Evidence-Based Reviews

Kleptomania: Emerging therapies target mood, impulsive behavior

Current Psychiatry. 2002 August;1(8):45-49

References

1. Grant JE, Kim SW. Clinical characteristics and associated psychopathology in 22 cases of kleptomania. Comp Psychiatry (in press).

2. McElroy SL, Pope HG, Hudson JI, Keck PE, White KL. Kleptomania: a report of 20 cases. Am J Psychiatry 1991;148:652-7.

3. Presta S, Marazziti D, Dell’Osso L, et al. Kleptomania: clinical features and comorbidity in an Italian sample. Comp Psychiatry 2002;43:7-12.

4. McElroy SL, Keck PE, Phillips KA. Kleptomania, compulsive buying, and binge-eating disorder. J Clin Psychiatry 1995;56:14-26.

5. McElroy SL, Hudson JI, Pope HG, Keck PE. Kleptomania: clinical characteristics and associated psychopathology. Psychol Med 1991;21:93-108.

6. Goldman MJ. Kleptomania: an overview. Psychiatric Ann 1992;22:68-71.

7. American Psychiatric Association Committee on Nomenclature and Statistics Diagnostic and statistical manual of mental disorders (4th ed, text rev). Washington, DC: American Psychiatric Association, 2000.

8. Krahn DD, Nairn K, Gosnell BA, Drewnowski A. Stealing in eating disordered patients. J Clin Psychiatry 1991;52:112-5.

9. Goldman MJ. Kleptomania: making sense of the nonsensical. Am J Psychiatry 1991;148:986-96.

10. Goldman MJ. Kleptomania: the compulsion to steal—what can be done? Far Hills, NJ: New Horizon Press, 1998.

11. Grant JE, Kim SW. An open-label study of naltrexone in the treatment of kleptomania. J Clin Psychiatry 2002;63:349-56.

12. Chong SA, Low BL. Treatment of kleptomania with fluvoxamine. Acta Psychiatr Scand 1996;93:314-5.

13. Kraus JE. Treatment of kleptomania with paroxetine. J Clin Psychiatry 1999;60:793.-

14. Burstein A. Fluoxetine lithium treatment for kleptomania. J Clin Psychiatry 1992;53:28-9.

15. Kmetz GF, McElroy SL, Collins DJ. Response of kleptomania and mixed mania to valproate. Am J Psychiatry 1997;154:580-1.

16. Lepkifker E, Dannon PN, Ziv R, Iancu I, Horesh N, Kotler M. The treatment of kleptomania with serotonin reuptake inhibitors. Clin Neuropharmacol 1999;22:40-3.

17. Durst R, Katz G, Knobler HY. Buspirone augmentation of fluvoxamine in the treatment of kleptomania. J Nerv Ment Dis 1997;185:586-8.

18. Kim SW. Opioid antagonists in the treatment of impulse-control disorders. J Clin Psychiatry 1998;59:159-64.

19. Grant JE, Kim SW. Pharmacotherapy of pathological gambling. Psychiatric Ann 2002;32:186-91.

20. Grant JE, Kim SW. Adolescent kleptomania treated with naltrexone: a case report. Eur Child Adolescent Psychiatry 2002;11:92-5.

21. Kim SW, Grant JE, et al. A preliminary report on a possible naltrexone and nonsteroidal analgesics interaction. J Clin Psychopharmacol 2001;21:632-4.

So far, uses of tricyclic antidepressants (imipramine, nortriptyline), SSRIs (fluoxetine, fluvoxamine, paroxetine), the opioid antagonist naltrexone, and mood stabilizers (lithium, valproate) have met with varying degrees of success. Strategies targeting urge and behavior reduction and mechanisms for coping with urges and behavior (e.g., cognitive-behavioral therapies) may represent important adjunctive components.^2,11-17

No medications are FDA-approved for treating kleptomania. Therefore, it is important to inform patients of any off-label use of medications for this disorder, as well as the empirical basis for considering pharmacologic treatment.

SSRIs Only case reports exist on the use of SSRIs in treating kleptomania. The disorder may share a common pathology with pathologic gambling, and in our clinical experience appears to respond to similar treatments.¹⁸ We draw on research of pathologic gambling as well as our clinical experience in choosing SSRIs as first-line treatment, especially for patients with significant mood symptoms.¹⁹

We suggest titrating SSRIs to the maximum recommended dosage. As in the treatment of pathologic gambling, dosages of SSRIs required to treat kleptomania symptoms appear to be higher than average dosages required to treat depressive disorders. An SSRI should not be considered ineffective unless it has been tried for at least 10 to 12 weeks and the highest dosage tolerated or recommended by the manufacturer has been reached.

Response to SSRIs usually is characterized by decreased thoughts about stealing, decreased stealing behavior, and improvement in social and occupational functioning. If an SSRI is only partially effective, we consider augmentation with naltrexone, buspirone, or a mood stabilizer.

Naltrexone Patients taking naltrexone often report less-intense urges to steal. The urges may not disappear but are often sufficiently reduced so that the patient can resist them more easily. Patients also report that the thrill associated with stealing is reduced or eliminated.

Naltrexone was used in the first medication study of kleptomania and showed a significant decline in the intensity of urges to steal, stealing thoughts, and stealing behavior. Average dosage was 150 mg/d;¹¹ a reduced dosage (e.g., 50 mg/d) may work in adolescents with kleptomania.²⁰

Nausea as a side effect can be reduced by starting patients on 25 mg/d for the first 3 or 4 days and possibly adding ondansetron, 4 to 8 mg/d. Nausea and diarrhea are usually mild and resolve within the first week. Clinically, most patients respond to naltrexone within 2 weeks. After that, the dosage usually needs to be adjusted.

In patients with comorbid depression, augmentation with an SSRI may prevent worsening of untreated depressive symptoms. It is prudent to obtain liver function tests prior to naltrexone administration and again 3 to 4 weeks after starting the drug.²¹ Repeat testing should be performed at 2-to 4-week intervals for the next 2 months, then once a month for the following 3 months. After 6 months, testing three to four times a year is usually sufficient.

Nonsteroidal analgesics should not be used with high dosages of naltrexone (>50 mg/d), as concurrent use may increase the risk of hepatic transaminase elevation.²¹

Mood stabilizers Responses to lithium and valproate have been described in two case reports of patients with kleptomania.^14,15 In the case of valproate, the effective dosage was 2,000 mg/d, whereas lithium reduced stealing urges at a serum level of 0.5 mEq/L.

Although it would be premature to recommend the use of mood stabilizers, their possible benefit may be related to their efficacy in bipolar disorder treatment and the existence of features (e.g., impulsivity) shared by kleptomania and bipolar disorder.

Atypical antipsychotics Although there is no evidence that atypical antipsychotics are useful in kleptomania, augmenting an SSRI with an atypical neuroleptic may be beneficial. Atypical antipsychotics have been explored as augmenting agents in the treatment of nonpsychotic disorders and behaviors, including pathologic gambling and obsessive-compulsive disorder.

The role of psychotherapy

Cognitive-behavioral therapy Based on the evidence of its effectiveness in treating pathologic gambling, CBT may hold promise as monotherapy for mild cases of kleptomania.

Combination therapy Combined pharmacologic and behavioral therapy may be the optimal treatment strategy for kleptomania. In our experience, patients who respond only partially or fail to respond to pharmacotherapy alone are more likely to find relief with a combination of drug and cognitive-behavioral therapies.

Related resource

Goldman MJ. Kleptomania: the compulsion to steal—what can be done? Far Hills, N New Horizon Press, 1998.
Shoplifters Alternative http://www.shoplifters.org
Impulse Control Disorders Clinic, University of Minnesota http://www.med.umn.edu/psychiatry/research/impulse.htm

Drug brand names

Citalopram • Celexa
Fluvoxamine • Luvox
Imipramine • Tofranil
Naltrexone • Revia
Nortriptyline • Aventyl, Pamelor
Paroxetine • Paxil
Quetiapine • Seroquel
Valproic acid • Depakote

Disclosure

The authors report no affiliation or financial arrangement with any of the companies whose products are mentioned in this article.