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Living with Pyromania _ Autism

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Living with Pyromania _ Autism Powered By Docstoc
					Living with Pyromania
& Autism

Dr. Leah Akinlonu SpR LD Psychiatry
&
Dr. Kaysi Thinn SpR Forensic Psychiatry

UCLAN 7th LD Offenders Conference March 2008
Pyromania – “an insane propensity to set
things on fire”
Aims

Background
Case report
Evidence base
Issues for clinicians & service
 providers
Outline of Presentation

 Autistic Spectrum Disorders
 Pyromania
 Case report
 The Literature
 Management & rehabilitation – risk &
  quality of life
 Service / resource issues
 Conclusions
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
Autism 2: Triad of Impairments


       Narrow/ repetitive          Qualitative
          Repertoire              impairments
     Stereotyped patterns         in reciprocal
         of behaviour           social interaction




                       Qualitative
                     communication
                      impairments
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)
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)
Pyromania 1

ICD-10 Classification:
 F60 DISORDERS OF ADULT
  PERSONALITY & BEHAVIOUR.
 F63 HABIT & IMPULSE DISORDERS
 F63.1 PATHOLOGICAL FIRE SETTING
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.
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 <1%, M>F
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 (Hellman‟s triad)
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.
Case Report




         AUTISM & PYROMANIA
In a young male resident in the community
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
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
Psychiatric history
 Moderate LD WAIS-III: Full Scale IQ:49 (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
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.
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
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
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
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
Psychology sessions 2

 Photos of sequence of setting a fire in a home:
  very enthusiastic; only glanced at watch once
  (rare in sessions) asked psychologist‟s 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
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.
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.
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
Current management –
containment & structure
 On guardianship order in a placement with a
    locked solid entrance & fully enclosed courtyard
   Accompanied 1:1 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
Literature Review

    Pyromania /Arson / Fire-setting
              & Autism
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)
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)
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)
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).
Management & Rehabilitation


      Treatment Approaches
          Managing Risk
     Maintaining Quality Of Life
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.
Treatment Approaches 2

 SSRIs - pyromania & impulse control disorders
 mood stabilizers (e.g. lithium)
 Opioid antagonists (e.g. naltrexone) (Dell‟Osso
  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
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.
Assessing Risk -2
General Behaviour:
Personality
       Psychopathology
       Psychological function of the fire
Health
Family
Peers
Education
Employment
Behaviours
Assessing Risk -3

Fire History:
Early supervision
Fire safety
Early fascination
Previous fires
Parent responses
Group progressing to solitary
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
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
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
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).
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
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)
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.
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.
Thank you

				
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