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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Chantix and Suicide

Anti-smoking pill joins the list—but is the risk real?

The U.S. Food and Drug Administration fired both barrels last week, announcing that a variety of anti-seizure medications—as well as the anti-smoking pill, Chantix—may increase the risk of suicidal thoughts in patients who take them. The FDA will require new label warnings for a total of 11 drugs used for epilepsy.

New label warnings are also in the works for Chantix, the nicotine cessation aid being widely used by people attempting to quit smoking cigarettes. In a public health advisory issued last Friday, the FDA declared it “increasing likely” that Chantix may be associated with psychiatric problems. A month earlier, the FDA had advised that Chantix users should be monitored for the onset of suicidal urges, but backed off from making a strict cause-and-effect connection.

The FDA reviewed clinical data on anti-epileptic medications, including Pfizer’s Neurontin and Ortho-MacNeil’s Topamax, and concluded that “patients who are currently taking or starting on any anti-epileptic drug should be closely monitored for notable changes in behavior that could indicate the emergence or worsening of suicidal thoughts or behavior or depression.” Topamax has shown additional promise as an anti-craving medication for alcoholism.

This follows on the heels of earlier warnings about increased suicide risk in adolescents taking SSRI antidepressants.

In the case of Chantix, the FDA’s Bob Rappaport, in a conference call with reporters, said the agency had “no definitive evidence there is a causal relationship here, they are just strongly appearing to be related.” Rappaport, quoted at WSJ.com, also said that “Chantix has proven to be effective in smokers motivated to quit,” and that the new warnings would help doctors and patients “make an informed decision regarding whether or not to use this product.”

A spokesman for Pfizer, quoted at Bloomberg.com, said that “no causal relationship has been established. There are some post-marketing reports and you cannot exclude those. We go by our scientific data, and from our clinical trial data we have not seen this.”

Discussions about a possible link between Chantix and suicide were fueled by the death last year of New Bohemians lead singer Carter Albrecht, who was shot while attempting to break into a house in Dallas. His girlfriend told authorities that his behavior had been erratic since he began taking Chantix in an effort to stop smoking.

In no case are the numbers of suicides linked to any of the drugs alarmingly high. The FDA study of epilepsy medications appears to demonstrate, as summed up by the San Francisco Chronicle’s Bernadette Tansey, “2.1 more people for every 1,000 on the medications exhibited suicidal thoughts or behavior, compared with every 1,000 on placebo.”

Note that the FDA is not discussing an increased risk of suicide, but rather an increased risk of suicidal thoughts or feelings. This is called “suicidal ideation.” The FDA usually refers to it as “suicidality.” Unlike an actual suicide attempt, suicidal ideation is the act of contemplating the act—a sort of “what if.” It is the difference, as a mental patient once put it, between buying the rope, and contemplating buying the rope

Persistent suicidal ideation is obviously not a desirable state of mind. But it does not downplay this behavior to note that it is, by nature, often fleeting and difficult to quantify. Moreover, the act of going cold turkey itself can cause heavily addicted people to feel temporarily suicidal—to ideate about killing themselves without killing themselves. These and other factors make it difficult to reach firm statistical conclusions about such risks.

For a Chantix user's point of view on the debate, visit www.stopsmokingcigs.com

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