Behavioral Addictions _ _______________________________________________________________________
TREATMENT Successful treatment of kleptomania involves educating patients that they have an illness that is likely to become life- long without treatment [349]. Psychotherapy should anticipate that, in some patients, kleptomania has become a part of their identity and gives them self-esteem and temporary relief. This should not be ignored when helping patients develop healthy coping skills to handle distress and should be discussed throughout the course of treatment [341; 349]. Because kleptomania is a relatively rare psychiatric disorder, few studies have evaluated psychosocial and pharmacologic treatments and empirically validated treatment options remain lacking. Most published treatment suggestions for kleptomania are extrapolated from conceptual models for substance use disorders, OCD-related or affective disorders, or ADHD [341]. Preliminary data from treatment-seeking patients show gender differences in clinical features and comorbid disorders that may reflect biologic and sociocultural factors with implication for prevention and treatment. Women and men with kleptoma- nia both show substantial symptom severity and functional impairment. Women are more likely than men to be married (47.1% vs. 25.9%), experience shoplifting onset at a later age (20.9 years vs. 14 years), steal household items, hoard stolen items, and have a comorbid eating disorder. Men are more likely to steal electronic goods and have another impulse- control disorder [351]. Psychological Interventions CBT is tailored for use in the treatment of kleptomania by applying the following strategies [340]: • Overt sensitization: The patient is instructed to imagine stealing and then to imagine a negative outcome, such as being caught or feeling nauseated or short of breath. • Aversion therapy: Patients practice aversive breath- holding until mildly painful when experiencing a steal- ing urge or image. • Systematic desensitization: The patient achieves a relaxed state through progressive muscle relaxation and is asked to imagine the different steps of a stealing epi- sode while suggesting they can better manage the urge to steal by controlling the anxiety. CBT or variants of cognitive and behavioral therapies seem promising for kleptomania, but large-scale studies with control groups are lacking. Furthermore, there may be a shortage of clinicians skilled in these therapies for kleptomania [340]. Findings also suggest that patients with kleptomania require longer treatment beyond the standard 6- to 12-session structure of CBT [352].
Pharmacologic Interventions Memantine is an N-methyl-d-aspartate (NMDA)-receptor antagonist with promising results in substance and behavioral addictions. A small, uncontrolled trial in patients with klep- tomania reported that after eight weeks of memantine (up to 30 mg/day), 91.7% met criteria for clinical response (defined as ≥35% improvement in symptom severity and clinician rating of improved/very much improved). All kleptomania disease severity scores decreased, and mood, anxiety, disability scores, and impulsivity improved. Memantine was generally well-tolerated, reduced shoplifting urges and behavior, and improved psychosocial functioning [339]. Naltrexone efficacy was evaluated after eight weeks and led to significantly greater reductions in overall kleptomania severity, stealing urges, and stealing behavior compared with placebo. The mean effective naltrexone dose was 116.7 mg/day, and 92% of subjects completed the study [353]. Naltrexone may decrease dopamine transmission in the nucleus accumbens, thus reducing the reward and reinforcement experienced with stealing and urges to steal [353]. The SSRI escitalopram has shown high response rates in uncontrolled trials, but failed to separate from placebo under double-blinded conditions [354]. Although SSRIs have been considered first-line pharmacotherapy in kleptomania, evidence indicates naltrexone is more effective, especially in patients with greater stealing urges. Patients with urges/crav- ings to steal and/or a family history of substance use disorders should receive a trial of naltrexone. If kleptomanic symptoms appear within the context of general impulsivity and inat- tentiveness in ADHD, psychostimulants can be considered. Consider antidepressants or mood stabilizers for comorbid affective disorders [341]. Twelve-Step Programs Shoplifters Anonymous defines itself as a 12-step group for compulsive shoplifters, stealers, thieves, and kleptomaniacs. Groups under the names Compulsive Shoplifters Anony- mous (CSA) and Cleptomaniacs and Shoplifters Anonymous (CASA) can also be found. Although there is little research about these groups, recommending them in conjunction with medication and individual treatment is reasonable to consider [341]. INDUCED BEHAVIORAL ADDICTIONS As noted, impulse control disorders and behavioral addiction can emerge during treatment with dopaminergic agents. Most published cases involve patients with Parkinson disease, who at some point require the dopamine precursor levodopa or dopamine agonists.
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