An Adolescent with Kleptomania and Attention-Deficit/Hyperactivity Disorder Treated with Methylphenidate

Case

A 16-year-old girl was brought to our outpatient clinic by her mother for her stealing behavior and irritability. She had started stealing candy, food, and money from her neighbors 2 years before. Over time both the frequency of the thefts and the value of the stolen items increased. She was going to stores alone and stealing clothes nearly everyday. She described this behavior as involuntary and irresistible and was not able to control her stealing. She was giving them to her friends as a gift and never used them. According to her report, she was stealing to relieve the anxiety she felt concomitant with the urges. After each theft she reported excessive guilt and shame. She had not been caught before.

She reported concentration difficulties and short attention span and had poor school performance. She had impulsivity, irritability, and problems with her friends and parents. In her psychiatric assessment, she met criteria for ADHD (combined type) and kleptomania according to DSM-IV criteria (APA 1994). OROS methylphenidate 27 mg/day was initiated and the dose was increased to 36 mg/day in the fourth week. Supportive therapy was provided during follow-up visits.

She reported significant reduction in the intensity of her intrusive urges to steal and she started to inhibit her stealing thoughts and behavior. Her school performance also improved. She had no stealing act during 5 months of followup.

Discussion

Kleptomania is generally believed to be a rare psychiatric disorder characterized by an inability to resist recurrent urges to steal. It has been reported to be more common in women, to begin typically during adolescence, and is mostly co-morbid with other psychiatric disorders (Aboujaoude et al. 2004; Grant 2006). We presented a female adolescent with kleptomania and ADHD who had significant reduction in her urges to steal and complete remission of stealing behavior during methylphenidate treatment.

In kleptomania, stealing behavior is not better accounted for by another mental disorder including conduct disorder, a manic episode, or antisocial personality disorder (APA 1994). In the differential diagnosis, conduct disorder needs to be considered for this case as she had impulsivity, irritability, and poor interpersonal relationships. In ordinary theft, the main motivation is the usefulness of the object or its monetary worth. However, the reported case described her behavior as involuntary and stole for achieving relief, not for personal gain. Additionally, she did not have other symptoms of conduct disorder including truancy, physical fights, and running away from home overnight.

Kleptomania remains poorly understood, with limited data regarding its pathophysiology or treatment. It is currently classified by DSM-IV as an impulse control disorder; however, literature suggests that kleptomania is a heterogeneous disorder that shares features of distinct clinical spectrums including obsessive compulsive, affective, and addictive disorders (Bayle et al. 2003). These categorizations are supported not only by specific clinical and phenomenological features but also by the high rate of co-morbidity with the major disorders in each spectrum (Dannon et al. 2004; Grant 2006). Recent studies also demonstrated that a group of patients with kleptomania met criteria for ADHD with a frequency between 7.5% and 15% (Presta et al. 2002; Aboujaoude et al. 2004; Dannon et al. 2004). Although there is no suggested association between ADHD and kleptomania, impulsivity is a key feature of these two conditions (Bayle et al. 2003; Brewer and Potenza 2008).

Dopaminergic systems have been implicated in impulsivity (Brewer and Potenza 2008). The ventral tegmental area–nucleus accumbens–orbital frontal cortex (VTA-NA-OFC) circuit is thought to be involved in the processing of reward and pleasure. Dopamine plays a major role in the regulation of this region's functioning. In a double-blind placebo-controlled study, naltrexone demonstrated significant reduction in stealing urges and behavior. It was hypothesized that naltrexone influences dopamine neurotransmission in the nucleus accumbens and decreases stealing-related excitement and cravings (Grant et al. 2009). Methylphenidate, a psychostimulant, influences dopamine and is highly effective in the treatment of ADHD. However, to date, there is no published report evaluating the efficacy of psychostimulants for kleptomania.

This case study suggests that methylphenidate may be effective in treating kleptomania, at least in subjects with ADHD, because of its ability to reduce impulsivity. When kleptomania symptoms appear to be associated with the general impulsivity of ADHD, stimulants may be beneficial.