Pathological Stealing in Dementia: Poor Response to SSRI Medications

To the Editor: Pathological stealing is kleptomanic behavior due to brain disease. As with kleptomania, there is an inability to resist stealing unneeded objects of insignificant value.1 Kleptomania may be related to obsessive-compulsive disorder (OCD) and could respond to selective serotonin reuptake inhibitor (SSRI) medications, the treatment of choice for OCD.2,3 Herein, we report 4 frontotemporal dementia patients with pathological stealing and their treatment with SSRI medications.

 

Case 1. Ms A, a 59-year-old woman, had a 2-year history of petty theft and a progressive personality change. She would go into stores and take items without concern for payment or witnesses. She made personal comments to strangers, had a decline in empathy and self-care, and developed compulsive behaviors and an addiction to ice cream. On examination, she had a memory deficit, poor naming, and executive dysfunction. Functional neuroimaging showed decreased perfusion in the frontal and anterior temporal lobes.

Case 2. Mr B, a 60-year-old man, began entering his coworkers’ areas and stealing small items from their desks, shelves, or cabinets. He had a 3-year history of a progressive personality change characterized by decreased initiative, disinhibition, lack of empathy, compulsive behaviors including hoarding, indiscriminate eating, and decreased personal hygiene. On examination, he had impaired memory, decreased naming, and executive dysfunction. Functional neuroimaging showed prominent frontal hypometabolism.

Case 3. Ms C, a 58-year-old woman with a personality change, was apprehended for stealing food in grocery stores and cafeterias. She had became disengaged from her prior activities and emotionally detached from her family. There were uncharacteristic incidents of disinhibited behavior in which she passed gas in public or made off-color comments. She had repetitive behaviors and dietary changes. On examination, she had a memory retrieval deficit and executive dysfunction. Functional neuroimaging showed prominent frontal hypometabolism.

Case 4. Mr D, a 48-year-old man with a 3-year history of a progressive personality change, got into difficulty for stealing oranges from his neighbor’s trees. His personality change began with decreased completion of his work, decreased concern for his family, and inappropriate verbal commentary and touching of others. He became disheveled, developed compulsive hoarding, and had a food fad for ice cream. On examination, his language and executive functions were impaired. On functional neuroimaging, he had hypometabolism of the frontal lobes.

Summary of treatment. All 4 patients met criteria for frontotemporal dementia.4 They underwent trials of sertraline (up to 200 mg), fluoxetine (up to 60 mg), and paroxetine (up to 60 mg) of 6 months or longer, without attenuation of pathological stealing.

 

Pathological stealing can be a prominent feature of neurologic disorders that involve the frontal lobes.2,5 The most common cause of pathological stealing appears to be frontotemporal dementia, a common dementia in the presenium characterized by disinhibition, inertia, lack of empathy, compulsive behaviors, and eating disorders.4,5 There is no established treatment for pathological stealing. One model suggests that compulsive, repetitive behaviors facilitate kleptomania,3 implicating the use of SSRIs for pathological stealing. Unfortunately, neither the literature nor our patients support a definite response to SSRI medications for pathological stealing.3,6 Kleptomania, and pathological stealing, may be more similar to substance use disorders than to OCD, and future research should establish whether pathological stealing would respond to medications like topiramate or naltrexone.7,8

References

1. American Psychiatric Association, Task Force on DSM-IV. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association; 1994.

2. Kozian R. Kleptomania in frontal lobe lesion. Psychiatr Prax. 2001;28(2):98–99. PubMed doi:10.1055/s-2001-11578

3. Grant JE. Understanding and treating kleptomania: new models and new treatments. Isr J Psychiatry Relat Sci. 2006;43(2):81–87. PubMed

4. Neary D, Snowden JS, Gustafson L, et al. Frontotemporal lobar degeneration: a consensus on clinical diagnostic criteria. Neurology. 1998;51(6):1546–1554. PubMed

5. Mendez MF, Chen AK, Shapira JS, et al. Acquired sociopathy and frontotemporal dementia. Dement Geriatr Cogn Disord. 2005;20(2–3):99–104. PubMed doi:10.1159/000086474

6. Koran LM, Aboujaoude EN, Gamel NN. Escitalopram treatment of kleptomania: an open-label trial followed by double-blind discontinuation. J Clin Psychiatry. 2007;68(3):422–427. PubMed doi:10.4088/JCP.v68n0311

7. Dannon PN. Topiramate for the treatment of kleptomania: a case series and review of the literature. Clin Neuropharmacol. 2003;26(1):1–4. PubMed doi:10.1097/00002826-200301000-00001

8. Grant JE, Kim SW, Odlaug BL. A double-blind, placebo-controlled study of the opiate antagonist, naltrexone, in the treatment of kleptomania. Biol Psychiatry. 2009;65(7):600–606. PubMed doi:10.1016/j.biopsych.2008.11.022

Mario F. Mendez, MD, PhD

mmendez@UCLA.edu

Author affiliation: Departments of Neurology and Psychiatry & Biobehavioral Sciences, David Geffen School of Medicine, University of California at Los Angeles; and Department of Neurobehavior, VA Greater Los Angeles Healthcare System, Los Angeles, California. Potential conflicts of interest: None reported. Funding/support: This work was supported by National Institute on Aging grant #R01AG034499-02.