Troubling Link Between Shoplifting and Suicide

Compulsive theft can lead to tragic results.

In the fall of 2011, 71-year old Julia Grodinsky of London was convicted of shoplifting ornamental crystals and sentenced to 18 months of probation. What made the case unusual was that Grodinsky had been convicted of shoplifting 63 times over the past 60 years. It seems likely that the elderly thief will continue to steal, given her history of poor decision-making.

In The Republic, Plato asked whether thieves are made or born. It’s an excellent question. Kleptomania, as it is traditionally called, is a special class of theft behavior: a chronic condition marked by compulsive stealing, often committed by people who could easily afford to buy what they steal. Brian L. Odlaug, a visiting researcher with the faculty of health and medical sciences at the University of Copenhagen, believes that kleptomania’s primary feature is that it strikes "people who had a good marriage, nice home, great job—and yet could not stop from stealing inconsequential items." It is a rare disorder, he notes, “while sociopathy and theft for gain are quite common.”

Curiously, the stealing never seems to be about money: The most recent study measuring income and shoplifting shows that people in the United States with incomes over $70,000 shoplift 30 percent more than those earning less than $20,000 a year. Today, compulsive shoplifting is labeled in the DSM-IV as an impulse control disorder. But historically this controversial diagnosis was variously seen as a biological disorder brought on by female agitation in department stores, an expression of repressed Freudian sexual desire, or a socially constructed disease that blossomed as a reaction to modernity. (A modest majority of shoplifters are women). Some observers in the early 20th Century even described kleptomania as a clever trick by psychiatrists to worm their way into law courts as purveyors of expert testimony.

Researchers today are more likely to be interested in what researcher Jon E. Grant, professor of psychiatry and behavioral neuroscience at the University of Chicago’s Pritzker School of Medicine, calls the “neurocognitive sequelae of shoplifting.” Grant and Orlaug are part of a group of psychiatric researchers who have been studying compulsive shoplifting for more than a decade. In the Archives of Suicide Research, lead author Odlaug documented abnormally high suicide rates among a group of 107 participants with kleptomania, 24.3 percent of whom had reported at least one suicide attempt. That figure is “6 to 24 times higher than in the United States general population,” according to the report—roughly similar to the rate of suicide attempts among patients with schizophrenic disorders. It is higher than the rate of suicide attempts reported in cases of major depressive disorder (16.5 percent).

93 percent of the participants reported that their suicide attempt “was directly or indirectly due to their kleptomania symptoms (e.g., shame over the behavior; legal or personal problems resulting from shoplifting).” Believed to be the first attempt to survey the association between suicide and shoplifting, the study also teased out a strong association between bipolar spectrum disorder and kleptomania symptoms. The odds of a past suicide attempt were five times greater for kleptomania subjects who had also been diagnosed with bipolar disorder.

“The suicide data are very troubling,” says Grant. “No one screens for this behavior, or when they are told about, most clinicians are very dismissive of it. There is definitely an attitude about kleptomania that it is more of a criminal problem.”

Dr. Howard Shaffer, an associate professor at Harvard Medical School and director of the division on addiction at The Cambridge Health Alliance, who was not involved in the research, says that the work “seems a reasonable heads-up for clinicians to consider the role of impulsivity and its impact on suicidal ideation and behavior; kleptomania is one kind of proxy for impulsivity.”

Compulsive shoplifting is commonly associated with substance abuse, pathological gambling, personality disorders, and bipolar syndrome, while sometimes overlapping with other impulse control disorders. Does it share common neurobiological deficits with these conditions? In a report published in Comprehensive Psychiatry, Grant and co-workers recruited young adults with no history of substance abuse or recognized mental health disorders, and ran them through a barrage of psychological testing. For the investigators, the important question was whether compulsive stealing is associated with certain neuropsychological dysfunctions that make kleptomaniacs different from other people. As it turned out, people with kleptomania risked more points in a test called the Cambridge Gambling Task, with results “similar to previous reports in people with damage to the ventromedial prefrontal cortices.” It was an admittedly small study, but the researchers think the results show that shoplifting is not just a rash act, but one associated with “specific decision-making and working memory deficits.”

A small neuromaging study published by Grant in 2006 showed evidence of “compromised white matter microstructure in inferior frontal areas,” suggesting to Grant that the frontal parts of the brain involved in decision making “may not be as healthy.” For his part, Odlaug thinks this finding may help explain “why so many patients report an 'irresistible' impulse to steal and a failure to inhibit that impulse.” Odlaug cautions that while deficits of executive functioning appear to be involved, “I think it is far too early to suggest cognitive predictors of kleptomania or other disorders characterized by impulse control deficits.”

Neuroscientist Marc Lewis, professor of human development and applied psychology at Radboud University in Nijmegen, The Netherlands, and author of Memoirs of an Addicted Brain, also questions whether sufficient data existed for asserting a link between impulsive behavior and working memory deficits. However, Lewis agrees that kleptomania “is seemingly its own disorder,” and “overlaps only partially with other psychiatric categories.”

Can kleptomania be cured, or treated successfully? In 2009, in an article for Biological Psychiatry, Grant and colleagues recorded the results of their work with 25 patients with kleptomania who were given high doses of naltrexone, a drug that blocks opioid receptors and is used to treat alcoholism and heroin addiction. All of the participants had been arrested, and had spent at least one hour per week stealing. The 8-week study, believed to be the first placebo-controlled trial of a drug for the treatment of shoplifting, resulted in a remission of symptoms in two-thirds of those on naltrexone. Says Odlaug: “With such a dearth of treatment data available, naltrexone appears to be the first-line treatment at this time. We have found that naltrexone at slightly higher doses is beneficial for a number of folks with kleptomania.” Some researchers are also investigating use of cognitive behavioral therapies.

“Kleptomania is thought of as a behavioral addiction within addiction circles,” Odlaug adds, while conceding that not everyone agrees with the concept of addiction to behaviors rather than substances. The neuropsychological approach to uncontrollable shoplifting as by no means unanimous. Writing in Global Society, Thomas Lenz and Rachel MagShamhrain argue that kleptomania is an “invented disease,” coinciding with the rise of the department store and strong beliefs in feminine “hysteria.”

“I think the general view,” says Grant, “is that criminal issues, or potential criminal issues, are not as biological as, say, depression. It then becomes a vicious cycle, as lack of research then continues to justify why people say it is not really biological or psychological.”

Lamentably, the connection between bipolar syndrome and shoplifting did not become apparent until recently, because people with bipolar symptoms are routinely ruled out of clinical studies of impulse control disorders. “Screening for people with co-occurring bipolar affective disorder and kleptomania is extremely important,” Odlaug stresses. “Especially in psychiatric settings where kleptomania and other impulse control disorders often go unrecognized by clinicians.”

(By Dirk Hanson. Originally published February 11, 2013, by the Dana Foundation.)

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Short Subjects

Brief news on drugs and addiction.

The editorial staff at Addiction Inbox (see photo), occasionally finds itself overwhelmed with news and opinion worth broadcasting. Hence, this bullet list of drug/alcohol related news from recent weeks:

•    Children with heavy alcohol exposure show decreased brain plasticity, according to recent research on fetal alcohol spectrum disorders (FAS) using magnetic resonance imaging (MRI) scans. The research, supported by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), included 70 children heavily exposed to alcohol in utero. According to NIAAA, the children showed “lost cortical volume,” described in the study as a pattern of static growth “most evident in the rear portions of the brain—particularly the parietal cortex, which is thought to be involved in selective attention and producing planned movement.”

•    Combining medications for a better outcome is a staple of medical practice. So it’s not surprising to see the same thing being investigated in addiction treatment. Scientists evaluating medications for alcoholism have found that in some cases, mixing the medicine gives better outcomes. In two separate trials, naltrexone proved to be a more effective treatment for alcoholism when combined with either acamprosate (reported in Addiction), or baclofen (as detailed by Dr Mark Gold at the recent meeting of the Society for Neuroscience). In the Addiction study, the authors concluded that “acamprosate has been found to be slightly more efficacious in promoting abstinence and naltrexone slightly more efficacious in reducing heavy drinking and craving,” which suggests the possibility of using different drugs at different stages of recovery for maximum benefit. In preliminary work on baclofen, some researchers now claim that combining it with naltrexone often leads to better outcomes.

•    Every year at about this time, the rumors start flying: Did you hear that Amsterdam is closing its marijuana coffee shops? This breathless annual announcement is never true, and this year, despite all the fuss over “weed passes” and border skirmishes over drug traffic in the south of the Netherlands, Amsterdam’s mayor recently announced that he has no attention of closing the roughly 200 cannabis shops in his city by year’s end, as originally mandated by the now-defunct conservative government. In addition, rumors are flying that the incoming cabinet of Prime Minister Mark Rutte is already backing away from the previous government’s position on banning foreigners from the shops, according to a New York Times report. “Changes to the new policy have not been finalized,” according to a spokesperson for the Dutch Justice Ministry, quoted in the Times. Rutte himself has hinted that the ban may remain intact, but that local councils may be allowed to override that decision—an outcome not untypical of Dutch politics. “I’m guessing that behind the curtains, it’s already been arranged,” said Michael Veling of the Dutch Cannabis Retailers Association.

•    Here’s a finding you can easily test for yourself. Conduct a conversation with a heavily intoxicated chronic drinker. Introduce ironic, “wink-wink” comments into the exchange. Really lay on the irony. And then sit back and watch most of it sail right by your drunk and maddeningly literal companion. And now science is attempting to confirm it: A modest recent study in Alcoholism: Clinical and Experimental Research says that “drinking too much alcohol can interfere with men’s feelings of empathy and understanding of irony.” 22 men in an alcoholic treatment program read a series of stories ending with either an ironic comment or a straightforward one. Chronic heavy drinkers identified ironic sentences 63 % of the time, compared to a group of non-alcoholics, who identified 90 % of the ironic comments. Lead researcher Simona Amenta said in a press release that the results may mean that alcoholics “tend to underestimate negative emotions; it also suggests that the same situation might be read in a totally different way by an alcoholic individual and another person.” Ya think?

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Broken Treatment: How the Addiction Industry is Failing its Clients

It’s not medical. It's not psychiatric. What is it?

1. Most clinicians who treat addicted patients are counselors, not physicians; thus they cannot prescribe medication and they generally don’t “believe” in the use of medication for addictive disorders.

2. Most patients have medical insurance that excludes or severely limits treatment of addictive disorders, so payment for service is not good. This situation may change in the near future with the advent of healthcare reform in the United States.

So writes Dr. Charles O’Brien of the University of Pennyslvania Perelman School of Medicine, in a recent article for The Dana Foundation’s website.  In his article—“If Addictions Can Be Treated, Why Aren’t They?”—Dr. O’Brien asks a basic question: “Why are most patients not even given a trial of medication in most respected treatment programs?”

Even though pharmaceutical companies have throttled back on their interest in anti-craving drugs in recent years, there are, in fact, a few medications recognized by the FDA, primarily for use in the treatment of alcoholism. But they are not much in favor, and O’Brien believes he knows why:

The answer seems to be that there is a bias among treatment professionals, perhaps passed down from past generations when addictions were not understood to be a disease. Medically trained personnel are minimally involved in the addiction treatment system and most medical schools teach very little about addiction so most physicians are unaware of effective medications or how to use them.

What is on offer at most addiction treatment facilities is not actual rehabilitation, but rather short-term detoxification. And what we’ve learned from neuroscience is that taking away the drug is only stage one. The addiction remains, the reward and memory systems still operating erratically. We understand some of this circuitry better than at any time in history, but the concrete effects of these insights at the level of the community treatment clinic have been small to nonexistent. Money, of course, is part of it, since addiction has only recently, and sporadically, gotten the attention of funding agencies in the public health community. 

Health journalist Maia Szalavitz, writing at Time Healthland concurs: “Unlike most known diseases, the treatment of addiction is not based on scientific evidence nor is it required to be provided by people with any medical education—let alone actual physicians—according to a new report.” The report in question, from Columbia University’s National Center on Addiction and Substance Abuse (CASA), notes that most people are shoehorned into a standardized approach built around the 12 Step model of Alcoholics Anonymous. “The dominance of the 12-step approach,” writes Szalavitz, “also leads to a widespread opposition to change based on medical evidence, particularly the use of medications like methadone or buprenorphine to treat opioid addictions—maintenance treatments that data have show to be most effective.”

  Szalavitz also believes she knows why, and her thinking is similar to O’Brien’s. “Other medications that are known to treat alcohol and drug addiction, such as naltrexone, are also underutilized,” she writes, “while philosophical opposition to the medicalization of care slows uptake.”

There is a straightforward reason for considering the use of medication in the treatment of addiction: strong suggestions of recognizable genetic differences between those who respond to a given medication, and those who don’t. As O’Brien explains, a prospective study now in progress will be looking to see if alcoholics with a specific opioid receptor variant show a better outcome on naltrexone than those with the standard gene for that opioid receptor. And if they do, the FDA may allow a labeling change “stating that alcoholics with this genotype can be expected to have a superior response to naltrexone.”

But that won’t be happening tomorrow. In the meantime, we are stuck with the addiction treatment industry as it is. “The [CASA] report notes that only 10% of people with substance-use problems seek help for them,” Szalavitz concludes. “Given its findings about the shortcomings of the treatment system, that’s hardly surprising.”

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A Drug for Kleptomania?

Naltrexone curbs shoplifting.

It seems like such an unlikely finding: In a University of Minnesota study of kleptomania—the compulsion to steal—a popular medicine used to treat both heroin addiction and alcoholism drastically reduced stealing among a group of 25 shoplifters. The drug, naltrexone, blocks brain receptors for opiates. It is one of the few drugs available for the treatment of alcoholism, and continues to gain momentum as a treatment for opiate addiction.

In an article for the April issue of Biological Psychiatry, Jon Grant and colleagues at the University of Minnesota School of Medicine record the results of their work with 25 kleptomaniacs, most of them women. All of the participants had been arrested for shoplifting at least once, and spent at least one hour per week stealing. The 8-week study is believed to be the first placebo-controlled trial of a drug for the treatment of shoplifting.

In the April 10 issue of Science, Grant said that “Two-thirds of those on naltrexone had complete remission of their symptoms.” According to Samuel Chamberlain, a psychiatrist at the University of Cambridge in the U.K., the study strongly suggests that “the brain circuits involved in compulsive stealing overlap with those involved in addictions more broadly.” The study, in short, strengthens the hypothesis that the shoplifting “high” may have much in common with the high produced by heroin or alcohol.

Researchers are also working with the drug memantine as a treatment for compulsive stealing.

The finding lends additional evidence to the theory that shoplifting is a dopamine- and serotonin-driven disorder under the same medical umbrella as drug addiction and alcoholism. Preliminary research has shown that naltrexone may also have an effect on gambling behavior.

If so-called “behavioral addictions” continue to display biochemical similarities with “chemical addictions,” the move to broaden the working definition of addiction will continue to intensify. And the same sorts of questions that plague addiction research will be replayed in the behavioral sphere: What level of shoplifting constitutes the disorder called kleptomania? Isn’t the medicalization of shoplifting just a way to excuse bad behavior? Is medical treatment more effective than jail time? From a legal point of view, what is the the difference between kleptomania and burglary?

In his book, America Anonymous, Benoit Denizet-Lewis quotes lead study author Jon Grant: “With all addictions, a person’s free will is greatly impaired, but the law doesn’t want to entertain that.... Why shouldn’t someone’s addiction be considered as a mitigating factor, especially in sentencing?”

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Anti-Craving Drug Eases Pain of Fibromyalgia

Naltrexone being studied for immune-related disorders.

A drug frequently used to treat heroin and alcohol addiction also eased the pain of women suffering the symptoms of fibromyalgia, according to a Stanford study published in the April 17 journal of Pain Medicine.

Fibromyalgia remains a controversial diagnosis. As reported by Coco Ballantyine in Scientific American online, it is a “mysterious ailment whose symptoms include chronic widespread muscle pain, fatigue, sleep problems, anxiety and depression, often appears between the ages of 34 and 53 and is more common in women.”

Jarred Younger and Sean Mackey of the Stanford School of Medicine’s pain management division reported that pain and fatigue ratings for the women dropped by 30% over the 14 weeks of the study. “Patients’ reactions were really quite profound,” said Mackey. “Some people went back to work really improving their quality of life.”

Tara Campbell, one of the patients involved in the study, told the Stanford News Service that she was feeling “really, really good.” She said “my improvement was about 40 percent in the study. When you’re not capable of doing much of anything, that’s a lot... I’m much more back to normal.”

Younger said he became interested in studying naltrexone after he began questioning patients who claimed to be suffering from the disorder. “I was asking patients, ‘Does anything work for you?’ A lot of people in support groups were saying, ‘Yeah, I tried naltrexone and it works for me.’”

Naltrexone is currently used as a treatment for heroin addiction and for alcoholism. (See my post, "Drugs for Alcoholism.") Naltrexone works by locking into central nervous system receptors normally occupied by opiates or by the body’s own endorphins. Researchers like Younger, however, believe that naltrexone also dampens the activity of immune cells known as microglia that are involved in inflammatory responses.

It is not uncommon for scientists to investigate the additional effects of drugs in common use. “From a regulatory point of view,” said Canadian addiction researcher Edward Sellers in my book, The Chemical Carousel, “companies don’t try to develop [new drugs] for forty-three different things. But these drugs still carry with them many other pharmacologic actions. The history of virtually every drug that comes to market is that all these other secondary applications start to manifest themselves.”

Graphics Credit: http://www.aocbv.com/fibromyalgia.html

Drugs for Alcoholism

Different meds for different drinkers


Although there are still only three drugs officially approved by the FDA for the treatment of alcoholism, the research picture is beginning to change. In an article by Greg Miller published in the 11 April 2008 edition of Science, alcoholism researcher Stephanie O'Malley of Yale University said: "We have effective treatments, but they don't help everyone. There's lots of room for improvement."

The medications legally available by prescription for alcoholism are: disulfiram (Antabuse), naltrexone (Revia and Vivitrol), and acamprosate (Campral), the latest FDA-approved entry. A fourth entry, topiramate (Topamax), is currently only approved by the Food and Drug Administration (FDA) for use against seizures and migraine. The controversial practice of “off-label” prescribing—using a drug for indications that are not formally approved by the FDA—has become so common that Johnson & Johnson said it had no plans to seek formal approval for the use of Topamax as a medicine for addiction. (See my post,"Topamax for Alcoholism: A Closer Look").

Addiction experts are beginning to focus on which treatment drugs work best for different types of alcoholics. Two recent discoveries might help clarify the picture. Psychopharmacologist Charles O'Brien at the University of Pennsylvania reported that alcoholics with a specific variation, or allele, of a prominent opioid receptor gene were more likely to respond positively to treatment with naltrexone. Other work reported in the February 2008 Archives of General Psychiatry came to the same conclusion.

The second research insight builds on a lifetime of work by Robert Cloninger at Washington University in St. Louis. Cloninger discovered that alcoholics come in two basic flavors--Type 1 and Type 2. Type 1, the more common form, develops gradually, later in life, and does not necessarily require structured intervention. Type 1 alcoholics do not always experience the dramatic declines in health and personal circumstances so characteristic of acute alcoholism. These are the people often found straddling the line between alcoholic and problem drinker. In contrast, so-called Type 2 alcoholics are in serious trouble starting with their first taste of liquor during adolescence. Their condition worsens with horrifying speed. They frequently have a family history of violent and antisocial behavior, and they often end up in prison. They are rarely able to hold down normal jobs or sustain workable marriages for long. Type 2s, also known as “familial” or “violent” alcoholics, are likely to have had an alcoholic parent.

Type 1 drinkers, who only get in trouble gradually, are also known as "anxious" drinkers, and research suggests that they may respond better to medicines that alleviate alcohol-related anxiety, such as Lilly's new suppressor of stress hormones, known as LY686017. (See my post, "Drug That Blocks Stress Receptor May Curb Alcohol Craving "). Researchers at the National Institute of Alcohol Abuse and Alcoholism (NIAAA), working with colleagues at Lilly Research Laboratories and University College in London, announced the discovery of a drug that diminished anxiety-related drug cravings by blocking the so-called NK1 receptor (NK1R). The drug “suppressed spontaneous alcohol cravings, improved overall well-being, blunted cravings induced by a challenge procedure, and attenuated concomitant cortisol responses.”

The NIAAA researchers are making effective use of recent findings about the role played by corticotrophin-releasing hormone (CRH) in the addictive process. CRH is crucial to the neural signaling pathway in areas of the brain involved in both drug reward and stress. As it happens, NK1R sites are densely concentrated in limbic structures of the mid-brain, such as the amygdala, or so-called “fear center.”

Researchers are understandably excited about these developing insights. Psychopharmacologist Rainer Spanagel of Germany's Central Institute of Mental Health in Mannheim called such research "a milestone in pharmacogenetics." In Greg Miller's Science article, Willenbring of NIAAA predicted that the field is poised for a "Prozac moment," marked by the discovery of "a medication that's perceived as effective, that's well-marketed by a pharmaceutical company, and that people receive in a primary-care setting or general-psychiatry setting."

In "Days of Wine and Roses, " the 1960s film about alcoholism, Jack Lemmon played a character who embodied Type 2 characteristics--early trouble with alcohol, extreme behavioral dysregulation, poor long-term planning, and a hollow leg. His wife, played by Lee Remick, demonstrates the slower, more measured descent from problem drinking into clinical alcoholism that characterizes Type 1 alcoholics. Research now suggests that Lee Remick might do better on LY686017, while Jack Lemmon's character would be a promising candidate for treatment with naltrexone.

Photo credit: About Alcohol Information

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