Kleptomania: making sense of the nonsensical.

OBJECTIVE: Kleptomania, or the irresistible impulse to steal unneeded objects, is a poorly understood disorder. The objectives of this paper are to critically review and integrate existing data and to make suggestions for further research. DATA COLLECTION: Information was gathered by reviewing the English-language literature on kleptomania. Cases were chosen for review that approximated the diagnosis as defined in DSM-III-R. These cases were analyzed in terms of their relationship to previous theories about the disorder, and larger relevant studies were examined. Using the data organized into a table, the author explores areas of convergence and disagreement and discusses the methodological difficulties of the different studies. FINDINGS: Kleptomania is more common than previously thought. The "typical" individual with kleptomania is a 35-year-old woman who began to steal when she was 20 years old. Her thefts bring both relief and guilt. She probably has not sought treatment on her own but suffers from a necessary, pervasive, repetitive, and self-destructive act. She may have a history of sexual dysfunction or sexual preoccupation and may be unhappily married to an emotionally unsupportive husband. She has been labile and dysphoric for many years and may have a personality disorder. She has probably had a tumultuous, stressful childhood and may dissociate. CONCLUSIONS: The author proposes a biopsychosocial model of the etiology of kleptomania based on data from the literature. This model emphasizes possible childhood abuse as a precipitating factor in later development of kleptomania. More complete research is needed in the study of kleptomania.

Childhood antecedents of antisocial behavior: parental alcoholism and physical abusiveness.

Hierarchical logistic regression was used to assess the independent and interactive effects of paternal alcoholism and physical child abuse on antisocial behavior in young adult men. Men with alcoholic fathers (N = 131) did not report or exhibit more antisocial behavior than comparison subjects (N = 70). Men with physical abuse histories, however, reported more aggressive and antisocial behaviors during a clinical interview and were rated by a clinical interviewer as more likely to act out aggression. Arrest records did not distinguish the groups. There was no evidence that paternal alcoholism and childhood victimization interacted to increase the risk of antisocial behavior.

Childhood origins of self-destructive behavior.

OBJECTIVE: Clinical reports suggest that many adults who engage in self-destructive behavior have childhood histories of trauma and disrupted parental care. This study explored the relations between childhood trauma, disrupted attachment, and self-destruction, using both historical and prospective data. METHOD: Seventy-four subjects with personality disorders or bipolar II disorder were followed for an average of 4 years and monitored for self-destructive behavior such as suicide attempts, self-injury, and eating disorders. These behaviors were then correlated with independently obtained self-reports of childhood trauma, disruptions of parental care, and dissociative phenomena. RESULTS: Histories of childhood sexual and physical abuse were highly significant predictors of self-cutting and suicide attempts. During follow-up, the subjects with the most severe histories of separation and neglect and those with past sexual abuse continued being self-destructive. The nature of the trauma and the subjects' age at the time of the trauma affected the character and the severity of the self-destructive behavior. Cutting was also specifically related to dissociation. CONCLUSIONS: Childhood trauma contributes to the initiation of self-destructive behavior, but lack of secure attachments helps maintain it. Patients who repetitively attempt suicide or engage in chronic self-cutting are prone to react to current stresses as a return of childhood trauma, neglect, and abandonment. Experiences related to interpersonal safety, anger, and emotional needs may precipitate dissociative episodes and self-destructive behavior.

Depressive illness among chemically dependent adolescents.

OBJECTIVE: The purpose of this study was to investigate the prevalence and correlates of depression among adolescents being treated for chemical dependence. METHOD: Using the National Institute of Mental Health Diagnostic Interview Schedule, the authors interviewed 223 adolescents, aged 15-19 years, who were in residential treatment for alcohol or drug dependence diagnosed according to DSM-III-R criteria. Data on sociodemographic characteristics, school and social performance, past history, family composition, familial alcohol and drug abuse, and previous victimization of the subjects were also gathered. RESULTS: Fifty-four (24.7%) of the subjects met the DSM-III-R criteria for depression. Very few of the traditional correlates of depression discriminated depressed from nondepressed subjects, suggesting that the presence of chemical dependence overrides other predictors of depression. Only female gender, paternal psychopathology, and victimization (physical abuse, sexual abuse) emerged as important variables associated with depression. However, subjects whose onset of depression preceded their chemical dependence had different characteristics from those whose depression began after their chemical dependence. CONCLUSIONS: The prevalence of depressive illness in these chemically dependent adolescents was approximately three times that reported for nonreferred groups of similar age. This high rate of depression reflects the contributions of two distinct groups--those with primary depression and those with depression subsequent to chemical dependence--whose characteristics differed, suggesting the possibility of two pathologic processes, similar in manifestation but with different associated features and possibly with distinct etiologies. Confirmation of these findings in further research could indicate that the two forms of depression may require different treatment approaches.

Sexual and physical abuse histories and psychiatric symptoms among male psychiatric outpatients.

Of 125 consecutive male patients at an adult psychiatric outpatient clinic, 48% reported histories of sexual abuse and/or physical abuse. The mean scores on the global severity index of the SCL-90-R at the first visit were significantly higher for those who reported histories of abuse than for those who had no such history. Childhood abuse also was associated with high levels of psychiatric symptoms in these men.

Childhood sexual and physical abuse in adult patients with borderline personality disorder.

Experiences of abuse and neglect were assessed in 24 adults diagnosed as having borderline personality disorder according to the Diagnostic Interview for Borderline Patients and in 18 depressed control subjects without borderline disorder. Significantly more of the borderline patients than depressed patients reported childhood sexual abuse, abuse by more than one person, and both sexual and physical abuse. There were no between-group differences for rates of neglect or physical abuse without sexual abuse. A stepwise logistic regression revealed that derealization, diagnostic group, and chronic dysphoria were the best predictors of childhood sexual abuse in this group of patients.

Psychiatric morbidity in adult inpatients with childhood histories of sexual and physical abuse.

OBJECTIVE: To extend the knowledge on long-term effects of childhood abuse in psychiatric patients to a large sample, the authors explored childhood sexual and physical abuse in adult inpatients over 1,040 consecutive admissions. METHOD: The 947 patients were admitted to a tertiary-care military medical center. Each patient was interviewed, and abuse history, DSM-III-R diagnosis, and other characteristics were recorded. RESULTS: The prevalence of reported childhood abuse was 18% overall: 9% for sexual abuse (with or without physical abuse), 10% for physical abuse (with or without sexual abuse), and 3% for combined abuse. More female than male patients reported abuse. Alcohol use disorders were more common in victims of physical or combined abuse than in sexually abused or nonabused patients. Axis II diagnoses, particularly borderline personality disorder, were more frequent in abuse victims than in nonabused patients. Histories of drug and alcohol abuse were more common in patients reporting physical or combined abuse than in nonabused patients. Suicidality was also more frequent in abused than nonabused inpatients and was noted in 79% of the patients with histories of combined abuse. Combined abuse in women and physical abuse in men were associated with a family history of psychiatric illness, most commonly alcoholism in male relatives. CONCLUSIONS: These findings emphasize the need for greater attention to family dynamics, aggressive diagnosis and treatment of alcoholism within the family, and, especially, determination of patients' abuse histories, even if repeated questioning is necessary.

Vertebral body fractures in child abuse. Radiologic-histopathologic correlates.

RATIONALE AND OBJECTIVES: Vertebral injuries are rarely reported sequelae of child abuse, and little is known concerning the mechanisms of injury and healing. A preliminary investigation of these issues included correlating radiologic and histologic findings in children with vertebral injuries who died of complications relating to physical abuse. METHODS: Ten vertebral body fractures from four abused infants and young children were studied radiologically and histopathologically. RESULTS: Infants ranged in age from 7 to 36 months (mean, 21 months). Three patients died of associated head injuries. One child died after abandonment. There were three pure vertebral body compression fractures, two superior end-plate fractures without compression deformity, and five anterosuperior end-plate fractures with associated compression deformity. Vertebral compression was generally mild (less than 25%). Typically, end-plate injuries were manifest histologically by extension of the fracture through the medullary trabeculae into the proliferative zone of the superior end plate. The resultant pattern was analogous to that described in a previous study, and could potentially result in a growth disturbance at the vertebral end plate. CONCLUSIONS: Observed radiologic patterns and histologic correlates may help explain previously described findings, such as vertebral notching, in abused infants.

Adolescent multiple personality disorder: a preliminary study of eleven cases.

The diagnostic features and treatment histories of 11 adolescents with multiple personality disorder (MPD) are presented. Clinical evaluation revealed that the majority of these adolescents manifested extremely variable school performance, disruptive behavior, trances, amnesias, mood swings, sharp changes in personality, apparent lying, voices heard in the head, and depression. All had a history of childhood trauma: Sexual abuse (73%), physical abuse (73%), and emotional abuse (82%). Seventy-three percent had a parent with a diagnosable dissociative disorder; 36% of the mothers had MPD. These adolescents had a mean number of 24.1 alter personalities and appear to have become multiple at a mean age of 3 years, 1 month. All patients had angry protector alters, depressed alters, scared alters, and child alters. Fifty-four percent of these cases have integrated during treatment or are progressing toward integration. The remaining cases dropped out of therapy.

Buspirone-associated mental status changes.

The pharmacological management of anxiety in children primarily has used antidepressants, such as imipramine. Buspirone, an atypical anxiolytic, has been shown to be of benefit in both adults and children. It has relatively few side effects and is generally well tolerated. Two cases are reported here involving children treated for anxiety with buspirone who subsequently suffered a possible psychotic deterioration.

Accidental head trauma and retinal hemorrhage.

Retinal hemorrhage and intracranial hemorrhage in a child with little external evidence of trauma and with a poorly documented history are considered pathognomonic child abuse. The mechanism and magnitude of force required to produce the injuries are seldom witnessed or known. This study was designed to determine the incidence of retinal hemorrhage in pediatric head injuries under known accidental circumstances, in association with forces sufficient to cause skull fracture and/or intracranial hemorrhage. Of 525 consecutive hospital admissions for head injuries, 200 children filled these criteria. Thirty children were excluded because of suspected child abuse or gunshot wounds. Of the remaining 170, 140 were evaluated by an ophthalmologist for retinal hemorrhage. Two children, who were both involved in side-impact car accidents, had retinal hemorrhages in associated with severe head injury. Retinal hemorrhage occurs rarely in accidental head injury and is associated with extraordinary force.

Self-reports of childhood abuse in chronically psychotic patients.

A heterogeneous sample of 61 chronically psychotic patients were subgrouped according to the presence or absence of a self-reported history of childhood abuse. Patients reporting childhood abuse (n = 27) had an earlier age of onset, scored higher on the Dissociative Experiences Scale, reported more amnesia, and relapsed more frequently than patients not reporting abuse histories. Histories of childhood abuse and of past stimulant abuse predicted the score on the Dissociative Experiences Scale. A history of childhood abuse may thus contribute to the symptomatology and course of illness in some chronically psychotic patients.

The affective and cognitive sequelae of child maltreatment.

This article discusses the affective and cognitive sequelae of child maltreatment. It provides a brief historical overview and various definitional issues in the field. The tasks of childhood are identified, and developmental processes are discussed. A review of the literature of the sequelae of maltreatment is presented, followed by a discussion of the impact of these sequelae and the implications for the child's development.

A comparison of male and female clients in substance abuse treatment.

To assess the extent to which women appear to have special treatment needs, this paper compares male and female patients receiving inpatient substance abuse treatment. The author analyzed completed intake interview forms from the files of all clients entering two private, nonprofit inpatient substance abuse treatment facilities during an 8-month period in 1989 (a total of 181 men and 48 women). The women were similar to the men with respect to sociodemographic characteristics, family history, alcohol/drug history, and treatment completion. However, they were more likely to report a sexual abuse history and indicated more emotional distress than the men. Implications for treatment are discussed.

Toward an ecological/transactional model of community violence and child maltreatment: consequences for children's development.

In recent decades it has become increasingly apparent that violence affects a significant proportion of families in the United States (Bureau of Justice Statistics 1983). Violence, in fact, is becoming a defining characteristic of American society. A recent comparison of the rates of homicide among 21 developed nations indicates that the United States has the highest homicide rate in the world, and its rate is more than four times higher than the next highest rate (Fingerhut and Kleinman 1990). What is even more alarming is the high incidence of violent death and injury for children and adolescents in the United States. Acts of violence are the cause of death for over 2000 children between the ages of 0 and 19 years each year, and more than 1.5 million children and adolescents are abused by their adult caretakers each year (Christoffel 1990).

Parental substance abuse and the nature of child maltreatment.

The authors reviewed 190 randomly selected records from the case load of a large juvenile court. These records involved cases in which the state took legal custody of the children following a finding of significant child maltreatment, based on a "clear and convincing" standard of evidence. Sixty-seven percent (127/190) of these cases involved parents who were classified as substance abusers. The results of this study revealed specific associations between (a) alcohol abuse and physical maltreatment and (b) cocaine abuse and sexual maltreatment. Logistic analyses, testing for the effects of polysubstance abuse, revealed that additional forms of substance abuse failed to add significantly to the effects of alcohol in predicting physical maltreatment or cocaine in predicting sexual maltreatment.

Treatment for abused children: when is a partial solution acceptable?

Physically maltreated children display a range of serious psychological problems. Despite the availability of effective treatment of similar problems in other populations of children, direct psychological treatment of abused children has rarely been reported. It is argued that such direct treatment, while constituting only a "partial solution" to the problem of child abuse, needs to be addressed through research and application.

Avoidance of criminality in abused and neglected children.

This paper compares previously abused and neglected children who have avoided official records of delinquency and adult criminality with those who have not. The goal of this analysis is to uncover potential mediating variables that may act to buffer or protect maltreated children from later delinquency and criminality. It is hoped that this analysis will provoke others to consider the "invulnerable" among the abused and neglected so that we might ultimately learn what works to protect them. In terms of "competence" as an outcome, these findings must be treated as preliminary.

Aggressive children in a day treatment program: changed outcome and possible explanations.

An earlier study (Gabel, Finn & Ahmad, 1988) of severely disturbed children treated in a day hospital program, found that outcome was particularly poor for children with preadmission histories of severe aggressive/destructive behavior. The study reported here compares the outcome in a more recent group of children treated in the same setting with the earlier group's outcome. The recent group of children, like the earlier one, was made up of youngsters who were often from dysfunctional and abusive families. Outcome for aggressive children, including aggressive children with histories of suspected child abuse/maltreatment, was significantly improved. Possible reasons for this improvement in outcome in terms of programmatic changes that had occurred are discussed.

The NIMH community violence project: II. Children's distress symptoms associated with violence exposure.

The rising tide of violence in American cities has placed the causes and consequences of violence squarely on the public health agenda. The U.S. Government's Year 2000 National Health Promotion and Disease Prevention Objectives includes a full chapter devoted to violence issues and delineates a number of goals and programs aimed at reducing the number of deaths and injuries associated with violence (Public Health Service 1990). Notably absent from these objectives, however, is attention to the possible adverse psychological consequences of exposure to acute or chronic violence. Nonetheless, in light of numerous media reports of children's exposure to community violence and recent reports documenting high levels of exposure even among very young children (Richters and Martinez 1993), it is reasonable to question whether the risks of exposure extend beyond death and physical injury to psychological well-being.