Kleptomania Or Common Theft – Diagnostic and Judicial Difficulties

Psychiatr. Pol. 2018; 52(1): 81–92 PL ISSN 0033-2674 (PRINT), ISSN 2391-5854 (ONLINE) www.psychiatriapolska.pl DOI: https://doi.org/10.12740/PP/82196 Kleptomania or common theft – diagnostic and judicial difficulties Justyna Sipowicz, Ryszard Kujawski Provincial Psychiatric Hospital in Swiecie Summary First descriptions of kleptomania as a mental disorder date back to the nineteenth century. For the first time, kleptomania as an accompanying symptom rather than a formal diagnosis was included in the classification of psychiatric disorders of the American Psychiatric Association DSM-I in 1952. It was included in the International Classification of Diseases ICD-10 and classified under “habit and impulse disorders”. Kleptomania is a serious disorder, as numerous thefts are impulsively carried out, carrying the risk of detection and consequently criminal liability. In Poland, we lack epidemiological data, however, it is estimated that 5% of those who commit theft are affected by kleptomania. People suffering from this disorder often do not seek a medical opinion so reviewing such cases is challenging for expert psychiatrists. The authors have proposed the term “kleptomania spectrum” for defining cases in which patients have an intense urge to steal, experienced a sense of tension from such an action, and relief following it, however, the criterion of theft of a superfluous object, without a profitable motive for themselves or others is not met. Key words: psychiatry, kleptomania, forensic psychiatry Introduction According to ICD-10, kleptomania (KLM) is defined as a repeated failure to resist the impulse to steal object with no intention of personal use or monetary gain. The objects may be discarded, given away, or hoarded. This behavior is usually ac- companied by a mounting sense of tension in the lead up to the action and a sense of relief during and immediately after it. Some effort is made to hide the act of stealing, but not all opportunities to do so are used. Theft is carried out alone. Between periods of theft, one may exhibit anxiety, depression, guilt, however, none of these prevents repetition of behavior [1, p. 179]. Diagnosis should be based on two criteria: 1) two or more thefts made without any financial motive directly for the person or others; 2) the person describes an intense urge to steal, with a sense of tension prior to the action and relief after it [2, p. 122–23]. According to DSM-5, people suffering from 82 Justyna Sipowicz, Ryszard Kujawski KLM, despite the overwhelming impulse to steal, are usually able to refrain from illegal activities when significant and immediate consequences are evident (presence of a security guard, policeman or surveillance camera). KLM runs in three patterns: 1) short episodes of theft with long periods of remission; 2) longer periods of theft with short periods of remissions; and 3) chronic, continuous episodes of theft with low frequency fluctuations [3]. KLM was first described in 1816 by a Swiss physician Andre Matthey, who used the term klopemanie to describe thieves who impulsively steal unnecessary objects. Later, two French psychiatrists, Jean-Étienne Dominique Esquirol and Charles Chré- tien Henri Marc changed the term to kleptomanie. According to them, a person with kleptomanie was “forced to steal” due to mental illness. Initially it was thought to be exclusively a female characteristic associated with uterus ailments or premenstrual syndrome [4, 5] as it was noted to occur during shopping (at that time the domain of women). The nineteenth century was a period of lush economic development with the first department stores being established which created enticing temptations and opportunities for misappropriation. Ladies touched by the affliction can be found throughout literature dating from this period (e.g., Agatha Christie’s novel Death on the Nile) [6]. KLM was classified as a symptom of hysteria (such a diagnosis was given to Maria Konopnicka’s daughter Helena, who committed a number of thefts at the house of a friend and when eventually brought to court was declared insane) [7]. KLM derives from the concept of monomania, introduced by Esquirol around 1810 [8], “which – to the detriment of forensic psychiatrists – is still applied among lawyers and laymen today” [9, p. 99]. In Polish psychiatric literature, Romuald Pląskowski in nineteenth century (1884) wrote in reference to KLM that this is “a pointless taking other people’s belongings without any regard to value, usefulness or even personal need. Such misappropriation of property is made […] almost absentmindedly and could easily be detected by other people” [10, p. 471]. Twentieth century views strongly rejected earlier beliefs regarding the impact of a woman’s reproductive system on the occurrence of this disorder. Historically, KLM was considered an affliction of Caucasian, upper or middleclass women [11–14]. Currently, KLM is acknowledged in both sexes, however, exhibited more frequently in women [15, 13], who account for approximately 75% of cases. It has been noted that first symptoms usually emerge before the age of 20, and in the US before the age of 18 [16]. Korzeniowski (1985) claims that although not everyone acknowledges the exis- tence of KLM, the fact that thefts carried out by people who could easily afford to buy the stolen object supports the view that KLM is a specific pathological manifestation. The structure of a psychopathic personality with a tendency towards impulsive activities lies at the core of KLM. KLM does not include thefts committed by psychiatric patients (e.g., suffering from schizophrenia or dementia) [17]. KLM, as an accompanying symptom – not a formal diagnosis – was for the first time included in the American Psychiatric Association’s classification of psychiatric disorders DSM-I in 1952. In DSM-II (1968), it was completely overlooked only to return in 1980 as a separate disorder during the revision of DSM-III [4]. Kleptomania or common theft – diagnostic and judicial difficulties 83 The International Classification of Diseases, ICD-10, included KLM in the group “Habit and impulse disorders” (F63) [18]. This group includes: pathological gambling (F63.0) – frequent, repeated episodes of gambling despite negative social consequences; pathological fire-setting (pyromania) (F63.1) – multiple acts of setting fire to property or other objects, without apparent motive, and a persistent preoccupation with subjects related to fire and burning; pathological stealing (KLM) (F63.2) – frequent impulses to steal objects; trichotillomania (F63.3) – noticeable hair-loss due to a recurrent failure to resist impulses to pull out hair. According to Ebert (1999), common features of above-mentioned disorders are: 1) no resistance to specific actions; 2) mounting tension and agitation are followed by a sense of relief or gratification during and immediately after the act; 3) impulsive actions are usually repeated and lead to negative psychosocial consequences [19]. In the 1960s, T. Bilikiewicz reverted to debates dating back to the first half of the twentieth century over the presence of an entity in impulsive disorders (Emil Krae- pelin’s Impulsives Irressein) which would be a form of constitutional psychopathy (so-called impulsive psychopaths) [20]. The classification of an impulsive behavior as mental disorder is determined by intensity. Descriptions of KLM usually derive from individual cases, although McErloy et al. and Prest et al. described a group of KLM sufferers and observed a higher likelihood of mood disorders than in the control group [21, 22]. Bayle et al. suggest that habitual behavior – such as KLM – has an antidepressant effect: when the patient starts stealing, the mood improves. Typically, depression preceded the theft [as cited in: 23]. Bayle et al. compared a group of KLM sufferers with a group of healthy persons and a group with dependencies on alcohol and other substances – they observed more pronounced mood disorders, increased nicotine dependence and a higher impulse rate in the group of KLM sufferers [24]. KLM is a rare disorder diagnosed in 0.3–0.6% of the population, with a female-male ratio of 3:1. Only 0.4% of students met KLM criteria [16]. The etiology and pathogenesis of KLM are still under discussion. Studies showed a serotonergic dysfunction of prefrontal cortex which led to formulating a hypothesis that patients with KLM have a weak decision-making process [25]. At the same time, neuroimaging techniques have shown a reduction in micro-areas of the white matter of the ventromedial frontal regions of the brain in people with KLM compared to the control group [26]. Different psychological theories are under consideration: the theory of learning, the theory of addiction, psychodynamic and biological theories [27, 28]. To date, none of those theories has gained any significant advantage over the other. Epidemiological data are also lacking. Some authors suggest that these disorders have an early onset (childhood or adolescence; [28]). The gender split varies depending on the type of disorder. The common feature of all disorders in this group is the chronic nature coupled with exacerbations and remissions. KLM also accompanies other mental illnesses and disorders (20–46% other impulse control disorders [29], 23–50% substance abuse [23, 29], 45–100% mood disorders [21, 30]. In the pharmacological treatment of KLM the following medications are recom- mended: antidepressants (SSRI), mood stabilizers (lithium, valproic acid), anti-epileptic 84 Justyna Sipowicz, Ryszard Kujawski medications (topiramate), and opioid antagonists (naltrexone) [16]. Psychotherapy of KLM mainly comprises of cognitive-behavioral techniques [31]. KLM should be distinguished from mere shoplifting. Studies show that approximately 64–82% of KLM sufferers have been stopped “in the act” [30, 32]. It is estimated that KLM accounts for about 5% of those who thieve. This data may well be underestimated, as KLM sufferers are often not under medical care. Studies on the legal consequences of KLM revealed that 68% faced arrest, 36% were arrested but found not guilty, 20% were convicted and imprisoned; 10% were convicted but not imprisoned [26].

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