Hoarding Disorder and Its Comorbidity with Kleptomania: A Case Report

Dear Editor,

Kleptomania, an impulse control disorder, is characterized by a recurrent inability to resist urges to steal objects not needed for personal use or monetary value, frequently co-occurring with obsessive-compulsive disorder (OCD), anxiety disorders (AD), and mood disorders (MD). ¹ The act is often accompanied by pleasure followed by guilt. ¹ Hoarding disorder (HD), classified under obsessive-compulsive and related disorders, involves persistent difficulty discarding possessions, regardless of value. ² The rare comorbidity of kleptomania and HD complicates clinical presentations. ³

This case report details the complex interplay of OCD, generalized anxiety disorder (GAD), major depressive disorder (MDD), HD, and kleptomania in a woman with significant childhood trauma, multiple life stressors, and medical comorbidities, along with the clinical management of this intricate condition. Written informed consent from the patient for publication of this case report.

Case Report

A 55-year-old female patient, previously diagnosed with OCD and MDD, presented with anhedonia, cleaning compulsions, stealing and hoarding bread, and intense anxiety related to social events. A detailed history revealed her symptoms were part of a complex psychiatric picture.

Her history included multiple traumatic experiences: her father died in a traffic accident when she was 10 years old, followed by separation from her mother. She was sexually abused at age 13 and forced into marriage at 14, subsequently experiencing neglect and infidelity by her husband. She provided care for her physically disabled children. Twenty-six years prior, she had experienced a severe earthquake, followed by years of economic hardship, which led to nutritional scarcity. Her child had not spoken to her for nine years. Two years prior to presentation, she experienced another severe earthquake.

Since early adulthood, the patient had experienced OCD symptoms, trichotillomania, and conversion seizures. Stealing and hoarding bread behaviors began during the period of economic hardship following the first earthquake and were limited to bread. Her initial psychiatric consultation occurred 10 years prior to a depressive episode. Following the earthquake two years before the presentation, her bread hoarding behavior significantly increased.

Her medical history was significant for five abortions, a hysterectomy for endometrial cancer (10 years prior), thyroidectomy (7 years prior), morbid obesity, Obstructive Sleep Apnea Syndrome (OSAS), and annual periorbital Botox injections for blepharospasm (5 years). Laboratory tests and electroencephalography (EEG) results were within normal limits.

On examination, she appeared her stated age, was morbidly obese, had normal speech, and was cooperative. Involuntary eye blinking was observed. Her consciousness was clear, and she was oriented. No psychopathological findings were noted in perception. Her intelligence was clinically normal, and her judgment was intact. Her thought process exhibited normal associations. The content of her thoughts included issues with her husband, problems in family relationships, imaginations of impending adverse events, cleaning and harm obsessions, and remorse regarding her bread-stealing behavior. No psychomotor agitation was observed. She denied active suicidal or homicidal ideation.

Anxiety symptoms were assessed with the Beck Anxiety Inventory (BAI),^4,5 depressive symptoms with the Beck Depression Inventory (BDI),^6,7 and obsessive-compulsive symptoms with the Yale-Brown Obsessive-Compulsive Scale (YBOCS).^8,9 Psychometric assessments revealed a BAI score of 40, a BDI score of 28, and a YBOCS score of 30.

Based on these findings, the patient was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) with OCD, MDD, GAD, HD, Kleptomania, and Chronic Motor or Vocal Tic Disorder. Her existing treatment of sertraline 100 mg/day and aripiprazole 5 mg/day was adjusted to sertraline 200 mg/day and aripiprazole 5 mg/day, and a follow-up appointment was scheduled. However, the patient did not return for six months. At the six-month follow-up, it was learned that she had been in another city due to family reasons, where she continued psychiatric follow-ups. Five months prior, she underwent bariatric surgery and experienced a 25 kg weight loss. She reported increased anxiety and depressive symptoms due to family problems. Notably, her bread-stealing and hoarding behaviors had decreased and disappeared after acquiring a cat during this period. A supportive interview was conducted. Her psychopharmacological treatment was revised to sertraline 200 mg/day and buspirone 15 mg/day, and cognitive behavioral therapy was planned. The patient’s psychiatric follow-up and treatment are ongoing.

Discussion

The patient’s cycle of brief pleasure followed by intense shame after stealing bread aligns with kleptomania. Psychoanalytic approaches explain kleptomania from various perspectives, including as a defense mechanism against anxiety, involving repressed sexual urges, a search for symptomatic relief, an attempt to replace a lost object, and a repair of narcissistic injury.^1,10–12 It has also been suggested that kleptomanic stealing may represent an attempt to compensate for early losses. ¹² In this regard, similar to this case, a case of kleptomania with a history of abortion and loss of father at an early age has been reported. ¹¹ Similarly, cases of kleptomania with a history of curettage and early separation from parents, ¹² and loss of father at the age of 12 due to a traffic accident have been reported. ¹³

The onset of the patient’s stealing and hoarding behaviors, limited to bread, following economic hardship after the earthquake, underscores the triggering and perpetuating role of trauma on symptom initiation and severity. Indeed, kleptomania has been reported to emerge after an anger-provoking event or stressors. ¹³

The patient’s report that her stealing and hoarding behaviors ceased after acquiring a cat is noteworthy. This suggests a potential influence of changes in the patient’s oxytocin levels following pet ownership on her impulsivity. While impulse control disorders have been associated with low oxytocin levels, ¹⁴ it has been reported that owning a pet can increase oxytocin levels. ¹⁵

Consistent with existing literature, this patient presented with co-morbid OCD and MDD, which were her primary complaints upon psychiatric presentation.^12,13,16 This complex presentation poses a risk of diagnostic overshadowing. That is, more prevalent disorders like MDD and OCD might obscure conditions such as HD and kleptomania, potentially leading to inadequate treatment for these specific issues. Conversely, focusing solely on a rarer condition like kleptomania risks underestimating the broader impact of underlying depression, anxiety, and trauma. The patient’s clinical picture demonstrates a significant overlap and interaction between diagnoses, suggesting a dynamic relationship rather than independent entities. Trauma likely played a fundamental role in affecting emotional regulation, impulse control, and attachment processes, potentially contributing to the various symptoms across different diagnostic categories.

As with other impulse control disorders, Selective Serotonin Reuptake Inhibitors (SSRIs) are considered first-line pharmacological treatment for kleptomania. ¹⁶ Given the patient’s co-morbid psychiatric diagnoses, sertraline, an SSRI, was chosen and titrated to the maximum recommended dose of 200 mg/day, with the addition of buspirone for augmentation.

This case demonstrates how trauma can manifest itself in complex, interrelated psychiatric symptoms that challenge traditional diagnostic boundaries. Comorbidity between HD and kleptomania is rare, and the emergence of bread-focused stealing and hoarding behaviors following economic hardship provides important clinical insights. It also offers a new perspective on the possibility of improvement through an oxytocin-mediated mechanism following pet ownership in impulse control disorders.

However, insufficient follow-up time and inadequate follow-up data for evaluating treatment responses are the limitations of this case.

Conclusions

This case highlights that trauma can lead to comorbidity with many psychiatric disorders, including kleptomania and HD, and that pet ownership may play a role in recovery from kleptomania and HD. The co-occurrence of kleptomania and HD is rare, making this case particularly interesting. These patients should be evaluated and treated comprehensively, taking into account their trauma history and other psychiatric diagnoses. Further research is needed to elucidate the role of pet ownership in recovery and its potential mechanisms.

Supplemental Material

Supplemental material for this article is available online.