KLEPTOMANIA AND ATTENTION DEFICIT HYPERACTIVITY DISORDER — CASE REPORT

Kleptomania as a type of impulse control disorder (ICD) characterized by an inability to resist urges to steal objects not valuable or needed for personal use. Kleptomania may co-occurs with many psychiatric disorders frequently other impulse control disorders, obsessive-compulsive disorder, anxiety disorders, affective disorders, eating disorders and substance use disorders. We presented two adolescent cases admitted to Marmara University Child and Adolescent Psychiatry outpatient clinic because of stealing behavior and diagnosed with Kleptomania and ADHD. Both cases had improvement in stealing behavior after ADHD treatment.Careful monitoring of comorbid conditions in the psychiatric evaluation of Kleptomania cases is very important in terms of treatment and prognosis.


INTRODUCTION
Kleptomania as a type of impulse control disorder (ICD )characterizedby an inability to resist urges to steal objects not valuable or needed for personal use (1).The average age is about 17, although 35% of the patients reports the onset of kleptomania as early as at age 11 (2).The prevalence and etiology of the disease is unknown due to low incidence of disease and not applying to hospital because of social stigma (3).The disorder is often diagnosed when patients seek help for comorbid disorders.Kleptomania may co-occurs with obsessive-compulsive disorder, anxiety disorders, affective disorders, eating disorders and substance use disorders (4).
The reare reports in the literature that Kleptomania cases benefit from different medications such as SSRIs, Lithium, Valproate, Opioid antagonists, stimulants in relation to the co-occuring psychiatric disorder.Subtyping of Kleptomania according to similarities to other psychiatric disorders may be useful to decide on treatment interventions (5).In this presentation, two adolescent cases who diagnosed with Attention Deficit Hyperactivity Disorder (ADHD)and Kleptomania and remitted after adding ADHD treatment will be described.

CASE 1
A 14-year-old girl was brought to our out-patient clinic because of her stealing behavior.In the interviews made with the mother, it was learnt that the behavior of the patient to receive non-essential objects had been presented for 5 years.It was also learned that she was a very active child, fidgeting in her seat, speaking too much, interrupting others and could not sit more than ten minutes while doing homework in her childhood.The patient expressed her complaints of unhappiness, irritability and forgetfulness too.The patient, who was embarrassed while talking about stealing behavior, said that in the third grade for the first time she stole her friends' pens and continued to steal without need.She also said that she had been feeling anxiety before this behavior, and she was feeling relief while stealing.Afterwards she regretted and put the stolen objects back.The mood of the patient was depressive, and the affect was markedly anxious.She felt guilty and remorse.She was diagnosed with Kleptomania, ADHD and Major Depressive Disorder due to history and psychiatric interviews.Patient's treatment was 1 mg of Risperidone and 50 mg of Sertraline daily.OROS MPH (osmotic release oral system Methylphenidate) 18 mg per day was initiated and planned dose increase.

CASE 2
A fifteen-year-old boy admitted to our outpatient clinic because of stealing money or goods belonging to others.His father said that the patient stole these objects although he did not need and that the patient continued to this behavior, even though his mother was ill after she heard what he had been done.It was also learned that the patient was easily distracted and delayed homework during the school years and was overactive in childhood, but had no behavioral problems, such as opposing to authority figures, harming animals or someone else's property.The patient verbally communicated, but gave short answers to the questions.Mental status examination revealed that patient's mood was depressiveand his affect was appropriate with depressive mood.Thought process was normal.There was regret and depressive themes about stealing behavior in thought contents.The patient was diagnosed with ADHD, Major Depressive Disorder, and Kleptomania.and Sertraline 25 mg perday, Risperidone 0,5 mg per day treatment was initiated.Subsequent interviews indicated that the patient was morally better but the desire to steal continued to be less.Significant improvement in the condition of the patient has been seen since the use of Risperidone medicine discontinued and OROS MPH added to treatment.The patient's treatment continues as Sertraline 25 mg, OROS MPH 27 mg per day.

DISCUSSION AND CONLUSION
We presented two adolescent cases admitted to Marmara University Child and Adolescent Psychiatry outpatient clinic because of stealing behavior and diagnosed with Kleptomania and ADHD.Both cases had improvement in stealing behavior after methylphenidate treatment.Kleptomania is defined as an impulse control disorder and the impulsivity is one of the main symptoms of the syndrome of ADHD.Dopaminergic systems have been implicated in impulsivity and impulse control disorders.Dysregulation of the dopamine system has been implicated in ADHD, too (6).The number of studies investigating the relationship between Kleptomania and other impulse control disorders in child and adolescents are rare.In one study, researchers reported that 15% of patients diagnosed with Kleptomania meet criteria for ADHD (5).Although the relation between Kleptomania and ADHD has not been proven, there are case reports indicating that the stealing behavior reduced after treatment of ADHD.Hergüner et al. reported that a 16 year-old girl diagnosed with ADHD and Kleptomania and remitted during methylphenidate treatment.They suggested that improving in Kleptomania may be related to the effect of MPH on dopaminergic systems (7).The other case report presents a school-age girl with ADHD suggested that the positive effects of methylphenidate on Kleptomania may be related to its ability to suppress the urges linked to experiencing reward and pleasure (8).
In the present case; it's indicated that MPH is effective in the treatment of Kleptomania comorbid with ADHD.Comorbid conditions need to be considered as they may affect the course and outcome of Kleptomania.

DECLARATION OF INTEREST
The autors declare that there are no conflicts of interests.
Klju~ne re~i: kleptomanija, psihijatrija. Correspondence This work is licensed under a Creative Commons Attribution 4.0 International (CC BY 4.0) License , Training and Research Hospital, Child and Adolescent Psychiatry Department, K2rºehir, Turkey