JOURNAL OF CHILD AND ADOLESCENT PSYCHOPHARMACOLOGY
Volume 21, Number 4, 2011
ª Mary Ann Liebert, Inc.
Pp. 381–382
DOI: 10.1089/cap.2010.0141
Pyromania Associated with Escitalopram in a Child
Mehmet Fatih Ceylan, M.D.,1 _Ibrahim Durukan, M.D.,2
Tümer Türkbay, M.D.,2 Omer Faruk Akca, M.D.,2 and Koray Kara, M.D.2
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 fi-
nancial gain, vengeance, or political extremism. The subject shows
interest in observing fires and feelings related with increased ten-
sion 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 de-
pression. 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 Sta-
tistical 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 interven-
tions 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
1
Department of Child and Adolescent Psychiatry, Kayseri Education and Research Hospital, Kayseri, Turkey.
2
Department of Child and Adolescent Psychiatry, Gulhane Military Medical Academy, Ankara, Turkey.
381
had started to set fires at approximately 10 days after starting esci-
talopram 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 esci-
talopram. 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 psy-
chopathological 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 dis-
inhibited individuals ( Jacobson 1985). Behaviorally inhibited
children are cowardly, poised, and shy and do not attempt dan-
gerous 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 administra-
tion. Therefore, actions that he wanted to do but could not normally
bring himself to do may have emerged. Disappearance of this be-
havior after cessation of escitalopram medication supports this
suggestion. High levels of aggressiveness, shyness, and peer re-
jection 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
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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 con-
trolled pharmacological trial has yet been conducted in patients with
pyromania. Nonpharmacological interventions for firesetters, includ-
ing 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 Psy-
chiatric Association 2000). However, firesetting related to medi-
cation 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.
Disclosures
The authors have nothing to disclose related to institutional or
corporate/commercial relationships. The authors did not receive
any support from any grant, funding source, or pharmaceutical
company. None of authors has financial relationships with any
pharmaceutical company.
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Address correspondence to:
Mehmet Fatih Ceylan, M.D.
Department of Child and Adolescent Psychiatry
Kayseri Education and Research Hospital, 38010
Kayseri
Turkey
E-mail: fatihceylan80@yahoo.com