Kleptomania

Kleptomania

Definition

Kleptomania shares with all other impulse control disorders the recurrent failure to resist impulses. Unfortunately, in the absence of epidemiological studies, little is known about kleptomania. Clinical case series and case reports are limited. Family, neuro-biological, and genetic investigations are not available. There are no established treatments of choice. Therefore, in reading this section the reader must keep in mind that much of what is de-scribed is based on limited data or on anecdotal information

Etiology and Pathophysiology

The etiology of kleptomania is essentially unknown, although various models have been proposed in an effort to conceptual-ize the disorder. The affective spectrum model suggests tha kleptomania and other impulse control disorders may share a common underlying biological diathesis with other disorders, such as depression, panic disorder, OCD and bulimia nervosa (McElroy et al., 1992; Hudson and Pope, 1990). In some indi-viduals, kleptomania responds to treatment with thymoleptic agents or electroconvulsive therapy. These observations are cited as support for an affective spectrum model.

Several lines of evidence support kleptomania as belonging to the obsessive-compulsive spectrum disorders. First, there are phenomenological similarities between the classical obsessions and compulsions of OCD and the irresistible impulses and repeti-tive actions characteristic of kleptomania. In addition, there ap-pears to be a greater than chance occurrence of OCD in probands with kleptomania and in their relatives. In addition, both condi-tions have significant comorbidity with mood, anxiety, substance use and eating disorders. However, OCD rituals are more clearly associated with relief of anxiety and harm avoidance, whereas kleptomanic acts seem to be associated with gratification or plea-sure. In addition, OCD is associated with a clear preferential re-sponse to SSRIs as opposed to general thymoleptics. The limited treatment literature does not support a similar response pattern in kleptomania. Unfortunately, the role of the serotonergic or of any other neurotransmitter system has not been investigated in kleptomania. Interestingly, a large study found subjects with mixed anorexia and bulimia nervosa to have a higher lifetime prevalence of kleptomania than those with either anorexia or bu-limia nervosa alone (Herzog et al., 1992). This could suggest a relationship between kleptomania and both the obsessive–com-pulsive (anorexic) and affective (bulimic) spectrum.

Alternatively, kleptomania could be conceptualized as an addictive disorder. The irresistible impulse to steal is reminis-cent of the urge and the high associated with drinking or using drugs. Marks (1990) has proposed a constellation of behavioral (i.e., nonchemical) addictions encompassing OCD, compulsive spending, gambling, binging, hypersexuality and kleptomania. This model postulates certain concepts thought to be common in all these disorders, such as craving, mounting tension, “quick fixing”, withdrawal, external cuing and habituation. These com-ponents have not yet been well investigated in kleptomania.

It should be emphasized that the lack of neurobiological or prospective pharmacological treatment data for kleptomania limits any conclusions that can be drawn with regard to biologi-cal models.

A frequent theme, reported by numerous authors is that of kleptomania as an acting-out aimed at alleviating depressive symptoms. From a psychodynamic point of view, kleptomania has been viewed over the decades as a manifestation of a variety of unconscious conflicts, with sexual conflicts figuring promi-nently in the literature. Case reports have described conscious sexual gratification, sometimes accompanied by frank masturba-tion or orgasm during kleptomanic acts (Fishbain, 1987). Thus, it has been suggested, kleptomanic behavior serves to discharge a sexual drive that may have forbidden connotations similar to those of masturbation, and the stolen object itself may have un-conscious symbolic or overt fetishistic significance. Although no systematic studies exist, there has long been an implication in the literature on kleptomania that those afflicted with klepto-mania suffer disproportionately from a variety of sexual dys-functions. Turnbull (1987) described six patients with a primary diagnosis of kleptomania, all of whom had dysfunctional sexual relationships with their partners, compulsive promiscuity, or anorgasmia.

Other cases of kleptomania have been understood as re-flecting conflictual infantile needs and attempts at oral gratifica-tion, masochistic wishes to be caught and punished related to a harsh guilt-inducing superego or primitive aggressive strivings, penis envy or castration anxiety with the stolen object represent-ing a penis, a defense against unwelcome passive homosexual longings, restitution of the self in the presence of narcissistic injuries, or the acquisition of transitional objects. One should probably conclude that the psychodynamics associated with kleptomania ought to be carefully tailored to the individual pa-tient. The literature on kleptomania has frequently implicated disturbed childhoods, inadequate parenting and significant char-acter disturbances in kleptomanic patients. From this perspective kleptomania can be more effectively understood in the context of an individual’s overall character. Unfortunately, no clinical stud-ies exist that systematically explore Axis II psychopathology in these patients.

Assessment and Differential Diagnosis

Phenomenology and Presentation

At presentation, the typical patient suffering from kleptomania is a 35-year-old woman who has been stealing for about 15 years and may not mention kleptomania as the presenting complaint or in the initial history. The patient may complain instead of anxi-ety, depression, lability, dysphoria, or manifestations of character pathology. There is often a history of a tumultuous childhood and poor parenting, and in addition acute stressors may be pres-ent, such as marital or sexual conflicts. The patient experiences the urge to steal as irresistible, and the thefts are commonly as-sociated with a thrill, a high, a sense of relief, or gratification. Generally, the behavior has been hard to control and has often gone undetected by others. The kleptomania may be restricted to specific settings or types of objects, and the patient may or may not be able to describe rationales for these preferences. Quite of-ten, the objects taken are of inherently little financial value, or have meaningless financial value relative to the income of the person who has taken the object. Additionally, the object may never actually be used. These factors often help distinguish theft from kleptomania. The theft is followed by feelings of guilt or shame and, sometimes, attempts at atonement. The frequency of stealing episodes may greatly fluctuate in concordance with the degree of depression, anxiety, or stress. There may be periods of complete abstinence. The patient may have a past history of psy-chiatric treatments including hospitalizations or of arrests and convictions, whose impact on future kleptomanic behavior can be variable.

Assessment

Generally, the diagnosis of kleptomania is not a complicated one to make. However, kleptomania may frequently go undetected because the patient may not mention it spontaneously and the psychiatrist may fail to inquire about it as part of the routine his-tory. The index of suspicion should rise in the presence of com-monly associated symptoms such as chronic depression, other impulsive or compulsive behaviors, tumultuous backgrounds, or unexplained legal troubles. It could convincingly be argued that a cursory review of compulsivity and impulsivity, citing multiple examples for the patient, should be a part of any thorough and complete psychiatric evaluation. In addition, it is important to make a careful differential diagnosis and pay attention to thevarious exclusion criteria before diagnosing theft as kleptoma-nia. Possible diagnoses of sociopathy, mania, or psychosis should be carefully considered. In this regard, the psychiatrist must in-quire about the affective state of the patient during the episodes, the presence of delusions or hallucinations associated with the occurrence of the behavior, the motivation behind the stealing, and the fate and subsequent use of the objects.

Although the typical patient may be a 35-year-old woman, it is important to remember that men, children and elderly per-sons may present with or engage in kleptomania. Interestingly, men may first present for evaluation 15 years later than women. Kleptomania occurs transculturally and has been described in various Western and Eastern cultures. Asian observers have also noted an overlap with eating disorders (Lee, 1994). Atypi-cal presentations should raise a greater suspicion of an organic etiology, and a medical evaluation is then indicated. Medical con-ditions that have been associated with kleptomania include cor-tical atrophy, dementia, intracranial mass lesions, encephalitis, normal-pressure hydrocephalus, benzodiazepine withdrawal and temporal lobe epilepsy. A complete evaluation when such suspi-cions are present includes a physical and neurological examina-tion, general serum chemistry and hematological panels, and an EEG with temporal leads or computed tomography of the brain.

Epidemiology and Comorbidity

Prevalence and Incidence

No epidemiological studies of kleptomania have been conducted, and thus its prevalence can be calculated only grossly and in-directly. Despite the lack of valid epidemiological data, there is general agreement that kleptomania is more common among women than among men. However, women generally seek psy-chiatric help more frequently than men, whereas men are more likely to become involved with the penal system. Consequently, this may not reflect true gender distribution.

Comorbidity

Among individuals with kleptomania who present for treat-ment, there is a high incidence of comorbid mood, anxiety and eating disorders, when compared with rates in the general population. Comorbidity patterns among individuals who pres-ent for treatment may be greater than among random samples. More reliable comorbidity rates can be found in a prospective investigation of 20 individuals with kleptomania conducted by McElroy and coworkers (1991a). Lifetime DSM-III-R comorbid-ity rates were 40% major depressive disorder, 50% substance abuse, 40% panic disorder, 40% social phobia, 45% OCD, 30% anorexia nervosa, 60% bulimia nervosa and 40% other impulse control disorders. Dissociative symptoms, significant charac-ter pathology and trauma histories are commonly encountered among this group.

Course

In two separate studies, the mean age at onset of kleptomania was reported to be 20 years (Goldman, 1991; McElroy et al., 1991a). The subjects included individuals who had begun stealing as early as 5 to 7 years of age. The disorder appears to be chronic, lasting for decades, albeit with varying intensity. Fifteen or 16 years may elapse before treatment is sought. Onset in and beyond the fifth decade of life appears to be unusual, and in some of these cases remote histories of past kleptomania can be elicitedAt peak frequency, McElroy and colleagues (1991a) found a mean of 27 episodes a month, essentially daily stealing, with one pa-tient reporting four acts daily. The majority of patients may even-tually be apprehended for stealing once or more, and a minority may even be imprisoned; more often than not these repercus-sions do not result in more than a temporary remission of the behavior. Individuals with kleptomania may also have extensive histories of psychiatric treatments, including hospitalization for other conditions, most commonly depression or eating disorders. Because of the unavailability of longitudinal studies, the progno-sis is not known. It appears, however, that without treatment the behavior may be likely to persist for decades, sometimes with significant associated morbidity. There may be transient periods of remission.

Treatment

Treatment Goals

The general goal of treatment is the eradication of kleptomanic behavior. Treatment typically occurs in the outpatient setting, unless comorbid conditions such as severe depression, eating disturbances, or more dangerous impulsive behaviors dictate hospitalization. The interview must be conducted in a respect-ful climate that ensures confidentiality. Patients not only may experience considerable guilt or shame for stealing but also may be unrevealing because of the fear of legal repercussions. In the acute treatment phase, the aim is to decrease significantly or, ideally, eradicate episodes of stealing during a period of weeks to months. Concurrent conditions may compound the prob-lem and require independently targeted treatment. The acute treatment of kleptomania has not been, to date, systematically investigated.

Psychiatrist–Patient Relationship

As with any condition that may be associated with intense guilt or shame, kleptomania must be approached respectfully by the psychiatrist. Patients can be reassured and their negative feel-ings alleviated to some degree with proper initial psychoeduca-tion. The treatment alliance can be strengthened by consistently maintaining a nonjudgmental and supportive stance. In addition, patients’ fears regarding breaks of confidentiality and criminal repercussions must be addressed.

No treatments have been systematically shown to be effective for kleptomania. These treatment recommendations are supported by case reports and retrospective reviews only. In general, it appears that thymoleptic medications and behavioral therapy may be the most efficacious treatments for the short term, whereas long-term psychodynamic psychotherapy may be indi-cated and have good results for selected patients.

Pharmacological and Somatic Treatments

Mixed results have been reported regarding the pharmacological treatment of kleptomania. In a literature review of 56 cases of kleptomania, McElroy and coworkers (1991b) noted that somatic treatments were described for eight patients. Significant improve-ment was reported for seven of these. Treatment included antide-pressants alone, antidepressants combined with antipsychotics or stimulants, electroconvulsive therapy alone, or electroconvulsive therapy with antidepressants. It is still unclear whether kleptoma-nia responds preferentially to serotonergic antidepressants, and this question awaits further study. Other agents reported to have treated kleptomania successfully include nortriptyline and ami-triptyline. In addition, it remains unclear if the antikleptomanic effect of thymoleptics is dependent on or independent of their antidepressant effect.

A number of other medications have been employed to treat kleptomania. These include antipsychotics, stimulants, valproic acid, carbamazepine, clonazepam and lithium. Lithium augmentation may be of benefit when kleptomania does not re-spond to an antidepressant alone. Finally, there have been some reports of successful treatment of kleptomania with electrocon-vulsive therapy, which may have been administered for a concur-rent mood disorder.

Although little is known about maintenance pharmacolog-ical treatment for kleptomania, there is a suggestion in the litera-ture that symptoms tend to recur with cessation of thymoleptic treatment and again remit when treatment is reinstituted.

Psychosocial Treatments

Formal studies of psychosocial interventions for kleptomania have not been performed. However, a number of clinical reports have supported behavioral therapy for kleptomania. The avail-able clinical literature suggests that for most patients this may be a more efficacious approach than insight-oriented psycho-therapy. Different behavioral techniques have been employed with some success, including aversive conditioning, systematic desensitization, covert sensitization and behavior modification. In their review of 56 reported cases of kleptomania, McElroy and colleagues (1991a) noted that the eight patients who were treated with behavioral therapy – mostly aversive conditioning – showed significant improvement. We give here some specific examples of behavioral techniques that have been successfully employed and described. One patient was taught to hold her breath as a negative reinforcer whenever she experienced an impulse to steal. Another patient was taught to use systematic desensitization techniques to control the mounting anxiety as-sociated with the impulse to steal. A patient treated by covert sensitization learned to associate images of nausea and vomit-ing with the desire to steal. A woman who experienced sexual excitement associated with shoplifting and would masturbate at the site of the act was instructed to practice masturbation at home, while fantasizing kleptomanic acts. There is a suggestion in the literature that these techniques remain effective over the long term.

Finally, it appears that the most effective behavioral treat-ment of all may be complete abstinence, that is, the patient should no longer visit any of the stores or settings where kleptomanic acts occur. A number of patients who never come to psychiatric attention apparently employ this technique successfully, and it may be an appropriate treatment goal if it does not result in ex-cessive restrictions of activity and lifestyle.

The psychodynamic treatment of kleptomania centers on the exploration and working through of the underlying conflict or conflicts. There are case reports in the literature of successful psychodynamic treatment of kleptomania. Such treatment, pos-sibly in combination with other approaches, may be indicated for patients for whom a clear conflictual basis for the behavior can be formulated, who also have the needed insight and motivation to undertake this type of treatment. In proposing such treatments, which may be long term, the psychiatrist should consider whether there are immediate risks that must be addressed, such as a high risk of legal consequences.

Special Treatment Considerations

Little is known about treating kleptomania and therefore special treatment considerations have not been elucidated. However, it is clear that comorbid conditions, such as depression, bulimia ner-vosa, OCD, or substance abuse, must be addressed along with the kleptomania. In addition to the inherent suffering and morbidity of these other disorders, their course and severity could compound the kleptomanic behavior. In the rare cases of a precipitating or exacerbating organic etiology, the underlying organic cause must be treated. In addition, the treatment of particular groups such as children or the elderly should take into account special contribut-ing life stage or situational factors. The involvement of family or others on whom the patient is dependent may be indicated.