________________________________________________________________________ Behavioral Addictions
DIAGNOSIS Kleptomania is a secretive disorder with a hidden nature. Patients often present for treatment from legal coercion after being arrested for shoplifting. The diagnosis is often missed in routine psychiatric evaluations, and clinicians do not usually inquire about it. Patients with kleptomania often do not initi- ate disclosure of the behavior, even when they are already in psychiatric treatment for another disorder, because of shame about their behavior [341]. One study found only 42% of married individuals with kleptomania had told their spouses about the behavior [340]. The 2000 DSM-IV-TR diagnostic category of impulse-control disorders not elsewhere classified was renamed disruptive, impulse-control, and conduct disorders in the DSM-5 and expanded to include oppositional defiant disorder, intermit- tent explosive disorder, conduct disorder, antisocial personal- ity disorder, pyromania, and kleptomania [11; 256]. Instead of assigning kleptomania to a work group, the DSM-5 Study Group placed it in this ill-fitting diagnostic category. Data that show similarity between kleptomania and conduct disorder or intermittent explosive disorder are virtually non-existent [183]. The DSM-5-TR diagnostic criteria for kleptomania are [11]: • Recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value • Increasing sense of tension immediately before commit- ting the theft • Pleasure, gratification, or relief at the time of commit- ting the theft • Stealing not committed to express anger or vengeance and is not in response to a delusion or a hallucination • Stealing not better explained by conduct disorder, a manic episode, or antisocial personality disorder Differential Diagnoses Kleptomania should be distinguished from ordinary theft, whereby stealing is motivated by the value of the object regard- less of whether it was planned or impulsive. Shoplifting and ordinary theft are common, but kleptomania is rare. Some individuals feign symptoms of kleptomania to avoid criminal prosecution, and malingering should be ruled out. Stealing in the context of conduct disorder or antisocial personality disorder is a pattern of antisocial behavior; stealing in the context of acute psychiatric or cognitive symptoms should be distinguished from kleptomania [11; 341]. Kleptomania is easy to mis- or overdiagnose because most diagnostic criteria are based on self-report, which is difficult to objectively confirm. Determination that stealing is not committed to express anger or vengeance may require several sessions to understand patient motives for the behavior, as patients are usually secretive and may not be consciously aware of their motive at the time of assessment [350].
under-represented. Legal problems did not correlate with suicide risk, but patients who complete suicide after arrest or conviction have been reported. Other suicide risk factors in patients with kleptomania include shame, poor self-esteem, high levels of impulsivity and disinhibition, and social isola- tion [341; 346]. Kleptomania is associated with significant legal consequences. In one study, common legal consequences included being arrested (68.3%), arrested but not convicted (36.6%), convicted and incarcerated after conviction (20.8%), and convicted but not incarcerated after conviction (10.9%) [344]. PATHOPHYSIOLOGY Evidence increasingly supports kleptomania as a behavioral addiction, and kleptomania shares several features with sub- stance use disorders [340; 341]: • Urges to engage in behaviors with negative conse- quences • Mounting tension unless the behavior is completed • Rapid but temporary urge reduction following the behavior • Return of the urge • External and unique behavioral cues • Secondary conditioning by external and internal cues (dysphoria, boredom) • A hedonic quality earlier in the natural history Substance use disorders are highly comorbid in patients with kleptomania (29% to 50%), and patients with kleptomania often have first-degree relatives with substance use disorders. Kleptomania responds to the anti-craving drug naltrexone, an opioid antagonist used in opioid and alcohol use disorders. In contrast, opioid agonists (tramadol, morphine), but not antagonists, have efficacy in OCD [340; 347; 348]. Clinical subtypes of kleptomania have been identified, based on the underlying drive of the behavior [341; 349]: • Urges often triggered by external cues (around 50% of patients), closely resembles substance use disorders • Emotional states of feeling bored, lonely, anxious, or depressed (10% of patients) that resembles affective spectrum disorder. However, patients with this subtype describe their behavior driven by a need to “escape” similar to patients with substance use disorder who experience relief from craving. • A combination of urges and emotion states (40% of patients), with urges to steal occurring during specific emotional states only
65
EliteLearning.com/Social-Work
Powered by FlippingBook