What is the first-line treatment for kleptomania?

Treatment of Kleptomania

Cognitive-behavioral therapy (CBT) combined with selective serotonin reuptake inhibitors (SSRIs) represents the first-line treatment approach for kleptomania, with naltrexone as an important adjunctive option, particularly when addictive features are prominent.

Primary Treatment Strategy

Cognitive-Behavioral Therapy as Foundation

• CBT should be initiated as the cornerstone of treatment, focusing on identifying triggers, resisting urges, and developing alternative coping strategies 1, 2.
• Exposure and response prevention techniques, similar to those used in OCD, can help patients resist the compulsion to steal 2.

Pharmacological Management

SSRIs as First-Line Medication

• Fluoxetine is the most commonly reported SSRI for kleptomania treatment, given the disorder's relationship to the obsessive-compulsive spectrum 1, 2.
• The rationale for SSRI use stems from the hypothesis of disturbed central serotonin reuptake in kleptomania 3.
• SSRIs address the repetitive intrusive thoughts and compulsive nature of the stealing behavior 2.

Naltrexone as Adjunctive or Alternative Agent

• Naltrexone (an opioid antagonist) should be strongly considered, especially when the disorder has addictive features 1, 3, 4.
• Case reports demonstrate successful reduction of kleptomanic symptoms when naltrexone is added to SSRI and CBT treatment 1.
• Naltrexone may target the reward-seeking and pleasure-driven aspects of the stealing behavior 3, 2.

Other Pharmacological Options

• Mood stabilizers (such as lithium) can be considered when mood instability is prominent or when kleptomania co-occurs with bipolar disorder 4, 2.
• Anti-epileptic medications have shown promise in some cases 4.

Treatment Algorithm

Step 1: Initial Assessment and Comorbidity Management

• Screen for psychiatric comorbidities, which are present in the majority of cases: mood disorders (45-100%), substance use disorders (23-50%), other impulse control disorders (20-46%), anxiety disorders, and eating disorders 4, 2.
• Address comorbid major depressive disorder or OCD first, as patients typically seek treatment for these conditions rather than the kleptomanic behavior itself 1, 2.

Step 2: Combined Treatment Initiation

• Start CBT immediately, focusing on impulse control and behavioral modification 1, 2.
• Initiate an SSRI (fluoxetine is most commonly reported) at standard antidepressant doses 1, 2.

Step 3: Augmentation if Inadequate Response

• Add naltrexone if response to SSRI plus CBT is insufficient after 8-12 weeks 1, 3.
• Consider mood stabilizers if affective instability is prominent 4, 2.

Step 4: Monitoring and Adjustment

• The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) can serve as a surrogate marker to gauge treatment response, given the obsessive-compulsive features of kleptomania 5.
• Monitor for legal, social, family, and occupational impairment, which are common consequences of the disorder 4.

Critical Clinical Considerations

Common Pitfalls to Avoid

• Do not overlook kleptomania when patients present with comorbid psychiatric conditions—the stealing behavior is often kept secret and only revealed when legal consequences force disclosure 5, 2.
• Recognize that kleptomania typically begins in late adolescence or early adulthood and appears more common in women 4.
• Understand that stolen items are typically worthless and not needed for personal use or monetary gain, distinguishing kleptomania from ordinary theft 1, 4.

Exacerbating Factors to Address

• Brain injury has been linked to kleptomania and should be considered in the history 5.
• Mood disorders and addictive behaviors may exacerbate kleptomanic symptoms 5.
• The disorder can last throughout a person's life if untreated, though it may wax and wane 1.

Evidence Limitations and Clinical Reality

The evidence base for kleptomania treatment consists primarily of case reports and case series rather than controlled trials 1, 3, 4. Despite the lack of randomized controlled studies, the combination of CBT with SSRIs (and naltrexone when needed) represents the most rational approach based on the disorder's phenomenology and its relationship to OCD and addictive disorders 3, 2. The successful use of these interventions in multiple case reports, combined with the significant impairment and legal consequences of untreated kleptomania, justifies aggressive treatment even in the absence of Level 1 evidence 4, 2.