hospital stays and
  his parents home. Repeated moving has been a
  result of verbal and physical aggression,
  repeated absconding, behavioural incontinence of
  urine and fire setting.

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Aggressive incidents

• First reports of verbal and physical aggression
  towards parents at age 15yrs. From this time they
  began to receive respite care.
• Father- boiling water 2x, stitches to eye,
  threats with hot pan knife Mother- slap
• Carers - pushed home proprietor down the stairs,
  kicked staff, tried to pull down fire
  extinguisher, smashed windscreen

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Fire Incidents1

• Nov.2002 threatened to start fire, sprinkled
  cooking oil over cooker kitchen floor when not
  allowed to speak to the proprietor
• Dec 2002 turned on all cooker gas hobs
  threatening to start a fire -stated wanted to see
  fire brigade. Denied intent to cause harm to self
  or others

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Fire incidents 2

• March 2007 set fire to his home, had obtained
  cooking oil, matches keys to locked linen
  cupboard containing staff clothing. Extensive
  damage to property, some required hospital
  treatment. Later told close female staff that he
  had set fire to her clothes smiled when asked by
  psychiatrist whether he liked fire engines
• June, July Nov. 2007 collecting lighters and
  matches

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Psychology sessions 1

• Difficult to engage, one word answers or not at
  all. Limited attention span, easily distracted,
  able to concentrate on tasks he was clearly
  enjoying such as puzzles and pictures of fires
• fire interest questionnaire suggests significant
  interest in fires, esp. watching buildings on
  fire.
• functional assessment of fire setting probably
  not motivated by anger, auditory hallucinations,
  or social attention may have been motivated by
  self stimulation

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Psychology sessions 2

• Photos of sequence of setting a fire in a home
  very enthusiastic only glanced at watch once
  (rare in sessions) asked psychologists name
• Near end of session, went to face the corner of
  the room, proceeded to unbuckle belt and attempt
  to remove his trousers, after being told several
  times went to toilet, returned looking slightly
  disorientated but this dissipated quickly

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Psychology sessions 3

• Good understanding of events that lead to a fire
  starting, progressing and being extinguished.
  Limited understanding of consequences of fires
• Fires and the procedures (e.g. fire brigade) are
  stimulating to him and may be sexually
  stimulating.
• Fire may be used to express feelings of
  unrequited love, both incidents were linked to
  women he had strong attachments to.

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Recommendations Psychology

• Work on increasing understanding of consequences
  of setting fires using visual material, in secure
  environment with good communication btw staff at
  home and psychologist as it may temporarily
  increase risk by raising level of excitement.
• Channel excitement in more appropriate ways-
  bonfire night etc
• Present all information in the most accessible
  way immediately - visual material with minimal
  language.

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Recommendations Forensic

• No unsupervised access to kitchen
• Twice daily searches
• Accompanied at all times in community
• Distress or agitation to precipitate MHA
  assessment consider admission to hospital
• Further psychology work with caution
• Encourage to restart medication
• Consider referral to specialist service for
  people with Autistic Spectrum Disorder

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Current management containment structure

• On guardianship order in a placement with a
  locked solid entrance fully enclosed courtyard
• Accompanied 11 on all community outings
• Room person searches twice a day
• Skilled staff communication, routines etc
• Attending college -doing Maths and English
• Liaison between home staff and LD team
• Receiving psychiatric outpatient follow-up
• Currently not on medication -refusing
• Psychology input -being addressed

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Literature Review

• Pyromania /Arson / Fire-setting
• Autism

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Literature 1

• Rarely diagnosed by psychiatrists, frequently
  applied by law enforcement and fire
  fighting/investigation personnel. Poor
  understanding of Pyromania (Geller et al, 1997)
• Arson as a rule is not the same entity as
  pyromania (Plinsinga et al,1997)
• Exclusion of aggressive motives, alcohol
  intoxication and alcoholism from definition of
  pyromania. Pyromania is largely a product of
  alcohol misuse (Laubichler et al,1996)

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Literature 2

• Arson recidivists with
• Personality disorder - wide range of criminal
  activity.
• Psychosis mental retardation - "pure
  arsonists"-persons guilty only of arsons during
  their criminal careers
• Concrete sexual motives and retaliation were
  found to be relatively rare causes. (Lindberg et
  al, 2005)

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Literature 3

• Puri, Baxter Cordess (1995) proposed a
  classification system for fire-setting to
  consider predisposing precipitating factors
  from Psychiatric, Psychological, Psychosocial
  components -emphasises assessment and mgt.
• Pyromania appears to be associated with high
  rates of psychiatric co-morbidity (Grant Kim,
  2007)

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Literature 4

• 3 antecedent emotions/events before fire-setting
  in LD angry feelings, not being listened to/
  attended to, and feeling sad/ depressed (Murphy
  and Clare, 1996)
• relationship of fire-setting to sexuality depends
  on the age of the fire setters. In the adult age
  group sexuality appears to play a part however
  there is limited progress made in understanding
  the nature and treatment of the adult fire setter
  (Fras, 1997).

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Management Rehabilitation

• Treatment Approaches
• Managing Risk
• Maintaining Quality Of Life

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Treatment Approaches 1

• Combination of psychological and pharmacological
  approaches
• lack of insight cooperation makes treatment in
  adults difficult.
• Behavioural therapy direct interest away from
  fire-setting activities and replace with more
  socially acceptable forms of tension reduction
• Long-term insight-oriented psychotherapy
• Fire safety education is useful in reducing fire
  involvement, fire interest, and risk.

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Treatment Approaches 2

• SSRIs - pyromania impulse control disorders
• mood stabilizers (e.g. lithium)
• Opioid antagonists (e.g. naltrexone) (DellOsso
  et al, 2006).
• The care or education environments are important
  to minimise the distressed and disturbed
  behaviours in persons with autism (McKernan,
  2002) - Communication, Noise levels, furniture
  and fittings, daily programme, consistent manner

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Assessing Risk -1

• no designated risk appraisal tool for offenders
  with ASD, transfer of presumptive risk factors
  from non LD offenders is the current norm
  (Johnston, 2002).
• Staufenberg (2005) highlights the potential of
  the BCFS-Risk Appraisal Grid to incorporate
  developmental and mental disorder for this
  purpose.

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Assessing Risk -2

• General Behaviour
• Personality
• Psychopathology
• Psychological function of the fire
• Health
• Family
• Peers
• Education
• Employment
• Behaviours

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Assessing Risk -3

• Fire History
• Early supervision
• Fire safety
• Early fascination
• Previous fires
• Parent responses
• Group progressing to solitary

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Assessing Risk -4

• Immediate environmental factors
• Access to materials
• Crisis or Trauma
• Distortions -Before, during, after
• Feelings -Before, during, after
• ETOH or Drug Use
• Reaction to Act
• Reinforcement
• Fire set/observed
• Specific Target
• Fire Aftermath

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Managing Risk -1 Psychosocial

• Group Work
• Offending behaviour
• Fire education
• Self image
• Assertiveness training
• Counselling for survivors of childhood abuse
• Grief counselling
• Social Skills
• Life Skills

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Managing Risk -2

• FACE, Andrew Muckley, Youth Justice Programmes
• Joint brigade and prison programs FACE UP,
  relapse prevention model
• Psychometric behavioural measures, group and
  individual, appropriate accomodation of treatment
  programmes and offenders, Mick Haggert at Rampton
• Government, Schools, Building Design

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Prevention

• need for studies of the effectiveness of
  socialisation and training programmes aimed at
  teaching children with LD alternatives to
  antisocial behaviour (Crocker Hodgins, 1997)
• a role has been suggested for the improvement of
  the social care of children with a LD, since
  those who go on to offend have often experienced
  several social care placements and considerable
  social adversity (Hall, 2005).

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Maintaining Quality Of Life

• Since deinstitutionalization, Valuing People
  (DOH, 2001) has emphasised the accountability of
  professionals and carers for the quality of life
  of people with learning disabilities.
• Social care placements in the community
• Specialist private care providers may be ideally
  equipped and structured, but distantly located
• NHS placements limited (low secure LD residential
  units
• Provision of safe, pleasant environment with
  social, educational and community opportunities

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Service / Resource Issues

• Development of specialist teams within LD
  services may be one approach to offering
  community intervention to individuals with LD and
  severe mental illness and additional complex
  needs such as forensic histories, is Hassiotis,
  Tyrer Oliver (2003)

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Conclusions 1

• Pyromania is a rare diagnosis whose diagnostic
  criteria and classification have been subject to
  debate. Pyromania has been associated with
  abnormalities of impulsivity, social
  estrangement, cognitive flexibility, and
  executive function features which are commonly
  seen in persons with learning disabilities and in
  persons with autism.

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Conclusions 2

• LD patients managed outside well-staffed
  hospital settings - potential for patients and
  communities to be at greater risk from fire.
  Clinicians and carers have a responsibility to
  increase level of awareness of fire risk in
  psychiatric patients, as well as assessing and
  monitoring that risk.
• Further research is needed in areas of
  prevention, assessment, treatment and care
  packages.

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Thank you