Kleptomania and Pyromania

Kleptomania and pyromania are impulse control disorders, which are psychiatric conditions characterized by the inability to resist an impulsive action that can lead to harmful results. People suffering from these disorders experience a feeling of increased anxiety prior to committing the action. Once the action is completed, patients feel relief in spite of the potentially dangerous consequences. Treatment includes psychotherapy and some medications.

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Introduction

Definition

Impulse control disorders such as kleptomania and pyromania are psychiatric disorders or conditions characterized by extreme and/or harmful desire and behavior. These disorders lead to significant damage or impairment in one’s social and professional life.

Included diagnoses:

  • Intermittent explosive disorder
  • Conduct disorder
  • Kleptomania
  • Pyromania

Stages of impulsivity

Impulse behavior is fast, insensitive, and unrestrained. There are 5 stages:

  • Rising impulse
  • Increase in internal tension
  • Acting on impulse brings pleasure.
  • Sense of relief after action
  • Guilt or remorse substitute for pleasure and relief.

Pathophysiology

  • Thought to be due to changes in parts of the brain:
    • Limbic system: responsible for memory and emotions
    • Frontal lobe: responsible for decision-making
  • Increase in level of testosterone (responsible for aggressive behavior)
  • Related to dopamine neurotransmitter (controls feelings of pleasure and satisfaction): Patients undergoing dopamine agonist therapy are at increased risk of developing an impulse control disorder.

Kleptomania

Definition

Kleptomania is the impulse to steal without the need to (e.g., items stolen are free, have no value, the person doesn’t need them or could afford them), accompanied by a feeling of relief or relaxation after the theft.

  • Thefts are unintentional, not planned.
  • Items stolen are usually disposed of or never used.
  • Symptoms often occur during times of stress.
  • Exclude the following disorders: conduct disorder, manic episode, or antisocial personality disorder.

Epidemiology

  • Incidence of 0.3%–0.6% (compared with lifetime prevalence of shoplifting of 11.3% in the United States)
  • Women:men incidence: 3:1.
  • High rates of comorbidity with mood and anxiety disorders

Management

Psychotherapy:

  • CBT: main treatment; helps patients identify triggers and how to cope with them
  • Insight-oriented psychotherapy: systematic desensitization and aversion conditioning

Medication:

  • Opioid antagonists (e.g., naltrexone) thought to work on altering dopaminergic pathways
  • Antidepressants (e.g., selective serotonin reuptake inhibitors (SSRIs) such as paroxetine) and mood stabilizers (e.g., topiramate) may be indicated with comorbid psychiatric conditions.

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Pyromania

Definition

Pyromania is fire setting that is impulsive, recurrent, and intentional without secondary gain (e.g., insurance payoff or revenge), preceded by tension or anxiety and followed by relief or excitement once the fire has been set.

  • Fires are usually set in random locations.
  • Can inadvertently cause harm, although this is not the goal
  • Exclude the following disorders: conduct disorder, manic episode, or antisocial personality disorder.

Epidemiology

  • Men > women
  • > 40% under the age of 18 
  • Comorbid conditions:
    • Mild intellectual disability
    • Anxiety disorder
    • Depression

Management

Behavioral therapies:

  • CBT helps patients understand the tension preceding fire starting and find other ways to release it.
  • Family therapy is indicated for juvenile offenders.
  • Recurrent offenders may need supervision and even incarceration.

Medications:

  • No FDA-approved treatments 
  • Can include SSRIs and potentially mood-stabilizing medications

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Differential Diagnosis

  • Bipolar disorder: psychiatric illness characterized by periods of depression and mania/hypomania. Part of the disorder’s symptomatology includes the impulse to seek pleasure or engage in dangerous activities regardless of consequences. Careful history taking must be completed to rule out the manic phase of bipolar disorder before kleptomania or pyromania can be diagnosed. 
  • Conduct disorder: mental disorder characterized by recurrent behavior in which patients do not comply with basic rights of others for duration of 1+ year. This disorder differs from stealing or fire-setting behaviors of kleptomania or pyromania as those are not done to cause personal harm. Patients with kleptomania or pyromania experience uncontrollable urges prior to their actions.

References

  1. Sadock BJ, Sadock VA, Ruiz, P. (2014). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Chapter 19, Disruptive, Impulse-control, and Conduct disorders, pages 611-615. Philadelphia, PA: Lippincott Williams and Wilkins.
  2. Leppink, E. (2017). Kleptomania, pyromania, and disruptive disorders. DeckerMed Medicine.
  3. Dell’Osso B, Altamura AC, Allen A, Marazziti D, Hollander E. (2007). Epidemiologic and clinical updates on impulse control disorders: a critical review. Eur Arch Psychiatry Clin Neurosci. https://pubmed.ncbi.nlm.nih.gov/16960655/

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