A 16-year-old boy comes to the office due to crippling anxiety. The patient recently quit his job at a local convenience store due to the anxiety. He was responsible for closing the store at the end of his shifts but was overwhelmed by an uncontrollable urge to take keychains from one of the displays. One evening, as the patient was closing the store, he acted on this impulse and felt better. However, he then felt guilty and could not sleep; the next morning, he returned the keychain before anyone noticed. Over the next few weeks, the patient felt increasingly restless during his shifts and scared about being left alone with the merchandise at the end of the day. After 3 more instances of taking keychains and returning them, he stopped going to work because he liked the manager and was afraid of getting caught. The patient has otherwise been attending high school classes regularly. He has no medical conditions. He smokes marijuana on weekends. Physical examination is unremarkable. TSH is within normal limits. Which of the following is the most likely diagnosis?

Question

A 16-year-old boy comes to the office due to crippling anxiety.  The patient recently quit his job at a local convenience store due to the anxiety.  He was responsible for closing the store at the end of his shifts but was overwhelmed by an uncontrollable urge to take keychains from one of the displays.  One evening, as the patient was closing the store, he acted on this impulse and felt better.  However, he then felt guilty and could not sleep; the next morning, he returned the keychain before anyone noticed.  Over the next few weeks, the patient felt increasingly restless during his shifts and scared about being left alone with the merchandise at the end of the day.  After 3 more instances of taking keychains and returning them, he stopped going to work because he liked the manager and was afraid of getting caught.  The patient has otherwise been attending high school classes regularly.  He has no medical conditions.  He smokes marijuana on weekends.  Physical examination is unremarkable.  TSH is within normal limits.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient's anxiety associated with repetitive impulses to steal is likely due to kleptomania, a rare impulse control disorder with typical onset in adolescence. These individuals experience impulses to steal objects of low monetary value or not needed for personal use. In contrast, typical shoplifters steal for personal gain, and their acts are usually premeditated. In kleptomania, overwhelming anxiety or tension precedes impulses and is relieved with the theft. Guilt and shame typically follow, so these individuals may return or give away stolen items. Kleptomania can be treated with psychotherapy and medications. Psychotherapy involves a cognitive-behavioral therapy orientation, focusing on techniques to resist and manage urges and anxiety. (Choice A) Individuals with antisocial personality disorder (diagnosed in individuals age ≥18) typically steal for personal gain and also engage in other behaviors that violate the rights of others (eg, aggression, property destruction). (Choice C) Although isolated instances of stealing may be seen as a form of limit testing in adolescence, this patient's repetitive impulses to steal, preceded by anxiety and followed by relief, are more consistent with kleptomania. (Choice D) Obsessive-compulsive disorder is characterized by intrusive thoughts and associated ritualistic behaviors performed in response to obsessional thoughts. Although it may also present with incapacitating anxiety, it would not explain the relationship of this patient's anxiety to his difficulty controlling his impulses to steal. (Choice E) Typical shoplifters steal for personal gain, and their acts are usually premeditated. (Choice F) Although marijuana can cause transient acute anxiety in some users, this patient's use is limited to weekends and would not explain his repetitive impulses to steal. Educational objective: Kleptomania is an impulse control disorder characterized by an inability to resist the impulse to steal objects of low monetary value or not needed for personal use. References: Stealing behavior and impulsivity in individuals with kleptomania who have been arrested for shoplifting. (http://www.ncbi.nlm.nih.gov/pubmed/29127886) Kleptomania: recent advances in symptoms, etiology and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/30341533)

A 16-Year-Old Boy Comes to the Office Due to Crippling