Differential diagnosis and psychodynamic approach in kleptomania: a case report
Mehmet Baltacıoğlu, Altan Eşsizoğlu, Çınar Yenilmez, Cem Kaptanoğlu
Article No: 7   Article Type :  Case Report
Kleptomania is the inability to refrain from the urge to steal items for reasons other than personal use or financial gain. The disorder is frequently under-diagnosed and is regularly accompanied by other psychiatric disorders; particularly anxiety disorders, eating disorders and affective disorders. Our patient is a 19-year-old female, who was referred to our hospital from a general state hospital. She suffered from a desire to steal things such as makeup materials and perfume. She also complained carrying out inappropriate sexual behavior. She had depressive and obsessive-compulsive symptoms and attempted suicide three times in past years. She knew her grandmother as her mother, despite living in the same household. According to classical psychoanalytical theory; kleptomania is a defense against unconscious impulses, desires, conflicts and needs. The individual who is prone to narcissistic injury tries to prevent the self from disintegrating by the way of stealing behavior. Among psychodynamic theories, ego psychology, self-psychology and object relations theory also have explanations for kleptomania. This case has symptoms that belong to other psychiatric disorders. Thus, the case presented here is important for its emphasis on the fact that categorical and symptom oriented approaches are far from considering patients as a whole.
Keywords : Differential diagnosis, kleptomania, psychodynamic approach
Dusunen Adam : The Journal of Psychiatry and Neurological Sciences : 2015;28:66-72
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INTRODUCTION

Kleptomania is defined as the inability to refrain the urge to steal things independent from their material value and without necessity (1). Before the act of stealing distress rises, the feelings of relief and gratification turns into a fear of being caught that converges with guilt, regret and self-hatred right after the action (2).

In the early 19th century, kleptomania was defined as the disorder of stealing worthless things (2). Mathey was the first to name this condition as “klopemania” in 1816; however, in 1838, this term was replaced with “kleptomania” by Marc and Esquirol (3). Even in that period, it was stated that people with kleptomania felt an irritating tension apparently increasing before performing the action and relief after the act of stealing, the lifestyles of these people are different from the real thieves and should be distinguished from them. At the beginning of the 20th century, Kraepelin and Bleuler considered kleptomania among pathological and reactive impulses, and indicated that kleptomania is irresistible and not related to the antisocial behaviors (2).

Kleptomania, is classified in the group ‘impulse control disorder not otherwise specified’ in Diagnostic and Statistical Manual of Mental Disorders (DSM-IV TR). Other than kleptomania, intermittent explosive disorder, pathological gambling, pyromania, trichotillomania are also classified in this group (4).

Similar to DSM-IV, kleptomania is defined very much alike in DSM-V and classified under the heading disruptive impulse - control and conduct disorders including opposition defiant disorder, intermittent explosive disorder, conduct disorder, antisocial personality disorder, pyromania, and other unspecified disruptive, impulse control and conduct disorders (5). Due to the inefficiency of the studies conducted, we have very limited knowledge about the epidemiology of kleptomania. It is estimated that 6 out of 1000 people have kleptomania (1). In general, majority of the kleptomania cases are shoplifters and are judged in the court and the data available are being reached by this way does not reflect the real frequency in the population. The estimated ratio of kleptomania among shoplifters is between 3.8% and 24%. Female to male ratio is 3:1 (2). Kleptomania is more frequently observed between ages of 30-35 in females and 50-55 in males. Kleptomania is accompanied by pyromania and pathological gambling in males whereas trichotillomania in females (6). Also, comorbid diagnosis of lifetime mood disorders, eating disorders and a variety of anxiety disorders are frequently reported in patients with kleptomania (7,8). High rates of mood disorders and obsessive-compulsive characteristics are found in first-degree relatives of people with kleptomania (9).

Even though the studies conducted on kleptomania showed that kleptomania is resulted from the lack of resistance to stealing impulse, its causes still need to be enlightened. After 1980’s neurobiological approach took over psychodynamic approach and this approach emphasized the remarkable comorbidity with mood disorders and obsessive compulsive disorder, especially serotonergic dysfunction assumption supported by response to serotonergic treatment is dwelled on. Dopaminergic system affecting rewarding and reinforcement behaviors are mentioned in impulse control disorders and indicated its role in kleptomania pathogenesis (10-12).

In the clinical characteristics perspective, although kleptomaniac behavior can occur spontaneously and abruptly, it is stated that a small portion of these behaviors are planned beforehand. On the other hand, it can emerge after an anger evoking event or under stressful conditions. Kleptomaniac behavior attacks mostly happen in public, at the shops and supermarkets and big shopping malls. The stolen items are generally worthless. These stolen items are given away, thrown away, donated to a charity, being put back to its original place secretly or returned with an unreal explanation. Some patients have the habit of collecting these items (7). A variety of studies reported that people with kleptomania experience 3-4 stealing impulses and steal 2-3 items per week on average (6).

Differential diagnosis of kleptomania should be made to distinguish it from real theft, acute mania, alcohol substance intoxication, antisocial personality disorder and obsessive-compulsive disorder. The onset of kleptomania begins usually in late adolescence, and continues for years yet; the data on spontaneous remission ratio and long-term prognosis is inadequate (1,3).

No controlled trials have been conducted on kleptomania treatment yet to our knowledge. Psychodynamic intervention and behavioral treatments have been used and gave inconsistent results. Some case reports showed that cognitive behavioral techniques might be useful. In some cases electroconvulsive treatment were reported to be effective. Currently, as a psychopharmacological treatment, selective serotonin reuptake inhibitors (SSRI) that contain antidepressant features besides anti-compulsive qualities are used. In general, considering the compulsive quality of the pathology, it would be appropriate to determine the dose at the level that is used for obsessive-compulsive disorders (twice the dose of the depression treatment) (3). The effectiveness of tricyclic antidepressants, mood stabilizers, and opioid antagonists are examined in the treatment. Paroxetine and lithium, fluvoxamine and valproate combinations are reported to be more effective alone compared to SSRIs. Naltrexone mentioned to be a promising treatment for kleptomania (7,8,13,14).

This case is presented to discuss the difficulties that are encountered in the process of differential diagnosis since it shares many of the symptoms with other psychiatric disorders which can be mistaken with or comorbid with kleptomania and to highlight the psychodynamic factors that are ignored in the literature. In the case report kleptomania will be discussed in the frame of classic psychoanalytic theory, ego psychology, self psychology and object relations theory.

CASE

Nineteen-year-old female, open high school sophomore student, living with family, first child among three siblings. Patient was referred from another institution admitted to our polyclinic with her grandmother because the irresistible urge to steal things like make up products and perfume with the feelings of regret and guilt afterwards. Her grandmother mentioned the same complaints.

Self-reported patient history: Her complaints started when she was in the first year of the elementary school in the form of curiosity. In that period she rummaged the bags and lockers of her friends and threw things like pencil and milk boxes in the trash. In the 5th and 6th grades she started to steal money from her grandmother’s wallet, buying trivial things with this money sharing them with her friends. This behavior repeated itself as stealing small amounts of money from home. With the money, she bought make up products and perfume, some of them to share, some of them to keep, some of them to throw away. Late of the 8th grade, she started to steal things like food, make up products, perfume from shops with her friends. Back then, she did this for fun almost every week. When she was a guest or a guest came to their home, she started to rummage their belongings, stole small amounts of money and kept the things she liked. Gradually, this desire grew into her so much that; she could not help herself from stealing even the little things from local grocery every time she goes there.

As the time passed she thought that these do not excite her enough anymore and she shifted her stealing behavior to big shopping malls. Due to the fact that there are security cameras and security staff, the pleasure she got before and during stealing and the pleasure when she was successful at it increased. The last incident was when she saw her friend putting money into the bag and locked it, following the stealing behavior occurred by her duplicating the keys of the locker. Compared to her previous incidents, the amount of money was much higher. When the thievery was realized and she was suspected, she told them she was sick and returned the money. It was seeing her friend putting her bag into the locker and seeing her locking it that excited her.

The urge to steal appears abruptly (sometimes she was making plans to achieve her goals) even though she was aware that her behavior was wrong, she could not resist the urge, when this urge arises she gets excited, she can feel her heartbeats, and being successful gives her a ‘tremendous’ pleasure and happiness. Afterwards, she regrets for what she had done and either throws them away or gives them to her friends. The patient describes this situation as “It is like a quickie, experiencing these are so much fun and exciting but the guilt and regret that comes after is unspeakable”.

After her father’s bankruptcy, she had to quit her private high school and go to vocational high school. During that period, she had the complaints of feeling sad, unhappiness, crying jags, constant gags, vomiting, losing weight that lasted 4-5 months. She did not receive any psychiatric treatment yet. After her father’s discharge from the jail, these complaints regressed.

At the new school she started, she became popular among boys. At first she complained about this popularity, but then she started to enjoy it. At that time she had many sexual partners. Being the first one at the age of 16, she got pregnant two times and had abortion without her parents knowing. Upon her grandmother’s reading her diary, her parents learned what she went through and engaged her, but this engagement did not last long as they did not get along well.

The patient likened her sexual desire to her urge to steal, which she could not resist. Also, after she became sexually active, she stated that her urge to steal decreased and she could control her stealing behavior.

The patient was referred from another institution to our hospital; that she admitted because of the complaints of feeling regretful, guilty and sinful about her stealing behaviors and sexual relations, unhappiness, despair, pessimism, feeling that she does not deserve her family, suicidal thoughts (three suicidal attempts, including taking pills for twice and inhaling the gas once), reluctance and having difficulty in gathering attention for three months.

At the time of her first admittance to our hospital, she had statements about herself such as “I have done everything that is bad and evil. Still, I have not satisfied my evil part. Living seems meaningless. I thought of dying every day but I could not do it. I have no purpose in life. I only survive. I think I consist of two parts. One is good one is bad. The good part is merciful, emotional, helpful, and full of hope, while the bad part is a liar who lies easily and too much, who has bad habits and who gets pleasure from the forbidden.”

The patient was born in a wealthy and traditional family as the first child however, since her mother got pregnant soon to her sibling, she was raised by her grandmother. She knew her grandmother as her mother until she was 5. She stated that she does not trust her mother and be distant with her and loves her grandmother more than her mother.

She stated that she was not understood by others and her friends seemed childish, she did not like to spend time with her peers, she is pessimist, daydreamer, temperamental, spontaneous, clean and tidy, like to control (washing hands frequently, arranging things in order and according to their colors, checking the door and the oven).

In her psychological assessment, she was conscious and fully oriented. Her appearance was appropriate to her age and socioeconomic status. She has light skin, wears a turban and her appearance is matching with her age. Her affectivity was collapsed, feeling depressed from time to time, in collaboration with her content of thoughts. The amount of speech was adequate, response time to questions was normal, clear, intelligible, goal oriented but she was giving her responses by waiting and thinking. The contents of the thoughts included guilt, sinfulness, hopelessness, pessimism and regret themes and the anxiety caused by irresistible stealing behaviors. The thought that she has to be punished for her impulsive life was dominant. Also, she had unplanned suicidal thoughts with unsuccessfulness, no future expectations. Cognitive abilities were functional. The outward behavior was defensive. Introspection was present.

Routine biochemistry, hemogram, thyroid function tests, vitamin B12, folic acid, electroencephalography and cranial magnetic resonation screening results were in the normal range. After applying Minnesota Multidimensional Personality Inventory, Rotter Sentence Completion and Rorschach tests, borderline personality organization opinion was given. After the history taken from the relatives and the patient, psychological examination, laboratory examination and psychometric assessments were evaluated, according to DSM-IV diagnosis criteria, kleptomania with comorbid major depressive disorder diagnose was given and sertraline 50mg/day was started. The following weeks the dosage was raised to 100mg/day. In the follow-ups, after realizing that she did not benefit from sertraline the treatment was rearranged to fluoxetine 40mg/day + valproic acid 1000mg/day and the patient was included to supportive psychotherapy program. However the patient did not follow the supportive program.

DISCUSSION

The case is diagnosed with kleptomania due to the findings that are irresistible and repetitive stealing behavior without considering its personal use or material value, feeling excitement increasing just before the act of stealing and the pleasure after stealing. In the patient’s history the last incidence of stealing big amount of money pre-planned from her friend’s locker is considered as atypical in terms of kleptomaniac stealing. However, her statement “the bag being locked” triggered her to steal and return the money with deceptive explanations is characteristic to kleptomaniac stealing behavior. Generally, most of the kleptomania cases being faced with clinicians for juridical reasons make it important to differentiate kleptomaniac stealing behavior and real theft (2). In real theft, stealing occurs because of the material value and used for personal goals and benefits (2). In antisocial personality disorder, theft is done for personal benefit without feelings of guilt and regret (9). In both situations there is no excitement before the pathological stealing action and pleasure comes after. She was diagnosed with comorbid major depression, as a result of collapsed affectivity, guilty, unhappy, pessimist, unwilling feelings, having difficulties gathering attention and suicidal thoughts. People who are diagnosed with kleptomania receive lifelong major mood disorder diagnose frequently, similar with this case (7,8). Additionally, in patient history it is known that she had a depression attack in high school, during the time when her father was in jail. The compulsions of frequently washing hands, ordering the belongings according to their colors, checking the doors and the oven led us consider obsessive compulsive disorder (OCD), yet, the duration of these behaviors during the day and not hindering the functionality eliminated the OCD diagnosis. Furthermore, kleptomania begins in late adolescence like OCD and family histories of patients consist of high rates of OCD (1). However, while feeling intense pleasure and satisfaction as a result of kleptomaniac stealing behavior, compulsive behaviors aim to get rid of anxiety and feeling relaxed in terms of differential diagnosis (1).

It is asserted that kleptomania can be addressed under the expanded diagnosis group named “affective spectrum disorder” including OCD, eating disorders and mood disorders (1). Being diagnosed with comorbid major depression and obsessive-compulsive symptoms discussed in this frame, the need of further research should be conducted on the shared symptoms with the other disorders in the same spectrum. Also it is important to note that the patient’s having risky intercourse with numerous different male partners, continuing this behavior despite of two pregnancies and abortions, associating sexual desires with kleptomaniac stealing behavior. Even though there is no consensus on the nature and the definition of sexual compulsions, they are fundamentally irresistible sexual thoughts, desires and behaviors. While compulsions in OCD aim to reduce anxiety and increase relaxation, sexual compulsions, as in this case, are intended to get pleasure and satisfaction. Thus sexual compulsions are considered to be closer to impulse control disorder (6).

As it is discussed above, the patient has symptoms and findings that lead to consider categorically different diagnosis groups. While some of these symptoms and findings are adequate to make diagnosis, the others do not meet the criteria. In fact, even though they are not adequate to make diagnosis, they need to be handled in the treatment process. In this context, psychodynamic approaches are important to comprehend the symptoms and findings as a whole.

In most studies, it is indicated that kleptomaniacs have stormy and worrisome childhood and it is suggested that the pathological stealing is to compensate the childhood losses (2,9). Being raised by her grandmother by her mother’s request, in spite of living in the same house, recognizing her real mother at the age of five might have caused her to experience a deep loss related to rejection. Being rejected by the object and its loss might be compensated by the behavior as stealing the objects that replaced the first love object. Apraham emphasized that the root of kleptomania can be traced back to childhood experiences, the patient feels herself love deprived, neglected, and stealing both substitutes the feeling of the lost happiness and reveals the anger toward the people who are responsible (15). In his kleptomania case, Zavitzianos (16) draws attention to his patient whose sibling was born when he was 3 years old and the patient’s feeling himself neglected and left alone and being depressed that was caused by his mother’s giving her attention to the newborn sibling. The psychodynamic approaches intend to explain kleptomania emphasize that stealing behavior represents a symbolic pleasure or defense against unconscious impulses, desires, conflicts and needs (9).

The patient’s inappropriate and intense sexual behaviors are like stealing behavior, which appears to be a compensative behavior. In people with kleptomania, defense against unconscious impulses may reveal themselves in sexual and masochistic themes (9). In this context, the patient’s “like a quickie” comparison of stealing behavior to sexual behaviors is important. Zavitzianos (16) draws attention to early childhood masturbation, onset of sexual intercourse at the age of 13 in his female case. There is a close relation with kleptomania and inappropriate sexual behaviors (16,17).

In classical psychoanalytic theory, penis is emphasized to be at the forefront considering the symbolic meaning of stolen things and this explains the reason why kleptomania is more frequently seen among females in comparison to males (18). However as Zavitzianos (16) mentioned, the anxiety wanted to be reduced is not only a castration, but also a separation anxiety. According to the self-psychology, kleptomania in females is interpreted as a defense representing struggle against castration anxiety or resistance against yearning and desire for males. The stealing behavior in females is interpreted as taking possession of penis that only males hold, that they are yearning and they get pleasure from it (16,17).

The case is considered as struggling to prevent herself from being disintegrated by unconscious impulses, on the other hand, cease the narcissistic damage: the rejective and lost first love object might have lead up to unheeded, easily offended, unwanted self-formation. The stolen objects can be regarded as the replacement of the lost love object and the desire toward it. From the point of the case, the inability of compensating the lost object with the stolen objects and the inability to improve self, lead to inevitable depressive periods. The thoughts of being guilty and sinful, deserving punishments are the symptoms of her having strict superego. Also, the patient’s mentioning of herself as she has distinct bad and good sides shows that she has an ambivalent attitude towards herself. In the psychodynamic explanation of depression, strict superego and ambivalent attitude are highlighted (19).

Psychodynamic approaches emphasize dynamic interactions. Such richness and appropriateness might not be found in classification systems such as DSM. Psychodynamic approaches provide important opportunities in terms of explaining the inexplicable features of life (20).

Due to the patient’s non-adherence to treatment process, the information taken is partially sufficient, still the case presented here is important for its emphasis on the fact that categorical and symptom oriented approaches are far from considering patients as a whole and hindering the underlying dynamics to be recognized.

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