INTRODUCTION:

Kleptomania is a well-known impulse control disorder characterised by recurrent failure to resist impulses to steal items even though the items are not needed for personal use or for their monetary value. The individual experiences a rising sense of tension before the theft and feels pleasure, gratification, or relief when committing the theft. The stealing is not committed to express anger or vengeance. It is also not done in response to delusion or hallucination¹.It is defined by a number of features including a consistent tendency to steal items not needed for personal use or monetary value. The objects are stolen despite that they are typically of little value to the individual, who could have afforded to pay for them and often gives them away or discards them². The disease is characterized by repeated, failed attempts to stop stealing. It is often seen in patients who are chemically dependent or who have a coexisting mood, anxiety, or eating disorder. People with this disorder have an overwhelming urge to steal and get a thrill from doing so and usually exhibit guilt after the theft³.

Occasionally the individual may hoard the stolen objects or surreptitiously return them. Although someone with this disorder will generally avoid stealing when immediate arrest is probable (such as in full view of a police officer), they usually do not plan the thefts or fully take into account the chances of apprehension. The stealing is done without collaboration with others⁴.There is a difference between ordinary theft and kleptomania: "ordinary theft (whether planned or impulsive) is deliberate and is motivated by the usefulness of the object or its monetary worth," whereas with kleptomania, there "is the recurrent failure to resist impulses to steal items even though the items are not needed for personal use or for their monetary value."^5,
6

Causes:

The cause of kleptomania is unknown, although it may have a genetic component and may be transmitted among first-degree relatives. Several theories that suggest that changes in brain may be at the root of kleptomania. It may be:

· Linked to problems with a naturally occurring brain chemical (neurotransmitter) called serotonin. Serotonin helps regulate moods and emotions. Low levels of serotonin are common in people prone to impulsive behaviours.

· Related to addictive disorders, and stealing may cause the release of dopamine (another neurotransmitter). Dopamine causes pleasurable feelings, and some people seek this rewarding feeling again and again.

· Linked to the brain's opioid system. Urges are regulated by the brain's opioid system. An imbalance in this system could make it harder to resist urges ⁷

Symptoms:

The handbook used by mental health professionals to diagnose mental disorders is the Diagnostic and Statistical Manual of Mental Disorders published by American psychiatric association. The DSM contains diagnostic criteria and research findings for mental disorders. It is the primary reference for mental health professionals in the United States. The 2000 edition of this manual (fourth edition, text revision known as the DSM-IV-TR, lists five diagnostic criteria for kleptomania:

• Repeated theft of objects that are unnecessary for either personal use or monetary value.

• Increasing tension immediately before the theft.

• Pleasure or relief upon committing the theft.

• The theft is not motivated by anger or vengeance, and is not caused by a delusion or hallucination.

• The behaviour is not better accounted by a conduct disorder, maniac episode or antisocial personality disorder.^{3, 6}

History:

Kleptomania has been mentioned in the medical and legal literature for centuries. Swiss physician Andre Matthey used the term, ‘kleptomanie’ to describe behaviour characterized by irresistible, involuntary urges. The person with kleptomanie was therefore “forced to steal” due to a mental illness, not a lack of moral fortitude. The term kleptomania was coined by the French psychiatrists Esquirol and Marc in the 19th century⁸.

Neurobiology:

Although individuals with kleptomania report an inability to resist their urge to shoplift, the etiology of this uncontrollable behaviour is unclear. Serotonergic dysfunction in the ventromedial prefrontal cortex has been hypothesized to underlie the poor decision making seen in individuals with kleptomania. One study examined the platelet serotonin transporter in 20 patients with kleptomania. The number of platelet 5-HT transporters, evaluated by means of binding of 3H-paroxetine, was lower in kleptomaniac subjects compared to healthy controls thereby suggesting some nonspecific serotonergic dysfunction.

One study of neurocognitive functioning in 15 women diagnosed with kleptomania revealed, as a group, no significant deficits in tests of frontal lobe functioning when compared to normative values. Those individuals with greater kleptomania symptom severity, however, had significantly below- average scores on at least one measure of executive functioning. Significantly higher rates of cognitive impulsivity (measured by Barratt Impulsiveness Scale, 10^thversion) were found in 11 subjects with kleptomania when compared to control group of psychiatric patients without kleptomania.

Case reports and neuroimaging studies provide additional clues as to possible etiology for kleptomania. Damage to the orbitofrontal-subcortical circuits of the brain has been reported to result in kleptomania. Neuroimaging techniques have demonstrated decreased white matter microstructural integrity in the ventral- medial frontal brain regions of kleptomaniacs compared to controls. These images are consistent with findings of increased impulsivity in kleptomaniacs. These studies also support the hypothesis that at least some individuals with kleptomania may not be able to control their impulse to steal⁹.

Treatment

Many people with kleptomania live lives of secret shame because they are afraid to seek mental health treatment. This is unfortunate because, although there’s no cure for kleptomania, treatment may help to end the cycle of compulsive stealing. There is no standard treatment approach for kleptomania as its cause is still not fully understood. There are, however, a range of treatment approaches which include psychotherapy, medication (pharmacotherapy) and support groups. A person suffering from kleptomania may, therefore, have to try several types of treatment to find something that works well for them.

Medication(pharmacotherapy)

There is not enough scientific research on the use of psychiatric medications to treat kleptomania, but certain medications seem to be helpful. The best medication for each individual depends on their overall situation and other conditions they may have – such as depression or obsessive-compulsive disorder. Often the individual will benefit from taking a combination of medications to see what works best with the fewest side effects. Medications generally prescribed include:

· Antidepressants: Selective serotonin reuptake inhibitors (SSRIs) are commonly used to treat kleptomania. These include fluoxetine (Prozac, Prozac weekly), paroxetine (Paxil, Paxil CR), fluvoxamine (luvox, luvox CR), Sertraline (Zoloft) and others.

· Mood stabilizers: These medications are meant to even out your mood so that you don’t have rapid or uneven changes that may trigger urges to steal. One mood stabilizer used to treat kleptomania is lithium (lithobid)

· Anti-seizure medications: Although originally intended for seizure disorders, these medications have shown benefits in certain mental health disorders, possibly including kleptomania. Examples include topiramate (Topamax) and valproic acid (Depakene, Stavzor).

· Addiction medications: Naltrexone (revia, vivitrol) known technically as an opioid antagonist, blocks the part of your brain that feels pleasure with certain addictive behaviours. It may reduce the urges and pleasure associated with stealing.

Psychotherapy:

Cognitive Behavioural Therapy (CBT) has become the psychotherapy of choice for Kleptomania. In general, CBT helps you identify unhealthy, negative beliefs and behaviours and replace them with healthy, positive ones. Cognitive Behavioural Therapy may include the following techniques to help someone overcome the urge to steal:

· Covert sensitisation: When the patient feels the urge to steal, he must imagine himself stealing and then facing negative consequences such as been caught until the impulse goes away.

· Aversion therapy: When the patient feels the urge to steal, he holds his breath until it is slightly painful. Eventually, he associates the unpleasant feelings with the urge, and the impulse to steal diminishes.

· Systemic desensitisation: The patient undergoes relaxation therapy and learns to substitute relaxing feelings for the urge to steal.

Other forms of therapy, such as psychodynamic therapy, family therapy or marriage counselling, may also be helpful^{1, 2}.

On March 22, 2004, the Food and Drug Administration (FDA) issued a Public Health Advisory that cautions physicians, patients, families and caregivers of patients with depression to closely monitor both adults and children receiving certain antidepressant medications. The FDA is concerned about the possibility of worsening depression and/or the emergence of suicidal thoughts, especially among children and adolescents at the beginning of treatment, or when there is an increase or decrease in the dose. The medications of concern mostly SSRIs (selective serotonin re-uptake inhibitors) are: Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Luvox (fluvoxamine), Celexa (citalopram); Lexapro (escitalopram), Wellbutrin (bupropion), Effexor (venlafaxine), Serzone (nefazodone), and Remeron (mirtazapine). Of these, only Prozac (fluoxetine) is approved for use in children and adolescents for the treatment of major depressive disorder. Prozac (fluoxetine), Zoloft (sertraline) and Luvox (fluvoxamine) are approved for use in children and adolescents for the treatment of obsessive compulsive disorder.) ²

Controversial role of serotonin in kleptomania

The neurobiological correlates of kleptomania have been steadily gaining credence over last few years. Decades of research show that dopamine and serotonin are the primary neurotransmitters involved in the pathogenesis and management of kleptomania, respectively. Selective serotonin reuptake inhibitors (SSRIs) have been used as first line agents for treating kleptomania. Kleptomania has often been considered to be a part of obsessive compulsive spectrum disorders (OCSD) which include diverse conditions like other impulse disorders (ICD), and disorders characterised by preoccupation with body appearance or sensation. These disorders have traditionally responded well to SSRIs at maximum recommended dosages.

Paradoxically, there are case reports of kleptomania being induced in adults who were started on SSRIs for depression. A recent Indian paper also reported a similar manifestation while on fluvoxamine treatment for obsessive compulsive disorder. Other diverse unlawful behaviours such as auto theft, robbery, shop lifting and property offenses have also been reported after starting SSRIs treatment for depression. Theses manifestations may be partly explained by the phenomenon of effective depletion of synaptic serotonin, following acute administration of SSRIs, through the serotonin mediated action on its auto-receptor. Another explanatory hypothesis is the theory that long term use of SSRIs may lead to down-regulation of serotonin receptor production.

Kleptomania and dopamine

While the role of serotonin is getting less clear, the role of dopamine is gaining importance in pathophysiology of kleptomania, especially in neurological disorders such as Parkinson’s disease (PD). Kleptomania is seen as an emergent side effect of the use of dopamine agonists in PD. Other ICDs like pathological gambling, compulsive shopping, compulsive eating and hypersexuality have also been reported with the use of dopamine agonists. This phenomenon is explained by the overdose theory. In PD, ventralstriatal dopamine is preserved relative to dorsalstriatal activity thus, dopaminergic treatment titrated to all eviate motor dorsal striatal deficiencies may result in an ‘over-dosing’ in ventral corticostriatal cognitive and limbic pathways. In support of this hypothesis, there is preliminary evidence for the benefit of a typical antipsychotics for treatment of ICDs, including kleptomania. At the same time, serotonergic and dopaminergic systems are not mutually exclusive. One hypothesis is that an alteration indopamine levels post SSRI initiation leads to the acute rise in impulsivity seen in behavioural activation or disinhibition. SSRIs are known to sensitize dopamine (D₂) receptors. It is considered as one of the mechanisms of its antidepressant action. Many serotonin receptors (5-HT 1A/1B/2A/3/4) facilitate dopamine release while 5-HT2C mediates an inhibitory effect. Thus it is suggested that the apparent effectiveness of SSRIs in kleptomania may be due to dopaminergic modulation, rather than primary effect on the serotonergic system ¹⁰.

CONCLUSION:

Kleptomania, a largely unrecognized disorder, presents as a chronic illness for many individuals. Since rare disorder it is very important to understand and identify the disorder and screen patients appropriately. Also proper treatment helps to alleviate the symptoms and relapses of kleptomania.

REFERENCES:

1. www.clairenewton.co.za/my-articles/insight-into-kleptomania.html.clairenewton.co.za/my-articles/insight-into-kleptomania.html.

2. https://www.psychologytoday.com/conditions/kleptomania.

3. http://www.minddisorders.com/Kau-Nu/Kleptomania.html.

4. https://www.psychologytoday.com/conditions/kleptomania.

5. https://en.m.wikipedia.org/wiki/kleptomania.

6. http://www.psychologistanywhereanytime.com/ mobile/disorders_psychologist_and_psychologist/psychologist_kleptomania.htm.

7. http://www.mayoclinic.org/diseases-conditions/kleptomania/basics/definition/con-20033010.

8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC32225132/.

9. Grant JE, Odlaug BL. Kleptomania: clinical characteristics and treatment. Rev Bras Psiquiatr, 2008, 30(1): S 11-5.

10. Mangot AG. Neurobiology of Kleptomania: an overview. SL J Psychiatry, 2014; 5(2), 2-4.