Prevalence and Correlates of Fire-Setting in the United States: Results From the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)
Objective: To estimate the prevalence, sociodemographic correlates, comorbidity, and rates of mental health service utilization of fire-setters in the general population.
Method: A face-to-face survey of more than 43,000 adults aged 18 years and older residing in households was conducted during the 2001–2002 period. Diagnoses of mood, anxiety, substance use disorders, and personality disorders were based on the Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV Version (AUDADIS-IV).
Results: The prevalence of lifetime fire-setting in the US population was 1.13 (95% CI, 1.0–1.3). Being male, never married, and US-born and having a yearly income over $70,000 were risk factors for lifetime fire-setting, while being Asian or Hispanic and older than 30 years were protective factors for lifetime fire-setting. The strongest associations with fire-setting were with disorders often associated with deficits in impulse control, such as antisocial personality disorder (ASPD) (odds ratio [OR] = 21.8; CI, 6.6–28.5), drug dependence (OR = 7.6; 95% CI, 5.2–10.9), bipolar disorder (OR = 5.6; 95% CI, 4.0–7.9), and pathological gambling (OR = 4.8; 95% CI, 2.4–9.5). Associations between fire-setting and all antisocial behaviors were positive and significant. A lifetime history of fire-setting, even in the absence of an ASPD diagnosis, was strongly associated with substantial rates of Axis I comorbidity, a history of antisocial behavior, a family history of other antisocial behaviors, decreased functioning, and higher treatment-seeking rates.
Conclusions: Our findings suggest that fire-setting may be better understood as a behavioral manifestation of a broader impaired control syndrome and part of the externalizing spectrum. Fire-setting and other antisocial behaviors tend to be strongly associated with each other and increase the risk of lifetime and current psychiatric disorders, even in the absence of a DSM-IV diagnosis of ASPD.
J Clin Psychiatry 2010;71(9):1218–1225
© Copyright 2010 Physicians Postgraduate Press, Inc.
Submitted: October 20, 2008; accepted April 21, 2009.
Online ahead of print: February 23, 2010 (doi:10.4088/JCP.08m04812gry).
Corresponding author: Carlos Blanco, MD, PhD, New York State Psychiatric Institute, 1051 Riverside Drive, Box 69, New York, NY 10032 (firstname.lastname@example.org).
Fire-setting, defined as starting a fire on purpose to destroy someone else’s property or just to see it burn, often results in property damage, injury, or death of the fire-setter or other people.1 Fire-setting and pyromania are sometimes used synonymously, yet there are important differences between them. Fire-setting is defined by a behavior, regardless of its motivation. By contrast, pyromania has a narrower meaning and refers to a psychiatric diagnosis characterized by recurrent failure to resist impulses to set fires, tension before setting the fire, and satisfaction and relief after doing it.2 Furthermore, the fire is not set to express anger or vengeance or to improve one’s living circumstances. Nationally, an estimated 31,500 fires are set intentionally in any given year. These fires lead to several hundred civilian deaths each year and close to 1 billion dollars in property loss, making fire-setting in the United States a problem of national importance.3 Some data suggest that the incidence of fire-setting may be increasing.4,5
Along with enuresis and cruelty with animals, fire-setting is 1 of the 3 behaviors commonly referred as the McDonald triad for sociopathy.6 In a recent study, Dadds and Fraser7 found that fire-setting in childhood was associated with chronic antisocial behavior. Not surprisingly, people who intentionally set fires often experience severe social and legal problems. Moreover, fire-setting appears to be related to emotional distress, but the relationship of fire-setting to other behaviors and psychiatric disorders is poorly understood.1 Previous studies have suggested that the lifetime prevalence of fire-setting may be 3%–26% in psychiatric patients8,9 and that a history of fire-setting may be more common among unemployed, unmarried male youths.1,10,11 Partially based on those studies, it has been hypothesized that fire-setting may be a manifestation of impulsivity,12–14 psychopathy,15 or affective16,17 or obsessive- compulsive spectrum disorder.18 However, because prior research was conducted almost exclusively on clinical samples or on convicted arsonists,11,13,19 the prevalence, demographic correlates, comorbidity, and rates of mental health service utilization of fire-setters in the general population are unknown.
The purpose of this study was to fill these gaps in knowledge. Specifically, we sought to (1) estimate the prevalence and demographic correlates of fire-setting in the general population, (2) examine antisocial behaviors associated with fire-setting, (3) investigate the lifetime and 12-month prevalence of psychiatric disorders associated with fire-setting and level of psychosocial functioning in individuals with a lifetime history of fire-setting, and (4) estimate lifetime prevalence and 12-month rates of mental health treatment-seeking among individuals with a lifetime history of fire-setting.
The 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) is a nationally representative sample of the adult population of the United States conducted by the US Census Bureau, under the direction of the National Institute of Alcoholism and Alcohol Abuse (NIAAA), as described in detail elsewhere.20,21 The research protocol, including informed consent procedures, received full ethical review and approval from the US Census Bureau and the US Office of Management and Budget.
Sociodemographic measures included age, sex, race/ ethnicity, nativity (US-born vs foreign-born), marital status, place of residence, and region of the country. Socioeconomic measures included education, family income measured as a continuous variable, and insurance type.
All lifetime psychiatric diagnoses were made according to DSM-IV criteria using the NIAAA Alcohol Use Disorder and Associated Disabilities Interview Schedule-DSM-IV version (AUDADIS-IV), a valid and reliable fully structured diagnostic interview designed for use by professional interviewers who are not clinicians. Diagnoses included in the AUDADIS-IV can be separated into 3 groups: (1) substance use disorders (including any alcohol abuse/dependence, any drug abuse/dependence, and any nicotine dependence); (2) mood disorders (including major depressive disorder, dysthymia, and bipolar disorder); and (3) anxiety disorders (including panic disorder, social anxiety disorder, specific phobia, and generalized anxiety disorder). The test-retest reliability and validity of AUDADIS-IV measures of DSM-IV disorders are adequate, as detailed elsewhere.22–28 Test-retest reliability and validity were good for major depressive disorder (κ = 0.65–0.73)22 and reliability (κ > 0.74) and validity were good to excellent for substance use disorders.22–24,29 Reliability was fair to excellent for other mood and anxiety disorders (κ = 0.40–0.60) and personality disorders (κ = 0.40–0.67).22,23 Due to concerns about the validity of psychotic diagnoses in general population surveys, as well as length of the interview, possible psychotic disorders were assessed by asking the respondent if the respondent was ever told by a doctor or other health professional that he or she had schizophrenia or a psychotic disorder.
Embedded in the antisocial personality disorder section was the following question: “Did you ever start a fire on purpose to destroy someone else’s property or just to see it burn?” This was queried to all NESARC respondents. Individuals who answered yes to this question were further asked, “Has this happened since you were 15?” While test-retest reliability of individual items is unavailable, the computed Cronbach α for the ASPD symptoms was 0.86, indicating excellent internal consistency for the ASPD section. This value was unchanged when the fire-setting item was excluded, suggesting high reliability for the item. All respondents on the NESARC were asked about a lifetime history of a broad range of other antisocial behaviors, as well as family history of antisocial behavior. The NESARC interview also used the Short Form 12v2 (SF-12v2) to generate measures of disability using the Physical Component Summary (PCS), Mental Health scale, Role Emotional scale, and Social Functioning scale. The Short Form-12v2 is a reliable and valid measure of current disability widely used in population surveys.30,31
To estimate rates of mental health service utilization, respondents were classified as receiving treatment if they sought help from a counselor, therapist, doctor, or psychologist or from an emergency room; if they reported being hospitalized for a psychiatric disorder at least 1 night; or if they reported being prescribed medications for a psychological problem.
Weighted percentages and means were computed to derive sociodemographic and clinical characteristics of respondents with and without a lifetime history of fire-setting. Standard errors and 95% CIs for all analyses were estimated using SUDAAN,32 a software package that uses Taylor series linearization to adjust for the design effects of complex sample surveys like the NESARC. Because the combined standard error of 2 means (or percentages) is always equal to or less than the sum of the standard errors of those 2 means, we conservatively consider that 2 CIs that share a boundary or do not overlap to be significantly different from one another.33 We consider ORs significant whose CIs do not cross 1.33 Logistic regressions were conducted to adjust the ORs for sociodemographic variables that were significantly different between individuals with and without lifetime history of fire-setting.
To examine whether the correlates of fire-setting were due to its association with antisocial personality disorder (ASPD), all analyses were repeated excluding individuals with a diagnosis of ASPD. Because these 2 sets of analyses resulted in a nearly identical pattern of significant ORs, only the results from the full sample are presented.
Table 1 shows prevalence and sociodemographic characteristics of individuals with and without a lifetime history of fire-setting. The overall lifetime prevalence of fire-setting in the general population was 1.13%. When individuals with ASPD where excluded from the analysis, fire-setting prevalence decreased by about half, to 0.55%. As shown in Table 1, rates of lifetime history of fire-setting were significantly higher in men than women. Being never married, US-born, or with a yearly income over $70,000 also increased the risk for fire-setting. Furthermore, rates of lifetime history of fire-setting were significantly lower in blacks, Hispanics, and Asians when compared with non-Hispanic whites, in respondents aged 30 years and older relative to those from 18 to 29 years old and to respondents living in the Northeast, Midwest, and South of the US when compared with those living in the West region of the country.
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Table 2 shows that, in most cases, individuals reported fire-setting occurring before age 15 but, in a substantial proportion of the cases (38%), fire-setting persisted after that age. Individuals with a history of fire-setting were more likely to have a family history of antisocial behaviors, as shown by both the adjusted ORs (AORs) and unadjusted ORs.
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Associated Antisocial Behaviors
Table 2 describes clinical characteristics of individuals with and without a lifetime history of fire-setting. The prevalence of all antisocial behaviors was higher among individuals with a history of fire-setting than among those without it. For both groups, the most common behavior was staying out at night against parental advice, which was endorsed by 61.4% of individuals with a history of fire-setting and 21.5% of those without a history of fire-setting. The behavior most strongly associated with fire-setting, as measured by the OR, was destroying other people’s property (OR = 29.5). Even after adjustment for sociodemographic factors, this association remained strong and significant (AOR = 18.4). Besides destroying someone’s property, the behaviors more strongly associated with fire-setting were robbing, mugging, or purse-snatching (OR = 19.4) and harassing, threatening, or blackmailing someone (OR = 18.0). When respondents with ASPD were excluded from the analyses, individuals with a history of fire-setting continued to show significantly greater rates of every antisocial behavior assessed than those individuals without a history of fire-setting (data available upon request).
Comorbidity and Treatment-Seeking
The vast majority of individuals with a lifetime history of fire-setting (95.1%) had a lifetime history of at least 1 psychiatric diagnosis (Axis I or II diagnosis), compared to 53.5% of the individuals who did not endorse ever intentionally setting a fire (Table 3). Both lifetime Axis I and Axis II disorders were more common among fire-setters than among nonfire-setters (90.9% vs 51.2% for Axis I, and 68.9% vs 14.5% for Axis II disorders, respectively). In both groups, the most prevalent disorder category was “any alcohol use disorder.” However, the strongest associations between fire-setting and any psychiatric diagnoses were found for ASPD even when adjusting for sociodemographic characteristics (AOR = 21.8) and drug dependence (AOR = 7.6). Other disorders often associated with deficits in impulse control, such as pathological gambling (AOR = 4.8) and bipolar disorder (AOR = 5.7) were also strongly associated with fire-setting when sociodemographic characteristics were adjusted for. Associations with anxiety disorders, although also significant, were of smaller magnitude.
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As shown in Table 4, a similar pattern was observed when examining current, rather than lifetime, comorbid diagnoses of Axis I disorders in adjusted ORs. Individuals with a history of fire-setting were significantly more likely than those without a history of fire-setting to have lower scores on Social Functioning, Role Emotional, and Mental Health scales on the SF-12 v2 after sociodemographic characteristics were adjusted for.
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Table 5 shows treatment-seeking characteristics of individuals with a lifetime history of fire-setting. Lifetime rates of mental health treatment-seeking were significantly higher among fire-setters than among the individuals without a lifetime history of fire-setting across all treatment settings regardless of whether lifetime or past-year timeframe was considered (45.7% versus 18.8%, respectively). Similarly, fire-setting in the absence of ASPD was significantly associated with lifetime and current psychiatric disorders, social and mental health low scores, and mental health service utilization even after adjusting for sociodemographic factors (data not shown).
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This is the first national study to examine the prevalence and characteristics of fire-setting in the US general population. We found that (1) the prevalence of fire-setting in the general population was about 1%; (2) individuals with a lifetime history of fire-setting, even those without ASPD, were more likely than the individuals without a history of fire-setting to engage in other antisocial behaviors; (3) almost all individuals with a lifetime history of fire-setting had lifetime or current psychiatric comorbidity (even when those with ASPD were excluded from the analysis); and (4) approximately half of the individuals with a lifetime history of fire-setting have used mental health services at some point of their lives, more than 3 times the rate in individuals without a history of fire-setting.
Confirming results from clinical samples,11 we found that individuals with a history of fire-setting were more likely than those without a history of fire-setting to be male, young, and never married. Sex differences may be due a greater rate of impulsivity and risk-taking behaviors among men,34,35 while the relationship of a lifetime history fire-setting and young age in this study may indicate a birth cohort effect of the youngest group, a recall bias of remote events, or higher mortality of fire-setters in the oldest age group.36 Although about 60% of cases of fire-settings occurred before age 15, almost 40% of the cases persisted after that age.
In accord with previous research in clinical samples,11,13,37,38 we found that individuals with a history of fire-setting were significantly more likely to have other psychiatric disorders associated with impaired impulse control, such as substance use disorders, bipolar disorder, pathological gambling, and ASPD, even after adjusting for other psychiatric disorders. Dysthymia and anxiety disorders had the weakest association with fire-setting in this study. Although obsessive-compulsive disorder was not assessed in the NESARC, obsessive-compulsive personality disorder (OCPD) was. Fire-setting was significantly associated with OCPD, but its association with ASPD was much stronger, suggesting that fire-setting may be closer to disorders of impulsivity than to obsessive-compulsive spectrum disorders. These findings are supported by the strong association of fire-setting with other antisocial behaviors reported in this study. Overall, these data are consistent with prior research indicating that antisocial behavior, substance use, and impulsivity share a common underlying vulnerability.39–41 These findings suggest that fire-setting may be better understood as a behavioral manifestation of a broader impaired control syndrome and part of the externalizing spectrum rather than the internalizing spectrum disorders.
The finding that a lifetime history of fire-setting and a family history of antisocial behaviors, even in the absence of an ASPD diagnosis, were strongly associated with a history of other antisocial behaviors and substantial Axis I comorbidity, raises questions about the current conceptualization of ASPD. About one half of the individuals with a lifetime history of fire-setting met criteria for ASPD. Removal of those individuals from the analysis diminished the strength but not the direction or significance of our findings regarding psychiatric comorbidity, associated antisocial behaviors, or treatment-seeking (data available upon request). Consistent with the recommendations of the DSM-V Research Planning Nomenclature Work Group to conduct research on dimensional models of existing typologies42,43 and specifically on the conceptualization of ASPD44,45 and on the broader category of externalizing disorders,39,45 our findings suggest that antisocial behaviors tend to be strongly associated with each other and increase the risk of lifetime and current psychiatric disorders, even in the absence of a DSM-IV diagnosis of APSD. These findings underscore the importance of antisocial syndromes of behaviors currently considered subthreshold. There may be certain nosologic advantages of a dimensional rather than a categorical conceptualization of ASPD.46 Future research should examine the clinical, research and policy-making utility of dimensional, categorical, or a combination of both approaches to better define ASPD and the implications of selecting specific diagnostic thresholds.
Our study also identified higher rates of lifetime and past-year treatment utilization across a broad range of service settings. Respondents in the NESARC study were not specifically asked whether they sought treatment for other reasons but rather if they sought treatment for any Axis I disorder. Based on prior reports,1 it appears that very few individuals seek treatment for fire-setting, and, when they seek treatment for other reasons, they are rarely queried about their history of fire-setting behavior. Given the high rates of comorbidity, disability, and treatment utilization of individuals with a lifetime history of fire-setting documented in this study, it seems important to screen for a history of fire-setting among psychiatric patients.
This study has the limitations common to most large-scale surveys. First, information was based on self-report, potentially resulting in overestimation or underestimation of the true rates of fire-setting. The NESARC did not examine the reliability of individual items. However, the ASPD module of the AUDADIS, which contained the fire-setting questions, had a κ = 0.67, which compares favorably with other standardized assessments of ASPD.29 Furthermore, the reliability of the ASPD module, as measured by Cronbach α, was 0.86, and it did not change whether or not the fire- setting questions were included in the calculation, supporting the reliability of the fire-setting questions. Third, because the NESARC sample included only civilian households and quarters populations, information on individuals in prison, who may have higher rates of fire-setting, was unavailable. Fourth, frequency, severity, and the negative consequences of fire-setting were not assessed, leaving the possibility that the behavior occurred only once in the individual’s life and/or might not have resulted in substantive damages. Even with this broad definition, the results of the study suggest that a lifetime history of fire-setting is strongly associated with high rates of psychopathology and treatment-seeking. At present, little is known about fire-setting or pyromania in the general population. Longitudinal data are needed to examine the course of fire-setting and to distinguish individuals with fire-setting from those who develop pyromania. Differences between individuals who set fires and those with the diagnosis of pyromania could inform the need for a broader definition of DSM-IV pyromania. Fifth, Wave 1 of the NESARC did not include data on borderline personality disorder or attention-deficit/hyperactivity disorder, both of which are associated with high levels of impulsivity. Finally, because the questions about fire-setting were embedded in the ASPD module, the associations detected in this study could have been better explained as correlates of ASPD. However, removal of individuals with ASPD did not change the pattern of associations, suggesting that our findings reflect true associations with fire-setting. Future research should evaluate whether the associations found in this study could be also be explained as correlates of pyromania.
Despite these limitations, our study constitutes a critical step toward improving the understanding of the prevalence and characteristics of fire-setting behavior in the United States. The study found high rates of other antisocial behaviors and comorbidity with externalizing spectrum disorders in a large, nationally representative sample of the general population. Given the legal and social consequences of fire-setting, its associated disability and high rates of treatment-seeking, and its cost to society, the results of this study suggest that more attention may be needed to address the needs of individuals with a history of fire-setting.
Author affiliations: Department of Psychiatry, New York State Psychiatric Institute, College of Physicians and Surgeons of Columbia University, New York (Drs Blanco, Simpson, and Hasin and Mss Alegría and Liu); University of Connecticut Health Center, Farmington (Dr Petry); Department of Psychiatry, University of Minnesota, Minneapolis (Dr J. Grant); and Laboratory of Epidemiology and Biometry, Division of Intramural Clinical and Biological Research, National Institute on Alcohol Abuse and Alcoholism (NIAAA), National Institutes of Health (NIH), Bethesda, Maryland (Dr B. Grant).
Potential conflicts of interest: Dr Blanco has received grant/research support from Pfizer and GlaxoSmithKline. Dr Jon Grant has received grant/research support from Forest, Somaxon, and GlaxoSmithKline. Dr Simpson has received grant/research support and study medication from Janssen and has been a member of the Scientific Advisory Board for Jazz. Drs Bridget Grant, Hasin, and Petry and Mss Alegría and Liu report no financial or other relationship relevant to the subject of this article.
Funding/support: This study is supported by NIH grants DA019606, DA020783, DA023200, MH076051 (Dr Blanco) and AA014223 (Dr Hasin), a grant from the American Foundation for Suicide Prevention (Dr Blanco), and the New York State Psychiatric Institute (Drs Blanco, Hasin, and Simpson). The National Epidemiologic Survey on Alcohol and Related Conditions was funded by the NIAAA, with supplemental support from the National Institute on Drug Abuse.
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