Most people with kleptomania try unsuccessfully to stop stealing, which often leads to feelings of shame and guilt.48 Many (64% to 87%) have been arrested because of their stealing behavior47; a smaller percentage (15% to 23%) have been incarcerated.48 Suicide attempts are common among these patients.49
Pharmacotherapy. There has been only 1 randomized, placebo-controlled study of pharmacotherapy for kleptomania (Table). An 8-week, double-blind, placebo-controlled trial was conducted to evaluate the safety and efficacy of oral naltrexone, 50 to 150 mg/d, in 25 patients with kleptomania. Those taking naltrexone had a significantly greater reduction in total score than those taking placebo on the Yale-Brown Obsessive Compulsive Scale Modified for Kleptomania; in stealing urges; and in stealing behavior. The mean effective dosage of naltrexone was 116.7 (± 44.4) mg/d.50
Naltrexone was well tolerated, with minimal nausea, and did not cause elevation of liver enzymes.
There is one available open-label study with a double-blind discontinuation phase assessing the efficacy of escitalopram for kleptomania. Continuation of escitalopram during the blinded discontinuation phase did produce lower relapse rates.51
Psychological treatments. There are no controlled studies of psychological treatments for kleptomania. Case reports suggest that cognitive and behavioral therapies might be effective:
• A young man who underwent 7 sessions of covert sensitization, combined with exposure and response prevention, over a 4-month period was able to reduce his stealing frequency.52
• In another case, a young woman underwent 5 weekly sessions when she was instructed to practice covert sensitization whenever she had an urge to steal. She remained in remission for 14 months with only a single lapse in behavior and with no reported urges to steal.53
• In 2 patients, imaginal desensitization in fourteen 15-minutes sessions over 5 days resulted in complete remission of symptoms for a 2-year period.54
Conclusions. The single controlled study of naltrexone for kleptomania suggests that naltrexone might be a beneficial treatment for this disorder. No controlled trials of psychosocial interventions have been reported. The current psychological research is based primarily on case reports.
This state of affairs likely is because of (1) the low prevalence of kleptomania and (2) clinical difficulties in treating patients involved in illegal activities. Nevertheless, there is a need for systematic studies of treating this disorder; such studies could involve collaboration across multiple treatment centers because of the disorder’s low prevalence.
Pyromania is characterized by (1) deliberate and purposeful fire setting on >1 occasion; (2) tension or affective arousal before the act; (3) fascination with, interest in, curiosity about, or attraction to fire and its situational contexts; and (4) pleasure, gratification, or relief when setting fires or when witnessing or participating in their aftermath.3
Although pyromania is thought to be a disorder primarily affecting men, recent research suggests that the sex ratio is equal among adults and may be slightly higher among adolescent females. Mean age of onset usually is late adolescence. Pyromania appears to be chronic if untreated.55
Urges to set fires are common and the fire setting is almost always pleasurable. Severe distress follows the fire setting, and persons with pyromania report significant functional impairment. High rates of co-occurring psychiatric disorders (depression, substance use disorders, other impulse-control disorders) are common among persons with pyromania.55
Pharmacotherapy. There are no randomized, controlled clinical trials examining pharmacotherapy for treating pyromania. There are no FDA-approved medications for pyromania.
In case reports, medications that have shown benefit in treating pyromania include topiramate, escitalopram, sertraline, fluoxetine, lithium, and a combination of olanzapine and sodium valproate. An equal number of medications have shown no benefit: fluoxetine, valproic acid, lithium, sertraline, olanzapine, escitalopram, citalopram, and clonazepam. A case report of an 18-year-old man with pyromania described successfully using a combination of topiramate with 3 weeks of daily CBT to achieve significant symptom improvement.56,57
Pyromania is a largely unrecognized disorder that causes significant psychological, social, and legal repercussions. Because few persons with pyromania volunteer information regarding fire-setting, it is important that clinicians recognize the disorder and screen patients appropriately. Various treatments have been helpful in case studies, but more research on the etiology and treatment of the disorder is needed.56,57
Conclusions based on the literature
In disruptive, impulse-control, and conduct disorders, the systematic study of treatment efficacy and tolerability is in its infancy. With few controlled studies published, it is not possible to make treatment recommendations with confidence. There are no FDA-approved drugs for treating any of these disorders.
Nonetheless, specific psychotherapies and drug therapies offer promising options, but often are based on small studies, often in patient populations with prominent comorbidities, and have not been replicated by independent investigators. For all of these disorders, issues such as which psychotherapy or medication to use and the ideal duration of treatment cannot be sufficiently addressed with the available data.