Introduction
Although in DSM-V kleptomania can be found within impulse control disorders, there is some evidence of subgroups of the disorder that share symptom features or are associated with obsessive compulsive spectrum disorders (OCD) (Grant and Chamberlain, Reference Grant and Chamberlain2018; Hollander et al., Reference Hollander, Kwon, Stein, Broatch, Rowland and Himelein1996) or substance abuse disorders (SAD) (Grant, Reference Grant, Hollander and Stein2006). Similarities between kleptomania and OCD or SAD also exist concerning treatment options that have been proven effective at least at case-report level: selective serotonin reuptake inhibitors (SSRIs) are regarded effective in OCD as well as in kleptomania (Lepkifker et al., Reference Lepkifker, Dannon, Ziv, Iancu, Horesh and Kotler1999). Opioid antagonists such as naltrexone have been used in SAD and kleptomania (Grant et al., Reference Grant, Kim and Odlaug2009, Grant et al., Reference Grant, Odlaug, Schreiber and Kim2014; Mouaffak et al., Reference Mouaffak, Leite, Hamzaoui, Benyamina, Laqueille and Kebir2017). Other treatment forms of kleptomania include cognitive behavioural therapy (CBT) (Christianini et al., Reference Christianini, Conti, Hearst, Cordás, de Abreu and Tavares2015; Rudel et al., Reference Rudel, Hubert, Juckel and Edel2009) with covert sensitization and systematic desensitization. However, only little knowledge exists about CBT including exposure and response prevention (ERP) therapy in the treatment of kleptomania although it is regarded as the therapy of choice for OCD (Abramowitz, Reference Abramowitz2006). Furthermore, there is a clear lack of neurobiological parameters that would allow an objective monitoring of treatment.
Therefore, we tried an ERP-like real-world protocol with visits in a supermarket to treat a patient with kleptomania. To establish a possible neurobiological marker of treatment response we further recorded galvanic skin response as a screening parameter of the arousal system during exposure and response prevention (Giesbrecht et al., Reference Giesbrecht, Merckelbach, van Oorsouw and Simeon2010). In addition, we aimed at augmenting the therapy with naltrexone medication at a later stage.
Method
Patient
The patient (‘Mrs D’) presented (self-initiated) at the beginning of 2014 at the Psychiatric Outpatients Clinic of the University Hospital Leipzig, specializing in OCD and related disorders. Mrs D was then 68 years old, and reported with shame of her stealing behaviour. It started in 2008 with rare events of stealing small items from supermarkets, but the symptoms worsened over time and at the time of presentation stealing occurred almost daily. She further admitted not being in need of the small items (mainly sweets and hygienic articles) that she stole by putting them in her jacket or her bag. Although in the beginning, she wrapped the goods into newspaper and threw them away once at home, she had now started to consume the goods.
Mrs D reported an increasing tension before stealing, a relief just afterwards and great feelings of guilt when she returned home. However, back in the supermarket she could not resist the urge to steal again, although she could financially afford to buy the items legally. There were no signs of other psychiatric disorders or symptoms as mania, delusions, anti-social behaviour or dementia that would have explained the stealing behaviour despite a former depressive episode in 2008 with depressed mood, sleep initiating problems and affective lability. Thus Mrs D fulfilled the criteria for kleptomania according to the DSM-V or ICD-10.
Mrs D gave her written informed consent for this case report.
Assessment
After her introduction in the outpatient clinic the patient underwent a routine diagnostic procedure including blood samples, electrocardiogram (ECG), electroencephalogram (EEG) and cranial magnetic resonance imaging (MRI). There was no somatic cause of her symptoms revealed. Treatment was first started with an SSRI (escitalopram up to 30 mg/day) without a change of symptoms over 1 year. We decided on a shared decision-making process to try out an exposure and response prevention (ERP) within a real-world setting, i.e. a supermarket.
The assessment of baseline severity of symptoms and treatment response were established using the Kleptomania Symptom Assessment Scale (KSAS) self-questionnaire, an instrument widely used in kleptomania research (Grant, Reference Grant, Hollander and Stein2006). The KSAS consists of 12 items assessing relevant symptoms; scores range between 0 and 48. In addition, the Clinical Global Impression Scale (CGI) was used as an overall measure for treatment response.
As indicator of the sympathetic branch of the autonomous nervous system, the galvanic skin response (GSR), was assessed continuously for 1-min blocks of 20 min recordings before ERP therapy, 45 min during ERP therapy and 30 min afterwards, using the SenseWear™ Armband (SWA; BodyMedia, Inc. Pittsburgh, PA, USA). The device was placed on the upper arm of the dominant side. Skin conductance measures have been shown to be sensitive to psychosocial stress situations and therefore were used to monitor the course of treatment.
Design and statistics
We used an ABA single case study design for three different treatment approaches. It is a matter of ongoing debates which statistical approaches should be used in single case studies (Crawford and Garthwaite, Reference Crawford and Garthwaite2012). Especially for single case designs comparing different treatments within one individual, analysis of variance (ANOVA) approaches have been suggested in the past (Shine and Bower, Reference Shine and Bower1971). Although there are also critics of these computations due to increased risk of type I errors (Toothaker et al., Reference Toothaker, Banz, Noble, Camp and Davis1983), we decided to use an ANOVA calculation (Gentile et al., Reference Gentile, Roden and Klein1972) for repeated measures (Armstrong et al., Reference Armstrong, Eperjesi and Gilmartin2002). For the analysis, values of fifteen 1-min blocks (highest number available for all blocks, all subjects and all conditions) from each time (baseline, exposure, post) and each treatment condition (no treatment with two visits, ERP with three visits, ERP + naltrexone with five visits) were entered into the model. A repeated measures ANOVA with a 3 condition (treatments) × 3 time point (pre, exposure, post) design was computed. Post-hoc pairwise comparisons were corrected using the Šidák approach. Significance level was set to p < 0.05, and we used software SPSS 23 (IBM Corp., Armonk, NY, USA; released 2015, Statistics for Windows, version 23.0).
Results
At the beginning of 2015, Mrs D decided to intensify her therapy due to her low quality of life. Her KSAS score was 32 at that point, and CGI index was 6 (‘severely ill’). Psychotherapy started with two baseline visits at a large supermarket. Mrs D was followed by the therapist and she was asked to look for three different goods that she would steal if she were on her own and put them into her shopping trolley. Then she was asked to remove these items from her trolley and put them back on the supermarket shelves. These actions were associated with high tensions and a clinically visible increase of sympathetic activity such as increasing breathing frequency and sweating. Afterwards Mrs D was allowed to buy one item (that she had to name before entering the shop) and to pass the cash desk. These actions were again associated with high tensions. Visits to the supermarket were restricted to about 45 minutes. For baseline GSR (see Fig. 1) there was a sharp increase of sympathetic arousal from before the visit to the supermarket compared with the visit at the supermarket.
Figure 1. Time courses of the sympathetic arousal as measured by galvanic skin response (GSR) before entering the supermarket (‘Before’), during the exposure and response prevention session (‘Exposure’) and during rest after leaving the supermarket (‘After’) for the three different conditions without treatment (‘Baseline’), with ERP treatment (‘ERP’) and with ERP treatment augmented with naltrexone (‘Naltrexone’).
After the two baseline visits, Mrs D received CBT sessions including short lessons of covert sensitization and psychoeducation. Three more visits (every 2 days) to the supermarket then took place. This time she repeatedly had to take the goods and put them back again until she felt a decrease of tension and anxiety >50% of her initially reported tension level. After these ERP therapy sessions, her KSAS score fell to 22 and CGI showed a severity of 4 (‘moderately ill’) and a therapeutic effect index of 3 (‘moderate’) marking the response to the treatment. GSR clearly decreased before, during and after a visit to the supermarket in comparison with baseline conditions (Fig. 1)
In addition, treatment with naltrexone was started at this point (at first 50 mg/day, after 5 days 100 mg/day) for treatment augmentation. Five more visits to the supermarket followed. However, KSAS score increased slightly from 22 to 23, and CGI did not show any further benefit in comparison with treatment without naltrexone. However, through the whole course of the treatment Mrs D did not steal, which was a great success for her.
The repeated measures ANOVA showed a significant effect of time (baseline–exposure–post) with F (2,146) = 72.89, p < 0.01 and a significant effect of time × group (no treatment–ERP–ERP+naltrexone) with F (4,294) = 20.34, p < 0.01). Post-hoc correction for multiple comparisons revealed a significant difference with lower GSR measures for the ERP condition in comparison with the no-treatment condition (p < 0.01) and the naltrexone condition (p < 0.01). No difference was found for the comparison of baseline with the naltrexone condition (for time series of conditions, see Fig. 1).
Discussion
The course of the treatment shows that ERP sessions in combination with other CBT features are a valid option to treat kleptomania (Rudel et al., Reference Rudel, Hubert, Juckel and Edel2009). Although it is a time-consuming method, the rapid decline of autonomic nervous system (ANS) activity levels in parallel with decreasing KSAS scoring suggests a strong effect on the behaviour and the nervous system of the patient, following classical cognitive behavioural therapy. Although the raw values of the ANS activity and the used ANOVA approach show clear results, an in-depth analysis has to been done for replication in a much larger sample.
It is also interesting that the additional augmentation with naltrexone did not result in further decline of symptoms. However, as the psychopharmacological intervention with naltrexone was established only after the ERP sessions, the results of this case do not allow any conclusion for naltrexone treatment as a first-line therapy. However, in the light of the ANS results it is remarkable that the GSR levels during naltrexone treatment rose above the baseline level (without therapy) during exposure and especially during rest afterwards, suggesting a totally different mechanism of action of this kind of treatment. Also, some evidence exists (Behnoush et al., Reference Behnoush, Memarian and Teimoory2013) for naltrexone to possibly induce a serotonergic syndrome with increased sympathetic activity. Although the patient in our case did not show any clinical signs of a serotonergic syndrome, this effect of naltrexone might have led to increased GSR levels.
Although a decrease of the KSAS from 32 to 22 points after ERP sessions only marks a partial response, the fact that the patient did not steal during the whole course of treatment remains remarkable (before the therapy, Mrs D stole almost every day), showing that treatment was effective despite the remaining symptoms as assessed via KSAS.
The very nature of kleptomania is the stealing of goods, e.g. from supermarkets. As this is a legal threat, it is not possible to completely duplicate this condition in an ERP setting. For ethical reasons it is advisable to talk to the patient about possible legal consequences and inform the supermarket officials before starting the therapy.
There is a considerable lack of diagnostic and/or predictive markers in psychiatry that are valid and easy to use for the transfer into a clinical setting (Venkatasubramanian and Keshavan, Reference Venkatasubramanian and Keshavan2016). However, within recent years an increasing amount of evidence has been accumulated that inflammatory (Fraguas et al., Reference Fraguas, Díaz-Caneja, Rodríguez-Quiroga and Arango2017), genetic (Breitenstein et al., Reference Breitenstein, Brückl, Ising, Müller-Myhsok, Holsboer and Czamara2015) or neuroimaging biomarkers (e.g. Xia et al., Reference Xia, Ma, Ciric, Gu, Betzel and Kaczkurkin2018) have discriminative or predictive power, although the associations between markers and treatment response are sometimes counter-intuitive. However, in the field of functional biomarkers, e.g. in neurophysiological research, several large studies have revealed meaningful patterns of ANS and CNS activity (Arns et al., Reference Arns, Bruder, Hegerl, Spooner, Palmer and Etkin2015; Olbrich et al., Reference Olbrich, Tränkner, Surova, Gevirtz, Gordon, Hegerl and Arns2016; Pizzagalli et al., Reference Pizzagalli, Webb, Dillon, Tenke, Kayser and Goer2018) that may inform the diagnostic process and the choice of treatment. The presented case now adds a possible marker for ERP treatment. It should be the focus of further research into how far GSR activity might help to identify patients that are in favour of a successful special treatment regime.
Conclusion
The results of this single case study underline the effectiveness of exposure and response prevention strategies in kleptomania. Although time intensive, this treatment approach grabs the symptoms where they occur and allows a personalized protocol for each patient. Patients suffering from kleptomania are likely to be able to transfer the new learned behaviours into their daily living routine.
Furthermore, the used GSR assessment seems to be a valid approach to monitor the sympathetic arousal and its decline during ERP sessions. Future approaches could use the direct assessment of arousal for direct neurofeedback to improve therapy outcome.
Author ORCID
Sebastian Olbrich, 0000-0001-5557-4878
Acknowledgement
We would like to thank Christian Sander for his support in using the skin conductance device.
Financial support
This work did not receive any grant support.
Conflicts of interest
The authors have no conflicts of interest.
Ethical statement
The study followed the Ethical Principles of Psychologists and Code of Conduct as set out by the APA. Ethical approval was not necessary as the treatment of the patient was part of a standard application of routine clinical practice in the specialized outpatients clinic of the hospital. Written informed consent for publication of the data was obtained from the patient.
Comments
No Comments have been published for this article.