Making the diagnosis
In our clinic, we have treated more than 50 patients with kleptomania. Rather than coming to us through the criminal justice system, they are usually self-referred. Often they contact us after discovering on the Internet that we specialize in treating persons with this disorder.
In our experience, kleptomania typically goes undiagnosed in clinical settings, in part because patients are ashamed and embarrassed to discuss their symptoms with physicians unless specifically asked.1 If left untreated, however, kleptomania frequently becomes chronic.4 If persons with kleptomania are to seek treatment, it is important that family, friends, and mental health professionals understand the myths and facts about this disorder (Box).
To make the diagnosis, we use the simple screening instrument shown in Table 1.7 In general, because of high comorbidity with certain disorders, we screen every patient presenting to our clinic with a mood, substance use, anxiety, or eating disorder, or who has a problem with impulse control. Kleptomania is likely if the patient answers “yes” to questions 1 through 4 and to question 5 or 6. Stealing may be a symptom of several other psychiatric disorders, however, and misdiagnosis is fairly common (Table 2).6-8
Data suggest that the female-to-male ratio in kleptomania is approximately 2:1, with onset in adolescence. Typical individuals with kleptomania steal because they have urges to steal, often triggered by specific stimuli such as the sights and sounds of stores or feelings of loneliness or stress.1 Most patients with kleptomania are fairly specific about the types of stores from which they steal and the items they steal, and most hoard stolen items.1
Although many patients with kleptomania function quite well, others are severely debilitated in social and occupational realms. In a series of 22 patients with kleptomania:
- 64% had been apprehended
- 23% had served jail time
- 27% had been hospitalized because of their kleptomania symptoms
- 18% had considered or attempted suicide because of the distress associated with their kleptomania.1
Patient history With patients who steal, we begin by identifying the motivation behind the stealing. Most patients with kleptomania report urges to steal. Some of these patients may have comorbid depression; for them, stealing makes them feel less depressed. Anger or irritability may point to borderline personality disorder. Stealing for the enjoyment of risk may suggest bipolar disorder.
DIFFERENTIAL DIAGNOSIS: DISORDERS THAT MAY INVOLVE STEALING
|Misdiagnosis||How to distinguish from kleptomania|
|Bipolar disorder||Patients with bipolar disorder may steal as a result of the impulsivity of mania. In fact, the diagnostic criteria for kleptomania require the exclusion of mania as the cause of stealing.7 Patients with bipolar disorder report an elevated, expansive, or irritable mood while stealing. Patients with kleptomania tend to report a depressed mood when not stealing|
|Borderline personality disorder||Unlike patients with borderline personality disorder, patients with kleptomania do not report long histories of unstable relationships or negative self-image; inappropriate anger and “psychotic-like” symptoms are rare in patients with kleptomania|
|Antisocial personality disorder (ASPD, or conduct disorder)||Patients with kleptomania suffer intense shame and guilt, unlike those with ASPD. Also, most patients with kleptomania do not report other illegal or antisocial behavior.|
|Eating disorders||Data suggests that about one-third of patients with an eating disorder also steal.6,8 Patients with kleptomania, however, do not have disordered eating patterns or distorted body images common to patients with eating disorders.|
Many patients with kleptomania have comorbid mood, substance, or anxiety disorders. Treating these other symptoms while ignoring the symptoms of kleptomania may be unsuccessful. Comorbidity also may influence the choice of medication.
Medical assessment Case reports have associated the onset of kleptomania with a variety of medical conditions, including presenile cortical atrophy in a 25-year-old, a parietal tumor that caused blackouts and obliterated any memory of stealing episodes, narcolepsy, and an insulinoma that caused severe hypoglycemia.9 The relationship of these conditions with the onset of kleptomania is unclear, but the reports suggest that medical causes—although unlikely—should be ruled out before you consider kleptomania as a psychiatric illness.
Patient education Persons with kleptomania often feel that no one else has the same problem. They do not think of their behavior as being an illness. It is helpful to explain that kleptomania is treatable and to connect patients with educational books, self-help groups, and Web sites providing information and support (see “Related resources”).
Cognitive-behavioral therapy (CBT) Although the evidence is quite limited, covert sensitization, exposure and response prevention, and imaginal desensitization have all been shown effective in case reports.10
What medications are effective?
Only case reports, a case series of five subjects, and a single open-label treatment study involving 10 subjects with kleptomania have been done.