Introduction
Although kleptomania, the irresistible impulse to steal objects not needed for personal use or for their monetary value, is currently classified in psychiatric nomenclature as an impulse control disorder, research suggests it is, rather, a variant of obsessive-compulsive disorder. The principle effects of the theft are repetitive, unwanted intrusions of thoughts, and an inability to avoid the compulsion to perform the theft, and the relief of tension following the act (Dannon, 2002). Comparison of both disorders, their comorbidity with other psychiatric disorders, and the treatment used to reduce and eliminate symptoms may have a baring on the “correct” classification.
Kleptomania, listed in the DSM-IV as an impulse control disorder not elsewhere classified, is a psychiatric condition still poorly understood and subject of only a few systematic studies (Presta, Marazziti, Dell‘Osso, Pfanner, Pallanti, & Cassano, 2002). Kleptomania is characterized by the persistent impossibility to resist the drive to steal objects. Kleptomania should be distinguished from shoplifting, in which the action is usually well-planned and motivated by need or monetary gain. Often a kleptomaniac steals things he or she could have easily bought or things that are not expensive. The objects stolen are not stolen for their immediate utility or monetary value; on the contrary, the person will most likely discard them, give them away, or collect them. This behavior is usually associated with a sense of satisfaction during and immediately after its accomplished. Stealing is not done to express anger or vengeance nor is it a response to delirium or hallucination (Cardoso, 1997). Most patients with this disorder seem to be women; their mean age is about 36 and their mean duration of illness is roughly 16 years.
Some individuals report the onset of kleptomania as early as age five, but on average, it seems to appear around adolescence and early adulthood (PsychNet-UK, 2003).
Since the thefts of the kleptomanic person cannot be explained by Antisocial Personality Disorder, Conduct Disorder, or a Manic Episode and involve the inability to control ones impulse to steal, it is classified as an impulse control disorder. The core feature of ICDs is the repeated expression of impulsive acts that lead to physical or financial damage to the individual or another person (TEXT). Since kleptomania represents this quality and shares the three characteristics of impulse control disorders one would easily agree with this classification. This being a failure to resist an impulse or temptation to perform some act, although they know the act is considered wrong by society or is harmful to them, experiencing tension or arousal before the act, and after committing the act there is a sense of excitement, gratification, or release that is felt (TEXT).
By definition, obsessive-compulsive disorder is closely linked to kleptomania. The two-part disorder contains obsessions, which are intrusive, repetitive thoughts or images that produce anxiety, and compulsions, which is the need to perform acts or to dwell on thoughts to reduce anxiety (TEXT). Obsessions can be broken down into two distinct subtypes. One being, autogenous obsessions, which tend to come abruptly into consciousness without identifiable evoking stimuli, which are perceived as ego-dystonic (considering the thoughts and actions alien and not subject to his or her voluntary control) and aversive enough to be repelled, and include sexual, aggressive, and immoral thoughts or impulses (Lee & Kwon, 2003). On the other hand, reactive obsessions are evoked by identifiable external stimuli, which are perceived as relatively realistic and rational enough to do something toward the stimuli, and include thoughts about contamination, mistake, accident, asymmetry, loss, etc (Lee & Kwon, 2003). Some clinicians view kleptomania as part of the obsessive-compulsive spectrum of disorders, reasoning that many individuals experience the impulse to steal as ego-dystonic (PsychNet-UK, 2003). For example, Dannon (2002) believed that pathological stealing resembled OCD in the experience of tension before the act and feature of a struggle to oppose the drive.
Taking a psychodynamic perspective of both obsessive-compulsive disorder and kleptomania, there is reason to derive a strong correlation between the two. For instance, the psychodynamic perspective suggests that obsessive-compulsive behaviors are attempts to fend off anal sadistic (antisocial), anal libidinous (pleasure soiling), and genital (masturbatory) impulses. The psychodynamic etiology of kleptomania has historically been linked to “ungratified sexual instinct” (Fishbain, 1987). A review of a case report of a woman, G.Z., who had kleptomania and only experienced orgasm when apprehended for stealing and the feelings of “shoplifting whenever levels of internal tension increased” (Fishbain, 1987), suggests that kleptomania may be more closely linked to OCD. The risk taking involved caused G.Z. to experience an extreme sexual thrill. Also, Fenichel (1945) reported the case of a woman who obtained a sexual thrill from shoplifting, to the point of orgasm, and had fantasies of shoplifting while masturbating. Abraham (1948) also reports that the stealing of a kleptomaniac represented doing a “forbidden thing secretly” such as masturbation. Holding the psychoanalytic perspective that these behaviors are a reflection of unconscious ego defenses against anxiety, forbidden instincts or wishes, unresolved conflicts or prohibited sexual drives, fear of castration, sexual arousal, sexual gratification and orgasm during the act of stealing, kleptomania would be classified as an obsessive-compulsive disorder.
Another correlational aspect linking kleptomania to OCD is seen in the biological perspective on obsessive-compulsive disorders, which bases assumptions on data relating to brain structure, genetic studies and biological chemical abnormalities. Recent preliminary studies of the brain using magnetic resonance imaging showed that the subjects with OCD had significantly less white matter than did normal control subjects, suggesting a widely distributed brain abnormality associated with OCD (Point, 2001-2003). Researchers hypothesize that OCD is a result of serotonin deficiency (TEXT). The use of selective serotonin reuptake inhibitors both with patients suffering from OCD and in patients with kleptomania is a key link to the relationship between the two. For example, fluoxetine has been used in both treatment for OCD and also for kleptomania. The use of fluoxetine (a medication that increases the activity level of serotonin) reported that the cerebral blood flow to the frontal lobes was decreased to values found in individuals without the disorder and patients with obsessive-compulsive disorder reported a reduction in symptoms (TEXT). Dannon (2002) states that biological etiology stems from different levels of serotonin in the brain synapses, which leads to many psychiatric disorders.
Treatment of kleptomania, since the disease is considered extremely rare, having a prevalence of only 1- 8% in cases of all shoplifters, in based a great deal on trial and error. In a diagnostic layout of kleptomania, Grant and Kim (2002) recommend a series of options, beginning with a review of the patient’s history, identifying the motivation for stealing. Patient education is also seen as a must, since many suffering from kleptomania feel alone in the struggle to ward off the impulses. It is necessary to explain that kleptomania is a treatable disease and to provide the patient with adequate connections to educational and supportive information resources. Books, websites, support groups are all options to give them. Behavioral therapy, which involves seeing the theft as an unconscious process, analyzing it as such, and emphasizing the importance of finding another occupation to replace the stealing activity, has been approached using a method called “exposure and response prevention.” The patient deliberately and voluntarily confronts the feared object or idea, either directly or by imagination. Studies have found successful treatment for the majority (Point, 2001- 2003). In recent cases for kleptomania, an expansion of behavioral therapy, known as cognitive-behavioral therapy, has been used more often. CBT involves covert sensitization, exposure and response prevention, and imaginal desensitization (Grant & Kim, 2002). Treatment for OCD patients is handled much in the same way, providing four levels in which you start with the education and rationale for exposure and response prevention. An exposure hierarchy is then developed and exposure to feared situations is administered until anxiety has diminished, and then refraining from rituals can be done (TEXT).
Current knowledge of psychopharmacological treatment of kleptomania has, for the majority of the time, been taken from case reports or from material collected from group studies. A study done by Young (2002) on the alterations in brain tryptophan levels was shown to cause changes in brain serotonin synthesis. The study revealed that low serotonin levels could predispose subjects to mood and impulse control disorders. A close resemblance between kleptomania and affective disorders has led to treatment with antidepressants and ECT, lithium, and valproic acid. Medications generally used for treatment of kleptomania include tricyclicantidepressants (imipramine, nortriptyline), SSRIs (fluoxetine, fluvoxamine, paroxetine), the opoid antagonist (naltrexone), and mood stabilizers (lithium, valproate) (Grant & Kim, 2002). All of which have met with varying degrees of success. Several recent cases reports suggest that SSRIs are the most effective in the treatment of disorders in the OCD spectrum and especially in kleptomania. Responses to the use of SSRIs are usually characterized by a decrease in thoughts about stealing, a decrease in stealing behavior, and an improvement in social and occupational functioning (Grant & Kim, 2002). In a study conducted by Lupkifer (1999) testing the effectiveness of serotonin reuptake inhibitors (SSRIs) on the symptoms of kleptomania, reported that in combination with a psychotherapeutic intervention successful decreases and elimination of the urge to steal resulted. Such SSRIs recently tested with kleptomania are fluoxetine (Prozac) and paroxetine. As a single-drug treatment with fluoxetine, a case series, the largest ever documented, reporting the result of biological treatment in 20 kleptomanic patients, proved effective in two cases (McElroy, Pope, & Hudson, 1991). With further treatment tests, fluoxetine proved effective in combination with other forms of medication, such as imipramine and lithium (McElroy & Pope, 1990). Kraus (1999) concluded that treatment of kleptomania with paroxetine provided remission of depressive symptoms and almost complete extinction of stealing impulses. Lepkifer and colleagues also found a reduction in the use of paroxetine when used in combination with alprazolam (1999). Another case report by Dannon et al, showed successful results with paroxetine in combination with naltrexone, a medication commonly used to treat substance abuse disorders, mostly for patients with alcohol abuse. The curative effect of naltrexone is attributed to the reduction of urge symptoms associated with impulse control disorders. Studies done by Dannon et al (1999) and Kim & Grant (2002) reported significant improvement in kleptomanic patients using naltrexone. A possible cause for the efficacy of naltrexone may be due to the fact that “naltrexone inhibits dopamine release in the nucleus accumbers through disinhibition of GABA input to the dopamine neurons in the ventral tegmental area.” Or possibly that there is a reduction in both urges and the subjective experience of pleasure in impulse control disorders in resultant (Dannon, 2002).
The comorbidity of kleptomania with various other psychiatric disorders may play a role in the classification in the DSM-IV. Numerous studies have been done to prove this correlation and the highest comorbidity with all is a link between kleptomania and mood disorders, eating disorders, anxiety disorders, and abuse of alcohol and other psychoactive substances, as shown by Kidler (1997), Grant & Kim (2002), and Dannon (2002). Some evidence suggests that kleptomania may be related to, or a variant of, mood disorders, such as depression. A review of 20 case studies by Russell (1973) of shoplifters showed unfilled emotional needs, matrimonial stress, loneliness, and depression as frequent predisposing factors. Evidence of this predisposition can be seen in the case study of G.Z. (Fishbain, 1987), in which the close association of depression and kleptomania showed that kleptomanic behavior may have served as an antidepressional effect because of the thrill aspects involved in the risk taking and association of this thrill for sexual excitement. A study on 20 outpatients with a lifetime diagnosis of kleptomania by DSM-IV criteria, in which they underwent a specially designed semi structured interview and the Family History Research Diagnostic Criteria, showed a lifetime comorbidity with other axis I disorders as being high, particularly for mood, anxiety, and impulse control disorders. In a related study that assessed compulsive buying behavior in persons hospitalized with major depression by comparing impulsivity and sensation seeking with a control group, the subjects representing compulsive buyers often had more disorders associated with deficits in impulse control, such as kleptomania, bulimia, and dependence disorders (Lejoyeux et al, 1997). Using the Minnesota Impulsive Disorders Interview, the Zuckerman Sensation-seeking Scale and the Barratt Impulsivity Rating Scale, Lejoyeux (2002) conducted another study assessed the frequency of impulse control disorders and their association with mood disorders and found that in cases of patients with kleptomania, a higher occurrence of previous depressive episodes were present. Although not clearly observed, depressive symptoms were seen in a study by Martimor (1966) of the backgrounds of convicted subjects that indicated the direct role of depressive states as seen in camouflaged obsessive guilt feelings, paranoia, and fears of police surveillance.
It was presumed that since kleptomania, an impulse control disorder was related to depression, that perhaps there was a correlation with bipolar disorder. McElroy et al (1996) determined that ICDs and bipolar disorders share a number of characteristics. For instance, there are phenomenological similarities, including harmful, dangerous, or pleasurable behaviors, impulsivity, and similar symptoms. The general onset in both is also in adolescence or early adulthood and follows an episodic and/ or chronic course. Both express a high comorbidity with one another and similar comorbidity with other psychiatric disorders and have similar responses to mood stabilizers and antidepressants.
In reviewing Point’s article (2001- 2003), it is shown that obsessive-compulsive disorders are sometimes accompanied by depression, eating disorders, substance abuse disorders, personality disorders, attention deficit disorders, or another of the anxiety disorders. This, again, shows a link between kleptomania and obsessive-compulsive disorders. The ‘obsessive-compulsive spectrum’ and ‘affective spectrum’ disorders and the phenomenological resemblance to other impulse control disorders suggest that medications that have proved to be beneficial to such disorders will be of help in treating kleptomania.
Conclusion
Hypothesizing that kleptomania is more a variant of obsessive-compulsive disorder, rather than as an impulse control disorder not elsewhere classified, of which it is classified under in psychiatric nomenclature(DSM-IV). In reviewing, and comparing, studies on the treatments and comorbidity with other psychiatric disorders of both kleptomania and obsessive-compulsive disorder, strong correlations were found linking the two closely together. Examples are the use of similar cognitive-behavioral and pharmacological treatment in kleptomania and obsessive-compulsive disorder. Research also suggested a comorbidity with kleptomania and mood, anxiety, eating, and substance abuse disorders, which are also present in studies of obsessive-compulsive disorder.
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