Pyromania Associated with Escitalopram in a Child

To the Editor:

T he term pyromania comes from the Greek words “pyr” (fire) and “mania” (madness). This disorder is characterized by the repeated setting of fires with no apparent reason, such as for financial gain, vengeance, or political extremism. The subject shows interest in observing fires and feelings related with increased tension before committing the act and intense excitement immediately after doing it (American Psychiatric Association 2000). Firesetting in childhood and adolescence is a relatively rare phenomenon, compared with psychiatric disturbances such as anxiety and depression. Nevertheless, the associated potential risk of harm to self and others is great (Chen et al. 2003).

Our case was a 9-year-old boy with separation anxiety disorder and encopresis who developed pyromania at 10 days after initiation of escitalopram treatment. Thus, pyromania might be induced by escitalopram.

The case was referred to our outpatient clinic for his soiling, overanxiety, shyness, fears, and difficulty in sleeping alone. His mother reported that fecal soiling was rarely seen since he was 5 years old, but was now occurring approximately every day. Fecal soiling was usually seen during play and he would be stubborn and angry with his mother about going to the toilet. A complete medical work-up was done, but no organic etiology was determined. He was then referred to a child and adolescent psychiatry outpatient clinic. He was unable to stay alone in a room because of fear and he went to sleep at night with his mother. He was good at his lessons, but he was sometimes alienated and ridiculed because of his bad smell caused by fecal soiling.

He was born after a full-term uneventful pregnancy as the first child of his family. His early motor and language development was within normal limits. His psychometric testing revealed a normal intelligence level. His mother had been treated for obsessive-compulsive disorder. In addition, his grandmother was being treated for schizophrenia. The patient was found to have separation anxiety disorder and encopresis according to Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) (American Psychiatric Association 2000) criteria. Escitalopram was initiated at 5 mg/day and behavioral interventions were used to reduce his fears, overanxiety, and fecal soiling.

One month later, in the second psychiatric examination, his mother emphasized that his fears and overanxiety had diminished and fecal soiling had not occurred during the last week. His mother reported that he had been braver and less shy after the treatment and he had been able to sleep alone. Despite that, his mother reported that his son had started to set fires at approximately 10 days after starting escitalopram treatment. He tried to set fires at home or outside at least once a day. He also attempted to set fire in the home, but his mother immediately noticed and extinguished the fire. According to his mother, he did not show this type of behavior previously. It started as a curiosity, but later he started to take pleasure and became relaxed when he set a fire. These firesettings were impulsive in manner. His sleep pattern was normal and there was no elevation in mood. No psychotic or manic signs (e.g., hallucinations, delusions, grandiosity, irritability, flight of ideas) were found upon psychiatric examination. A complete blood count, biochemical analysis, and thyroid function tests revealed no abnormality. He was found to have “pyromania” according to DSM-IV-TR criteria because of his repetitive firesetting behavior despite his family's attempts to prevent it and the pleasure he took from this behavior. Behavioral suggestions to control this drive were given to the patient, but escitalopram was stopped after 2 weeks because of the continuation of the firesetting behavior. The firesetting desire was no longer noted after discontinuation of escitalopram. The patient has been examined regularly for the past 6 months and these behaviors did not reemerge. Encopresis did not occur again and anxiety symptoms were no longer of the intensity to be described as an anxiety disorder.

Individual features of temperament, male gender, parental psychopathological factors, social and environmental factors, and possible neurochemical predispositions have been hypothesized to be causes of childhood firesetting (Soltys 1992). Angry, ignored, sad, or depressed feelings were also commonly reported prior to acts of firesetting (Moore et al. 1996). Firesetting is also associated with substance use during adolescence (MacKay et al. 2009). However, to date, a causal connection between selective serotonin reuptake inhibitors (SSRIs) and firesetting has not been defined.

Firesetting has been reported to occur more frequently in disinhibited individuals (Jacobson 1985). Behaviorally inhibited children are cowardly, poised, and shy and do not attempt dangerous activities. These children are at risk for anxiety disorders and many of them are diagnosed with anxiety disorder over the course of time (Kagan et al. 1987). Behavioral inhibition, in our case, may have disappeared because of escitalopram administration. Therefore, actions that he wanted to do but could not normally bring himself to do may have emerged. Disappearance of this behavior after cessation of escitalopram medication supports this suggestion. High levels of aggressiveness, shyness, and peer rejection are stated to increase the likelihood of becoming involved in firesetting. Children with these issues have been reported to become involved in firesetting at a rate of 13.1 times higher than other children (Chen et al. 2003). Peer rejection, stubbornness, and anger toward his mother may have promoted a disposition to firesetting related to escitalopram use in our case.

Drugs of the SSRI class are beneficial in treating impulsivity, but they are not good choices for pyromania (Rossi 2006). Although SSRIs are effective in treatment of kleptomania (which is one of the impulse control disorders), an emergence of kleptomanic behavior has been reported in the literature following treatment of three depressive patients with SSRIs (Kindler et al. 1997). SSRIs block reuptake of serotonin, but a secondary change in 5-HT2A and 5-HT2C receptors may disinhibit the mesocorticolimbic pathways, thereby enhancing aggression and impulsivity (Stahl 1998). To our knowledge, no controlled pharmacological trial has yet been conducted in patients with pyromania. Nonpharmacological interventions for firesetters, including cognitive behavioral therapy, short-term counseling, and day-treatment programs, have shown some efficacy (Slavkin 2002).

Mania, delusions, and conduct disorders are exclusion criteria for pyromania according to DSM-IV-TR criteria (American Psychiatric Association 2000). However, firesetting related to medication is not excluded in this classification system. For this reason, pyromania can be diagnosed in our case because taking pleasure and relief sensations accompanied the recurrent firesetting. There were no secondary benefits in our case, as occurs with arson.

In conclusion, in this case, firesetting may have been induced by escitalopram administration for behavioral disinhibition.